Empty Sella Syndrome
Empty sella syndrome refers to an imaging appearance in which the sella turcica—the bony recess at the base of the skull that houses the pituitary gland—appears partially or completely filled with cerebrospinal fluid, with the pituitary gland flattened against the floor of the sella. It is a common finding, often identified incidentally on brain or pituitary MRI performed for other reasons. Most patients have normal pituitary function and no symptoms (primary empty sella), while a smaller proportion have secondary empty sella from prior pituitary surgery, radiation, tumor infarction, or other causes. When symptoms do occur, they most often relate to headaches, hormonal changes, or, uncommonly, visual disturbances. Evaluation combines MRI, targeted hormonal testing, and, when appropriate, visual assessment.
What is it?
The pituitary gland is a small pea-sized gland at the base of the brain, housed in a bony recess of the skull called the sella turcica. The sella is normally almost completely filled by the pituitary gland and covered above by a thin layer of tissue called the diaphragma sellae, which separates the pituitary from the cerebrospinal fluid (CSF) that surrounds the brain. When the diaphragma sellae is incomplete or weakened, CSF can extend downward into the sella, flattening the pituitary against the floor of the sella and creating the imaging appearance called an “empty sella.” Despite the name, the sella is not truly empty—the pituitary gland is still present but compressed or thinned.
Empty sella is broadly classified into primary and secondary types. Primary empty sella occurs without any identifiable prior pituitary injury and is generally thought to result from a congenital or acquired defect in the diaphragma sellae, sometimes combined with elevated CSF pressure. Secondary empty sella occurs after an event that has affected the pituitary, such as pituitary surgery, radiation, tumor infarction (including after successful treatment of a pituitary tumor), pituitary apoplexy, or postpartum pituitary infarction (Sheehan syndrome).
The distinction between “empty sella” as an incidental imaging finding and “empty sella syndrome” is important. Empty sella describes the anatomic appearance and is common, particularly in middle-aged women, patients with obesity, those with a history of multiple pregnancies, and those with idiopathic intracranial hypertension. Empty sella syndrome is generally reserved for cases in which the finding is accompanied by symptoms or hormonal abnormalities that require attention. Most patients with an empty sella on imaging have normal pituitary function and no significant symptoms attributable to the finding.
Symptoms and clinical effects vary widely. Many patients with empty sella have no symptoms and normal pituitary function. When symptoms occur, they may include headaches (which are common but often nonspecific and not always attributable to the empty sella itself); symptoms of pituitary hormonal deficiencies (hypopituitarism), which are more common in secondary empty sella and can include fatigue, weakness, cold intolerance, weight changes, menstrual irregularity, low libido, erectile dysfunction, reduced facial or body hair, and, when antidiuretic hormone is affected, excessive urination and thirst; and, uncommonly, CSF leakage from the nose (rhinorrhea) when the empty sella is associated with a defect in the sella floor. Visual disturbances are unusual with typical empty sella but can occur in a small subset of patients with associated conditions or when the optic pathways are affected.
Empty sella is frequently associated with idiopathic intracranial hypertension (also called pseudotumor cerebri), a condition of elevated CSF pressure without an identifiable structural cause. Patients with idiopathic intracranial hypertension often have empty sella along with other imaging findings, and their symptoms (including headaches, visual disturbances, and pulsatile tinnitus) may prompt the initial imaging that reveals the empty sella.
Certain populations have higher rates of empty sella. These include middle-aged women, patients with obesity, those with a history of multiple pregnancies, patients with idiopathic intracranial hypertension, and, less commonly, patients with specific hereditary or congenital conditions. Many patients have no identifiable predisposing factor.
Diagnosis begins with imaging. MRI of the brain or dedicated pituitary MRI is the primary imaging test and clearly shows the characteristic appearance of a partially or completely empty sella, with the pituitary gland compressed against the floor. CT can also show the finding but provides less detail about pituitary tissue. Once empty sella is identified, targeted hormonal testing is often performed to assess pituitary function. Testing typically includes prolactin (which can be mildly elevated due to stalk effect), IGF-1 (as a marker of growth hormone activity), morning cortisol and ACTH, TSH and free T4, LH and FSH, and estradiol (in premenopausal women) or testosterone (in men). Additional testing may be appropriate in specific clinical situations, such as dexamethasone suppression testing if features of Cushing disease are present, or dynamic testing of the growth hormone or ACTH axes when specific deficiencies are suspected.
