Clinical presentation, evaluation and case management of primary empty sella syndrome: a retrospective analysis of 10-year single-center patient data

The Influence of Pituitary Morphology on the Occurrence of Hormonal Disorders in Patients with Empty Sella or Partial Empty Sella

Background/Objectives: The aim of the study was to prospectively assess the impact of certain parameters of pituitary morphology assessed with the use of magnetic resonance imaging on the occurrence of hormonal disorders in patients with primary partial empty sella (PES) or primary empty sella (ES). Methods: Forty-three patients were divided into two groups: group 1-patients with PES (n = 20); group 2-patients with ES (n = 23). Results: Patients with ES were characterized by larger both the transverse (14.8 ± 2.9 mm vs. 17.2 ± 2.9 mm, p = 0.016) and anteroposterior (AP) diameters of the pituitary (11.4 ± 1.4 mm vs. 13.2 ± 1.9 mm, p = 0.003), a smaller craniocaudal (CC) diameter (3.9 ± 0.62 mm vs. 2.2 ± 0.6 mm, p = 0.001), and a lower pituitary volume (332.8 ± 107.6 mm3 vs. 243.5 ± 70.9 mm3, p = 0.001). Moreover, an AP infundibular displacement was more common in patients with ES (7 [35%] vs. 16 [69.6%]., p = 0.023). Despite the fact that secondary adrenocortical insufficiency was shown to be significantly more common and ACTH levels to be significantly lower (27.5 ± 13.2 pg/mL vs. 21.8 ± 17.6 pg/mL, p = 0.039) in patients with ES (0 [0%] vs. 3 [13.4%], p = 0.046), univariate logistic regression did not reveal any significant associations of pituitary diameters, pituitary volume, or pituitary stalk displacement with endocrine disorders, such as secondary adrenocortical insufficiency or hyperprolactinemia, which was confirmed with multivariate logistic regression adjusted for age, sex, BMI, and arterial hypertension. Conclusions: Radiologically assessed CC, AP, and transverse pituitary diameters, pituitary volume, or pituitary stalk displacement in patients with PES or ES have no bearing on the rates of hormonal disorders. Nonetheless, certain hormonal disorders may be more common in patients with ES, which suggests a need for hormone-level assessments in this population.

Asymptomatic Empty Sella: A Literature Review and Suggestions for Evaluation in Clinical Practice

Empty sella (ES) is a radiographic finding defined by the presence of cerebrospinal fluid in the sella turcica, with associated compression of the pituitary gland. Empty sella syndrome (ESS) is the combination of this radiographic finding with endocrine, ophthalmological, and/or neurological symptoms. The focus of this literature review is to synthesize information about asymptomatic or incidental ES specifically, meaning the radiologic finding of an empty sella without symptoms. This condition is typically discovered incidentally through imaging when patients present with unrelated pathologies. Our intention is to strengthen the existing body of work on this clinical presentation and call for a standardized management protocol of ES. This literature review was performed in concordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). Data were extracted on paper characteristics, epidemiology, diagnostics, management, and outcomes. Overall, patients with radiographic findings of ES have a good prognosis. The majority of patients never become symptomatic (progression to ESS), and if symptoms do arise, they usually have little impact on quality of life. However, despite its inherent asymptomatic nature, given ES's estimated prevalence within society, the possibility of a critical underlying pathology, and the potential for subsequent development of consequential symptoms, this paper calls for the implementation of a standardized management protocol. We suggest that all patients with this finding and an unidentified underlying etiology, at a minimum, receive an endocrine panel for evaluation of pituitary function and a referral to ophthalmology for formal assessment of papilledema. We then recommend tailored management and referrals based on the results of these evaluations, as well as treatment of any subsequent symptomatology. While these are our recommendations based on a thorough review of the literature, further studies are necessary to reach a consensus on best clinical practices.

Arginine vasopressin deficiency (central diabetes insipidus) with partial empty sella: a case report

BACKGROUND

Arginine vasopressin deficiency (central diabetes insipidus) is defined as a reduction in the release of arginine vasopressin (AVP) resulting in a variable degree of polyuria. Partial empty sella refers to an enlarged sella turcica that is not completely filled by pituitary gland. It can be either primary or secondary and its manifestation ranges from asymptomatic cases to isolated posterior pituitary, isolated anterior pituitary or both anterior and posterior pituitary dysfunctions. Diabetes insipidus caused by a partially empty sella is rare.

