Empty Sella Syndrome
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Direct answer
A sella turcica filled with cerebrospinal fluid, with the pituitary gland flattened against its floor, is an empty sella — and in the great majority it is an incidental finding with normal pituitary function that needs no treatment at all. Primary empty sella arises when arachnoid tissue herniates through a deficient diaphragma sellae, classically in middle-aged, multiparous, obese women and in association with raised intracranial pressure; secondary empty sella follows pituitary surgery, radiotherapy, apoplexy or Sheehan infarction. The clinical task is narrow: exclude hormonal deficiency with a basal pituitary screen, check visual fields if there is any chiasmal concern, and resist the reflex to intervene — surgery is contemplated only for complications such as CSF rhinorrhoea or genuine chiasmal compression.
What you must remember
- Primary empty sella: deficient diaphragma sellae plus CSF pulsation remodels the sella; found in a few per cent of autopsies and increasingly on incidental MRI.
- Classic demographic: obese, hypertensive, multiparous woman in middle age; headaches are the commonest presenting complaint but causation is often uncertain.
- Secondary empty sella: previous pituitary surgery, irradiation, apoplexy or postpartum infarction (Sheehan) — the gland has been destroyed or removed, so deficiency is far likelier.
- Pituitary function is normal in most primary cases; when deficiency occurs, GH and gonadotrophins go first, following the usual ordering of hypopituitarism.
- Mild hyperprolactinaemia occurs in a minority from stalk compression; check macroprolactinaemia before treating.
- MRI: CSF-intensity sella contents, flattened pituitary rim, no enhancing mass — the finding that ends tumour worry.
- Association with idiopathic intracranial hypertension (headache, visual obscurations, papilloedema) — worth screening for when the empty sella is marked and the patient is symptomatic.
- Rare complications needing surgical opinion: CSF rhinorrhoea and chiasmal descent (visual field defects); benign intracranial hypertension treatment (weight, acetazolamide) may reverse the latter.
Approach to the finding in practice
A 47-year-old woman undergoes MRI for chronic headaches; the report describes a partially empty sella with a thin rim of pituitary tissue. The structured approach: verify no prior pituitary surgery or postpartum catastrophe (secondary empty sella changes the prior for deficiency substantially), then run the basal screen — 8–9 a.m. cortisol, free T4, LH/FSH with oestradiol or testosterone, prolactin, IGF-1 — and check visual fields once to be safe. If all are normal, management is reassurance and treatment of the headache on its own merits; no serial imaging is required.
When deficiency appears, it follows the standard hypopituitarism pattern. A woman with secondary empty sella after Sheehan syndrome presents with fatigue, amenorrhoea and failure to lactate historically; her screen shows low cortisol, low free T4, low gonadotrophins — replacement begins with hydrocortisone before levothyroxine, then sex steroids, mirroring any hypopituitarism pathway.
The distinctive complication set defines the surgical boundary. Spontaneous CSF rhinorrhoea — clear watery discharge from one nostril, worse on bending, with a salty taste — needs neurosurgical repair. Descended chiasmal syndrome (visual decline from the optic apparatus sagging into the sella) is treated by addressing raised intracranial pressure if present, with chiasmapexy reserved for refractory cases.
Where students slip
The reflex error is treating the radiology report as the disease: "empty sella" on a scan becomes the explanation for headaches, obesity and fatigue, and the patient is sent toward unnecessary interventions. The second slip is skipping the function tests because the sella "looks empty" — a flattened gland usually still works, but deficiency is commoner than in the general population and is entirely treatable when found. Third, candidates forget the secondary causes: in a patient with past transsphenoidal surgery or Sheehan syndrome, empty sella is the expected scar, and the clinical question is replacement adequacy, not aetiology. Finally, missing the rare red flags — rhinorrhoea, progressive field loss, papilloedema — turns a benign entity into a missed complication.
Frequently asked questions
What is an empty sella and why does it occur?
A sella filled with cerebrospinal fluid in which the pituitary is compressed into a thin rim — primary forms from arachnoid herniation through a defective diaphragma sellae (aided by CSF pulsation and raised intracranial pressure), secondary forms after surgery, radiation, apoplexy or infarction.
Does empty sella syndrome require treatment?
Usually not: with normal pituitary function and intact vision, reassurance suffices. Treatment is confined to replacing identified hormone deficiencies and to surgical correction of rare complications such as CSF rhinorrhoea or chiasmal compression.
How is pituitary function assessed in empty sella?
By a basal panel — morning cortisol, free T4, LH/FSH with sex steroids, prolactin and IGF-1 — with dynamic testing reserved for equivocal cortisol results, exactly as in any hypopituitarism workup.
Can empty sella cause hyperprolactinaemia?
Yes, mildly, in a minority, through stalk compression removing dopamine inhibition; levels are typically modest. Exclude macroprolactinaemia and drug causes before attributing the elevation or treating it.
Which empty sella patients need specialist referral?
Those with biochemical hormone deficiency, visual field defects, suspected idiopathic intracranial hypertension (progressive headaches, visual obscurations, papilloedema), or CSF rhinorrhoea — the small subgroup in which the anatomy actually matters.