As a primary care provider, what steps should I take when a patient’s MRI reveals a partially empty sella?

Management of Incidental Partially Empty Sella in Primary Care

All patients with partially empty sella should undergo comprehensive hormonal screening regardless of symptoms, as hormonal deficiencies occur in 30-52% of cases, though urgent workup is unnecessary in asymptomatic patients. 1, 2, 3

Immediate Clinical Assessment

Key symptoms requiring urgent evaluation include: 1, 2

• Visual changes or visual field defects
• Signs of hormonal deficiencies (fatigue, cold intolerance, sexual dysfunction)
• Headache with features of increased intracranial pressure (papilledema, morning predominance, positional worsening)
• CSF rhinorrhea

Important clinical context: 2

• Partially empty sella is a typical neuroimaging feature of idiopathic intracranial hypertension (IIH), particularly in patients presenting with headache and papilledema
• Do not attribute the patient's headache directly to the empty sella finding—it is usually an incidental finding unrelated to headache symptoms 1, 2

Mandatory Hormonal Screening Panel

Perform the following baseline hormonal tests in all patients: 1, 2, 3

• Thyroid axis: TSH, free T4 (deficiency in up to 48% of cases)
• Adrenal axis: Morning cortisol and ACTH (8 AM fasting)
• Gonadal axis: Testosterone (males), estradiol (females), LH, FSH
• Prolactin level (elevated in approximately 28% of cases)
• Growth hormone axis: IGF-1

The rationale for universal screening: 4, 3, 5

• Affected-axis rates often exceed 10% and may reach 50-52% in pooled analyses
• Hypogonadism is the most common finding in primary empty sella (25.8% of patients)
• Complete empty sella (≥50% CSF filling) carries higher risk of secondary adrenal insufficiency and hypogonadism than partial empty sella
• Males are at higher risk for hormonal deficiencies, particularly secondary hypothyroidism

Imaging Considerations

No additional urgent imaging is needed if MRI already confirms partially empty sella without other concerning features (mass lesions, optic chiasm compression). 1, 2

MRI characteristics: 2

• MRI is the preferred and definitive imaging modality
• High-resolution pituitary protocols can confirm the diagnosis even without IV contrast
• CT has limited utility and is insensitive compared to MRI

Specialist Referrals

Endocrinology referral is indicated if: 1, 2

• Any hormonal abnormalities are detected on screening
• Patient has symptoms suggestive of pituitary dysfunction (fatigue, cold intolerance, sexual dysfunction, menstrual irregularities)

Ophthalmology referral is indicated if: 1, 2

• Visual symptoms are present
• Concerns about increased intracranial pressure exist
• Optic chiasm compression is noted on imaging
• Papilledema is detected on fundoscopic examination

Consider neurology referral if: 2

• Features suggest idiopathic intracranial hypertension (headache with papilledema in the setting of partially empty sella)
• Weight loss is the primary treatment for IIH-associated cases

Follow-Up Strategy

For patients with normal baseline hormonal function: 5

• The risk of developing hypopituitarism during follow-up is low (only 2 out of 119 patients in one longitudinal study)
• Regular follow-up hormonal assessments are not justified in patients with intact pituitary function at diagnosis
• Counsel patients to return if symptoms of hormonal deficiency develop

For patients with detected hormonal deficiencies: 2

• Manage in collaboration with endocrinology
• Hormone replacement therapy as indicated by specific deficiencies

Critical Pitfalls to Avoid

Do not dismiss the finding without hormonal screening even in asymptomatic patients, as the prevalence of hypopituitarism is substantial (30-52%). 2, 3

Do not overlook IIH in patients presenting with headache and partially empty sella—this represents a distinct clinical entity requiring specific management with weight loss as primary treatment. 2

Do not attribute headache directly to the empty sella without considering more common primary headache disorders (migraine, tension-type headache). 1, 2, 6

Do not order unnecessary urgent tests that won't change immediate management in asymptomatic patients with confirmed partially empty sella on MRI. 1, 2

Do not miss rare CSF rhinorrhea, which occurs in approximately 11.8% of cases and may be discovered only at surgery in some patients. 7