CASE PRESENTATION

The patient, an 18-year-old Ethiopian woman who presented with long standing headache, increased urination, increased thirst, absence of menses and weight loss. Urine and serum osmolality was done and suggested diabetes insipidus. On further workup, brain magnetic resonant imaging was done and partially empty sella was diagnosed.

CONCLUSION

Diabetes insipidus secondary to partially empty sella is uncommon. In patients presenting with headache and anterior or posterior pituitary dysfunction, empty sella should be considered, whether partial or complete.

A Comprehensive Review of Empty Sella and Empty Sella Syndrome

OBJECTIVE

Incidental radiographic findings of an empty sella are prevalent in up to 35% of the general population. While empty sella was initially considered clinically insignificant, a subset of patients exhibits endocrine or neuro-ophthalmologic manifestations which are diagnostic of empty sella syndrome (ESS). Recent studies suggest that more patients are affected by ESS than previously recognized, necessitating a deeper understanding of this condition. This comprehensive review describes a practical approach to evaluating and managing ESS.

METHODS

Literature review was conducted on etiologies and risk factors associated with primary and secondary empty sella, the radiologic features that differentiate empty sella from other sellar lesions, and the role of clinical history and hormone testing in identifying patients with ESS, as well as treatment modalities.

RESULTS

Pituitary function testing for somatotroph, lactotroph, gonadotroph, corticotroph, and thyrotroph abnormalities is necessary when suspecting ESS. While an isolated empty sella finding does not require treatment, ESS may require pharmacologic or surgical interventions to address hormone deficits or intracranial hypertension. Targeted hormone replacement as directed by the endocrinologist should align with guidelines and patient-specific needs. Treatment may involve a multidisciplinary collaboration with neurology, neurosurgery, or ophthalmology to address patient symptoms.

CONCLUSION

This review underscores the evolving understanding of ESS, stressing the significance of accurate diagnosis and tailored management to mitigate potential neurologic and endocrine complications in affected individuals.

Empty Sella in Neuro-Ophthalmology Patients Without Raised Intracranial Pressure

BACKGROUND

Empty sella often supports a diagnosis of raised intracranial pressure (ICP) but is also seen in normal individuals. This study's objective was to determine the prevalence of empty and partially empty sella in neuro-ophthalmology patients undergoing MRI for indications other than papilledema or raised ICP.

METHODS

Consecutive patients without papilledema or suspected raised ICP who underwent brain MRI between August 2017 and May 2021 were included in this study. Sagittal T1 images were evaluated by 2 independent, blinded neuroradiologists who graded the sella using the published criteria (Categories 1-5, with 1 being normal and 5 showing no visible pituitary tissue). Clinical parameters were also collected.

RESULTS

A total of 613 patients (309 men; average age 56.69 ± 18.06 years) were included in this study with optic neuropathy as the most common MRI indication. A total of 176 patients had moderate concavity of the pituitary gland (Category 3), 81 had severe concavity (Category 4), and 26 had no visible pituitary tissue (Category 5). Sella appearance was mentioned in 92 patients' radiology reports (15%). There was a statistically significant difference in age between composite Categories 1 and 2 (mean 52.89 ± 18.91; P < 0.001) and composite Categories 4 and 5 (mean 63.41 ± 15.44), but not the other clinical parameters.

CONCLUSION

Empty sella is common in neuro-ophthalmology patients without raised ICP; 17.4% of patients have severe concavity or no pituitary tissue visible. An isolated finding of empty or partially empty sella on imaging is therefore of questionable clinical value in this patient population.

Approach to a case with an unusual cause of hypopituitarism

Hypopituitarism refers to insufficiency of one or more hormones of the pituitary and can be due to myriad causes. The clinical and radiological spectrum of the condition is heterogeneous, based on the age, gender, clinical setting and/or other past medical history. Hypopituitarism includes central hypocortisolism, hypothyroidism, hypogonadism and growth hormone deficiency. Both hypo- and hyperprolactinemia can be associated with hypopituitarism, with low prolactin signifying more extensive pituitary damage. Posterior pituitary insufficiency (arginine vasopressin deficiency), occurs either in isolation or with anterior pituitary hormone deficiency. Clinical symptomatology of hypopituitarism is usually non-specific and insidious in onset and progression. Overall, the most common cause of hypopituitarism is a pituitary adenoma and/or its management (surgery, radiotherapy, pharmacotherapy or a combination of these). However, it is this subset of patients which is more likely to be identified and managed timely, possibly alleviating the premature mortality associated with hypopituitarism. What is more challenging is the recognition of hypopituitarism in less common settings, which may be either due to direct involvement of the pituitary (infection, traumatic brain injury, or infiltrative causes) or indirectly as a consequence of the primary process (thalassemia, vasculotoxic snakebite, subarachnoid hemorrhage). These entities are often under-recognised, and increased awareness can help in greater recognition of the problem burden. Further, pituitary insufficiency in most of these settings is dynamic, which may progress, or rarely, show recovery of function. This renders complexity to the problem, but makes it even more imperative to suspect, screen and appropriately manage patients with less common causes of hypopituitarism.

