Management of Partially Empty Sella on MRI
Immediate Clinical Assessment
All patients with partially empty sella require comprehensive hormonal screening regardless of symptoms, as approximately 30% demonstrate some degree of hypopituitarism upon testing, though most remain asymptomatic. 1, 2
Key Clinical Features to Evaluate
Visual symptoms (visual field defects, decreased acuity, papilledema) warrant urgent ophthalmology referral, as these may indicate increased intracranial pressure or optic chiasm compression 3, 2
Headache characteristics should be carefully assessed—particularly features suggesting increased intracranial pressure (worse with Valsalva, morning predominance, positional changes)—as partially empty sella is a typical neuroimaging feature of idiopathic intracranial hypertension (IIH), especially in obese middle-aged women 2, 4
Symptoms of hormonal deficiency including fatigue, cold intolerance, sexual dysfunction, menstrual irregularities, or decreased libido should be documented 3, 2
CSF rhinorrhea must be specifically asked about, as it occurs in approximately 12% of patients with empty sella and may be difficult to treat 5, 6
Mandatory Hormonal Screening Panel
The following baseline morning fasting hormonal evaluation should be performed in all patients with partially empty sella: 3, 2, 7
Thyroid axis: TSH and free T4 (deficiency seen in 8-81% of patients with pituitary pathology) 7
Adrenal axis: Morning cortisol and ACTH (deficiency in 17-62% of patients) 7
Gonadal axis: Testosterone (males), estradiol (females), FSH, and LH (deficiency in 36-96% of patients) 7
Prolactin: Routine measurement to detect hyperprolactinemia, which occurs in approximately 28% of cases and may be clinically silent 3, 8
Growth hormone axis: IGF-1 (most commonly affected axis, with deficiency in 61-100% of patients with pituitary pathology) 7
Electrolytes: Serum sodium and osmolality to screen for diabetes insipidus or SIADH 7
Dynamic Testing When Indicated
1 mcg cosyntropin stimulation test should be performed when morning cortisol is equivocal (3-15 µg/dL) to confirm or exclude adrenal insufficiency 7
All dynamic tests must be completed before initiating any glucocorticoid therapy to avoid false-negative results 7
Imaging Recommendations
MRI with high-resolution pituitary protocols is the preferred and definitive imaging modality for characterizing empty sella, and can reliably confirm the diagnosis even without IV contrast. 1, 2
No additional urgent imaging is needed if MRI already demonstrates partially empty sella without other concerning features (mass lesions, optic chiasm compression, or cavernous sinus invasion) 3, 2
IV contrast is not routinely necessary for diagnosis of empty sella and should be reserved for operative planning or when alternative sellar pathology needs characterization 1, 2
CT has limited utility and is insensitive compared to MRI for detecting pituitary pathology 1, 2
Specialist Referrals
Endocrinology Referral
Endocrinology consultation is indicated if: 3, 2
- Any hormonal abnormalities are detected on screening
- Patient has symptoms suggestive of pituitary dysfunction
- Interpretation of equivocal laboratory results is needed
- Initiation and titration of hormone replacement therapy is required
Ophthalmology Referral
Ophthalmology evaluation is indicated if: 3, 2
- Visual symptoms are present
- Concerns about increased intracranial pressure exist
- Optic chiasm compression is noted on imaging
- Papilledema is suspected
Management Considerations for Specific Scenarios
If Associated with Idiopathic Intracranial Hypertension
Weight loss is the primary treatment for IIH-associated empty sella, with referral to weight management programs 2
Surgical CSF diversion is reserved for imminent visual loss only 2
The combination of partially empty sella, headache, and obesity (particularly in middle-aged women) should raise strong suspicion for IIH 4, 6
If Hormonal Deficiencies Are Confirmed
Glucocorticoid replacement must always be initiated before thyroid hormone replacement to avoid precipitating adrenal crisis 7
Free T4 (not TSH) should guide levothyroxine dosing in central hypothyroidism, targeting the upper half of the reference range 7
Patients with confirmed adrenal insufficiency require education on stress-dosing, emergency injectable steroids, and should obtain a medical-alert bracelet 7
Follow-Up Strategy
If initial hormonal screening is normal and no concerning features are present, careful reevaluation at 24-36 months is suggested given the low risk of progression 9
Repeat imaging is not routinely necessary unless new symptoms develop or hormonal abnormalities emerge 3, 2
Critical Pitfalls to Avoid
Do not attribute headache directly to empty sella—it is usually an incidental finding unrelated to headache symptoms; consider more common headache etiologies 3, 2
Do not overlook IIH in patients with headache and partially empty sella, as this represents a distinct clinical entity requiring specific management, particularly in obese women 2, 4
Do not skip hormonal screening even in asymptomatic patients, as affected-axis rates often exceed 10% and may reach 50%, with many patients remaining clinically silent despite significant deficiencies 2, 8, 9
Do not order unnecessary urgent tests that won't change immediate management in asymptomatic patients with confirmed partially empty sella on MRI 3, 2
Do not miss CSF rhinorrhea—specifically ask about clear nasal drainage, as this complication occurs in 12% of cases and may require surgical intervention 5, 6