Formal visual field testing is generally not required for typical empty sella but may be appropriate when visual symptoms are present or when the empty sella is associated with idiopathic intracranial hypertension or other conditions affecting the optic pathways. Evaluation for associated conditions—including idiopathic intracranial hypertension, prior pituitary tumor, or CSF leak—is guided by the clinical context.
In patients with secondary empty sella, the underlying cause (such as prior pituitary surgery or Sheehan syndrome) is typically already known, and evaluation focuses on assessing pituitary function and any residual disease.
Important to Know
Management of empty sella depends on whether pituitary function is normal, whether symptoms are present, and whether associated conditions are contributing to the clinical picture. Care is typically coordinated by primary care clinicians and endocrinologists, with involvement from neurologists, neurosurgeons, ophthalmologists, and other specialists as needed.
For patients with an incidental empty sella and normal pituitary function, no specific treatment is needed. Reassurance about the benign nature of the finding, along with baseline hormonal testing to confirm normal pituitary function, is often sufficient. Periodic reassessment may be reasonable if new symptoms develop, but routine follow-up imaging is generally not required in the absence of clinical concerns.
For patients with confirmed hypopituitarism, treatment involves appropriate hormone replacement for the specific deficiencies identified. Options include glucocorticoids for ACTH/cortisol deficiency (with careful attention to stress dosing during illness or injury), levothyroxine for central hypothyroidism (typically started only after adrenal function has been assessed to avoid precipitating adrenal crisis), sex hormone replacement for LH/FSH deficiency (individualized based on age, reproductive plans, and other factors), growth hormone replacement in selected adults with confirmed deficiency and specific indications, and desmopressin for antidiuretic hormone deficiency (central diabetes insipidus). Careful monitoring and dose adjustment are required over time, and patients receive education about medical alert identification, emergency plans, and warning signs of hormone-related complications.
For patients with empty sella associated with idiopathic intracranial hypertension, treatment focuses on the underlying condition. Options include weight loss (which is often highly effective in patients with obesity), medications that reduce CSF production (such as acetazolamide), and, in selected patients with severe or refractory symptoms, procedures to divert CSF or surgically manage related issues. Coordination with neurology and, when relevant, neuro-ophthalmology and neurosurgery is important.
For patients with headaches attributed to empty sella, standard headache evaluation and management principles apply. It is often difficult to determine whether a specific headache is caused by the empty sella itself or by another common headache disorder, and treatment is guided by the specific headache pattern. Evaluation for associated conditions such as idiopathic intracranial hypertension is important.
For patients with cerebrospinal fluid leakage (rhinorrhea) associated with empty sella, evaluation typically includes confirmation of CSF leak, identification of the defect (often at the floor of the sella), and, in most cases, surgical repair by neurosurgery or otolaryngology. Untreated CSF leaks carry a risk of meningitis and require timely evaluation.
For patients with secondary empty sella after pituitary surgery, radiation, or tumor infarction, care includes assessment of residual disease, monitoring of pituitary function over time (as deficiencies can develop years after treatment), and ongoing follow-up by an endocrinologist familiar with pituitary conditions.
Pregnancy planning and pregnancy require special attention. Patients with hypopituitarism require careful adjustment of hormone replacement doses during pregnancy, and coordination with endocrinology and obstetrics is essential.
Care is typically coordinated by primary care clinicians and endocrinologists, with involvement from other specialists as needed. Imaging and laboratory findings are interpreted alongside the patient’s symptoms, examination, and broader clinical context rather than in isolation.
Patient education plays an important role. Understanding that empty sella is usually a benign incidental finding, the meaning of any hormonal abnormalities, the rationale for recommended monitoring or treatment, medication adherence when hormone replacement is needed, and warning signs of complications all contribute to better outcomes. Many patients benefit greatly from clear reassurance that most empty sella findings are not concerning.
Red flag symptoms include sudden severe headache (often the worst of one’s life), sudden loss or change of vision, double vision, severe nausea and vomiting, confusion or altered mental status, severe weakness, low blood pressure or signs of shock, high fever with headache and neck stiffness (which may suggest meningitis, particularly with associated CSF leak), clear fluid drainage from the nose (which may indicate CSF leak), severe symptoms of adrenal insufficiency (severe weakness, vomiting, low blood sugar), or rapid clinical deterioration. These warrant immediate emergency evaluation, as they may indicate serious complications such as pituitary apoplexy, adrenal crisis, meningitis, or other emergencies.