An Overview of Pituitary Incidentalomas: Diagnosis, Clinical Features, and Management

Simple Summary

A pituitary incidentaloma is a pituitary tumor or mass that is incidentally discovered in imaging studies which have been performed for reasons other than the symptoms of pituitary lesions. The majority of pituitary incidentalomas are pituitary neuroendocrine tumors (PitNETs) and Rathke cleft cysts. PitNETs have received attention because of their distinction from pituitary adenoma in the new World Health Organization (WHO) classification. The natural history of PitNETs is partially known, and the management of pituitary incidentalomas has been determined based on this history; however, the pathology of PitNETs has significantly changed with the new WHO classification, and studies with a high level of evidence are required to consider treatment guidelines for pituitary incidentalomas.

Abstract

Pituitary incidentalomas are tumors or mass lesions of the pituitary gland. These are incidentally discovered during imaging studies for symptoms that are not causally related to pituitary diseases. The most common symptom that triggers an examination is headache, and the most common type of pituitary incidentalomas are pituitary neuroendocrine tumors (PitNETs) and Rathke cleft cysts. The existing treatment strategy is controversial; however, surgical resection is recommended in cases of clinically non-functioning PitNETs with optic chiasm compression. In contrast, cystic lesions, such as Rathke cleft cysts, should be followed if the patients are asymptomatic. In this case, MRI and pituitary function tests are recommended every six months to one year; if there is no change, the follow-up period should be extended. The natural history of PitNET is partially known, and the management of pituitary incidentalomas is determined by this history. However, the pathogenesis of PitNET has significantly changed with the new World Health Organization classification, and follow-up is important based on this new classification. Therefore, a high level of evidence-based research is needed to consider treatment guidelines for pituitary incidentalomas in the future.

Pituitary incidentaloma

Pituitary incidentalomas (PI) are lesions of the pituitary region discovered fortuitously by imaging for reasons unrelated to pituitary disease. They range from small cysts to large invasive adenomas. All over the world, improvements in the quality and availability of radiological examinations are leading to an increase in the discovery of PI. In the last four decades, significant advances have been made in the understanding of PI. Autopsy studies have shown that about 10% of deceased individuals harbour a PI, most often a non-functioning microadenoma. In contrast, modern patient series showed that among PIs that come to endocrinological attention, a significant proportion are macroadenomas, and many patients suffer from asymptomatic or pauci-symptomatic endocrine or ophthalmologic disturbances. Other than adenomas, empty sella, Rathke's cleft cyst, craniopharyngioma and meningioma are the most frequent types of PIs. About 10% of micro-incidentalomas and 25% of macro-incidentalomas grow over time. Most cases can be managed conservatively by mere surveillance. Follow-up is necessary in all patients with macroadenoma, but uncertainty remains for microadenomas as to the extent of endocrinological work-up as well as the necessity and duration of follow-up. Visual and endocrine anomalies constitute the most common indications for surgery. When needed, surgery yields better outcome in PIs than in symptomatic pituitary lesions.

Empty Sella Prevalence: Step By Step

An empty sella (ES), also known as an empty sella turcica (empty pituitary fossa) is defined as an intrasellar herniation of subarachnoid space within the sella which leads to flattening of the pituitary gland towards the posteroinferior wall. Purpose — to analyze studies of ES prevalence in the world. Methods — We carried out a systematic search in both Russian and English databases (E-library, PubMed, GoogleScholar, OxfordPress, ClinicalKeys) using keywords “empty sella”, “empty sella turcica”, “empty pituitary fossa”, “prevalence” and their combinations. The period of search: 2000-2020. It is also worth noting that earlier publications of historical interest were included in the review. Results — We have analyzed 23 studies. They can be roughly devided into two groups: the first group – screening studies of ES, the second group – targeted studies of ES.

