Adult female with 10‑day nape pain, new right‑hand swelling and numbness, resolved right‑sided weakness, diplopia, moderate headache, CT showing empty sella, and ibuprofen allergy—what are the appropriate next diagnostic steps and symptomatic management?

Management Plan for Empty Sella Syndrome with Acute Neurological Symptoms

Immediate Diagnostic Priorities

This patient requires urgent MRI brain with and without gadolinium contrast plus MR venography (MRV) to exclude cerebral venous thrombosis, which can present with headache, diplopia, and hand swelling and represents a neurosurgical emergency. 1, 2, 3

The combination of diplopia, headache, nape pain, and right hand swelling/numbness in the setting of empty sella raises critical concern for cerebral venous thrombosis (CVT), which can mimic idiopathic intracranial hypertension but requires urgent anticoagulation rather than observation. 1, 3 CVT can present with initially normal CT and even normal MRI, making dedicated venography mandatory. 1, 3

Critical Imaging Protocol Required

• MRI brain with and without gadolinium contrast to evaluate for dural thickening/enhancement (which may indicate CVT), assess pituitary anatomy, and exclude mass lesions 1, 2, 3
• MR venography with contrast (or CT venography if MRI contraindicated) to definitively exclude cerebral venous thrombosis 1, 3
• MRA or CTA if any concern for third nerve involvement given the diplopia, as posterior communicating artery aneurysm must be excluded urgently 2, 4, 3

Detailed Neuro-Ophthalmologic Examination Required

• Characterize the diplopia pattern: horizontal diplopia worse at distance suggests sixth nerve palsy (most common with increased intracranial pressure), while vertical diplopia with ptosis suggests third nerve palsy requiring urgent aneurysm exclusion 2, 4, 3
• Assess pupillary function carefully: pupil-involving third nerve palsy is a medical emergency requiring immediate neurosurgical evaluation for compressive aneurysm 1, 2, 4
• Fundoscopic examination to evaluate for papilledema, which would confirm increased intracranial pressure and suggest idiopathic intracranial hypertension versus CVT 1, 5
• Visual field testing to assess for optic chiasm compression or visual field defects associated with increased intracranial pressure 1, 6, 5

Endocrine Evaluation

All patients with empty sella require baseline pituitary hormone assessment, as 19-52% have at least one hormone deficit. 6, 7, 8

Recommended Hormone Panel

• Morning fasting cortisol (8 AM) 7, 8
• Free thyroxine (fT4) and TSH 7, 8
• Prolactin (hyperprolactinemia occurs in up to 40% of empty sella cases) 6, 5, 7
• IGF-1 (growth hormone deficiency is common) 6, 5, 7
• Estradiol (given irregular menses history and female patient) 7
• Electrolytes to assess for possible SIADH or adrenal insufficiency 6

Symptomatic Management While Awaiting Diagnosis

For Diplopia

• Press-on prism glasses or part-time eye patching to temporize diplopia during diagnostic workup 1, 2, 4
• Avoid driving until diplopia is controlled 2

For Headache and Nape Pain

• Continue acetaminophen (patient already using, ibuprofen-allergic) 1
• Consider topical intranasal corticosteroids if any component of sinus congestion contributing to headache 1
• Avoid opioids given unclear etiology and risk of masking neurological deterioration 1

For Hand Swelling and Numbness

• Elevate right hand and monitor for progression 1
• Document neurovascular status serially (pulses, capillary refill, sensation, motor function) as this may represent venous congestion from CVT 1

Medication List

1. Acetaminophen 650-1000 mg PO every 6 hours as needed for headache (maximum 3000 mg/24 hours) 1
2. Continue Neurobion (B-complex) as currently prescribed—no contraindication
3. Hold Norgesic (orphenadrine/aspirin/caffeine) until CVT excluded, as aspirin may complicate management if hemorrhagic transformation occurs 1

Critical Red Flags Requiring Immediate Escalation

• Worsening diplopia or new ptosis (suggests progressive cranial nerve involvement) 1, 2, 4
• Pupil asymmetry or decreased pupillary reactivity (suggests third nerve compression from aneurysm) 1, 2, 4
• Altered mental status or seizure (suggests CVT with venous infarction) 1, 3
• Progressive visual loss or new visual field defects (suggests optic chiasm compression or papilledema) 1, 6, 5
• Worsening right-sided weakness or numbness (suggests stroke or venous infarction) 1, 3

Follow-Up Plan

• Urgent ophthalmology consultation within 24-48 hours for formal visual field testing and fundoscopic examination 1, 2, 4
• Endocrinology referral for pituitary hormone evaluation and management once acute neurological issues excluded 6, 5, 7, 8
• Neurosurgery consultation if CVT confirmed or if any evidence of CSF leak (given nape pain and empty sella) 1, 6
• Repeat imaging in 24-36 months if all acute pathology excluded and patient remains asymptomatic, as empty sella has low but measurable risk of progression to empty sella syndrome 8

Critical Pitfalls to Avoid

• Do not assume empty sella explains all symptoms—this patient's acute presentation with diplopia, hand swelling, and progressive symptoms demands exclusion of CVT, which is life-threatening and treatable 1, 3
• Do not delay imaging based on normal initial CT—CVT can be missed on non-contrast CT and even on routine MRI without dedicated venography 1, 3
• Do not dismiss pupil examination—even partial pupil involvement changes the differential dramatically and requires urgent aneurysm exclusion 1, 2, 4
• Do not overlook the postpartum timing (10 days postpartum)—this is a high-risk period for CVT, and the epidural anesthesia history may be a red herring 1