What should a primary-care physician do when an incidental partially empty sella is identified on imaging?

Management of Incidental Partially Empty Sella

When a primary care physician identifies an incidental partially empty sella on imaging, comprehensive hormonal screening should be performed regardless of symptoms, as 30-40% of patients demonstrate hypopituitarism on testing, with individual axis involvement potentially reaching 50%. 1, 2

Initial Clinical Assessment

The absence of urgent symptoms does not eliminate the need for evaluation. Key red flags requiring immediate specialist referral include: 2

• Visual changes or papilledema (suggesting increased intracranial pressure or optic chiasm compression)
• Signs of hormonal deficiencies: profound fatigue, cold intolerance, sexual dysfunction, menstrual irregularities
• Headache with features of increased intracranial pressure (morning headaches, positional changes, pulsatile tinnitus)
• CSF rhinorrhea

Partially empty sella may indicate underlying idiopathic intracranial hypertension (IIH), particularly in patients presenting with headache and papilledema. 2 Do not attribute headache symptoms directly to the empty sella itself, as this is typically an incidental finding unrelated to headache etiology. 1, 2

Mandatory Hormonal Screening Panel

All patients require comprehensive baseline hormonal evaluation (morning fasting samples): 1, 2, 3

• Thyroid axis: TSH and free T4 (deficiency seen in 8-81% of pituitary disorders) 3
• Adrenal axis: Morning cortisol and ACTH (deficiency in 17-62% of cases) 3
• Gonadal axis: Testosterone (males) or estradiol (females), FSH, and LH (deficiency in 36-96%) 3
• Prolactin: Routine measurement (elevated in approximately 28% of cases) 1, 3
• Growth hormone axis: IGF-1 (most commonly affected axis, 61-100% involvement) 3
• Electrolytes: Serum sodium and osmolality to screen for diabetes insipidus or SIADH 3

The rationale for universal screening is compelling: approximately 30% of patients with empty sella demonstrate hypopituitarism, though most remain asymptomatic initially. 1, 2 Individual hormone axis deficiencies often exceed 10% prevalence and may reach 50%. 1, 2

Imaging Confirmation

If the partially empty sella was identified on CT or non-dedicated MRI sequences, obtain high-resolution pituitary MRI using dedicated sellar protocols. 1, 2, 3 MRI can reliably demonstrate empty sella without intravenous contrast; contrast is reserved only when surgical planning is anticipated. 2, 3 CT has limited utility and is insensitive compared to MRI for detecting pituitary pathology. 2

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

Specialist Referrals

Endocrinology referral is indicated for: 1, 2

• Any detected hormonal abnormalities on screening
• Symptoms suggestive of pituitary dysfunction (even with normal initial screening)
• Guidance on dynamic testing when baseline results are equivocal (e.g., morning cortisol 3-15 µg/dL warrants 1 mcg cosyntropin stimulation test) 3

Ophthalmology referral is indicated for: 1, 2

• Visual symptoms or visual field defects
• Concerns about increased intracranial pressure
• Optic chiasm compression noted on imaging
• Formal assessment for papilledema

Critical Management Pitfalls to Avoid

• Never start thyroid hormone replacement before confirming adequate cortisol status and initiating glucocorticoid replacement if needed. This can precipitate adrenal crisis. 3
• Do not overlook IIH in patients with headache and partially empty sella, as this represents a distinct clinical entity requiring specific management (weight loss as primary treatment, with surgical CSF diversion reserved for imminent visual loss). 2
• Do not skip hormonal screening in asymptomatic patients. The high prevalence of subclinical hypopituitarism (30-40%) mandates evaluation regardless of symptoms. 1, 2
• Do not order unnecessary urgent interventions that won't change immediate management in confirmed asymptomatic cases. 1, 2
• Do not use TSH alone to guide levothyroxine dosing in central hypothyroidism; free T4 should guide therapy, targeting the upper half of the reference range. 3

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 to symptomatic empty sella syndrome. 4 However, patients diagnosed with any hormone deficiency require ongoing endocrine management, education on stress-dosing for adrenal insufficiency, and consideration of medical-alert identification. 3