Primary hypothalamic lymphoma with clinical findings mimicking pituitary apoplexy: a case report

BACKGROUND

Primary central nervous system lymphoma (PCNSL) is a rare but well-known extra-nodal lymphoma, which usually presents with non-Hodgkin B-cell lymphomas. PCNSL is generally located around the ventricle and is often detected as multiple lesions. It is rarely seen in the area of the hypothalamus.

CASE PRESENTATION

We report the case of a 48-year-old Caucasian woman with progressive short-term memory deterioration, headache, mental confusion, diabetes insipidus (DI) and hypopituitarism. Early findings were suggestive of a pituitary apoplexy. The results of tests performed during the initial admission at the tertiary health center revealed hypernatremia, hypopituitarism and DI. Intravenous hydrocortisone treatment was initiated for the secondary adrenal insufficiency, and 75 mcg/day of levothyroxine was started for the secondary hypothyroidism on the fourth day following hydrocortisone treatment. A daily dose of 120 mg desmopressin melt tablet was started twice a day for polyuria/polydipsia after the patient's volume status was balanced. A brain magnetic resonance imaging scan revealed a mass lesion in the hypothalamic area, which was surrounded by marked edema. Anti-edema treatment was initially started considering the suggestion by our neurosurgery team. The patient's clinical and laboratory findings improved after the initiation of the anti-edema therapy. Afterwards, a biopsy was performed, which diagnosed a malignant diffuse large B-cell lymphoma. Subsequently, intravenous high-dose methotrexate-based therapy was started; however, after the second cycle of chemotherapy, the patient died due to sepsis.

CONCLUSION

In this report, we present a case of hypopituitarism that developed due to the mass effect of hypothalamic lymphoma with clinical findings of pituitary apoplexy. Intracranial masses may cause obvious endocrinological findings related to hypopituitarism, while vague findings may also be observed due to partial failure. Therefore, it is important to perform a comprehensive endocrinological examination at the time of diagnosis in patients with intracranial masses.

Primary empty sella: The risk factors and associations with the cerebral small vessel diseases-An observational study

OBJECTIVE

To investigate the risk factors of primary empty sella (PES) and its associations with cerebral small vessel diseases (CSVD).

METHODS

A total of 132 consecutive patients were recruited from Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University from December 2018 to January 2020, including 69 cases of PES, and age, gender-matched 63 subjects without PES. Demographics and clinical characteristics were recorded. Enlarged perivascular spaces (PVS) and white matter hyperintensities (WMH), which are image markers for CSVD, were assessed. Univariate logistic regression models and multivariate logistic regression models were performed to predict the independent risk factors of PES.

RESULTS

There was a significant difference in baseline characteristics in terms of hypertension (p < 0.001) and pregnancy (p = 0.019) between PES and the control group; among markers of CSVD, whole WMH (p = 0.030) and periventricular hyperintensities (PVH) (p = 0.027) were significantly different; however, no significant differences concerning deep WMH, total PVS, basilar ganglia-PVS and centrum semiovale-PVS (p > 0.05). After adjusting relevant potential confounders, multivariate logistic regression revealed hypertension (OR=3.158, 95 %CI: 1.452∼6.865, p = 0.004) and pregnancy (OR=2.236, 95 %CI: 1.036-4.826, p = 0.040) were independent risk factors for PES.

CONCLUSION

Hypertension and pregnancy are independent risk factors of PES. There is a possible correlation between PES and WMH, especially PVH, however, further studies are required to confirm these findings.

Dealing With Brain MRI Findings in Pediatric Patients With Endocrinological Conditions: Less Is More?

Neuroimaging is a key tool in the diagnostic process of various clinical conditions, especially in pediatric endocrinology. Thanks to continuous and remarkable technological developments, magnetic resonance imaging can precisely characterize numerous structural brain anomalies, including the pituitary gland and hypothalamus. Sometimes the use of radiological exams might become excessive and even disproportionate to the patients' medical needs, especially regarding the incidental findings, the so-called "incidentalomas". This unclarity is due to the absence of well-defined pediatric guidelines for managing and following these radiological findings. We review and summarize some indications on how to, and even if to, monitor these anomalies over time to avoid unnecessary, expensive, and time-consuming investigations and to encourage a more appropriate follow-up of brain MRI anomalies in the pediatric population with endocrinological conditions.