![]() ![]() In most cases, the pituitary function is normal (despite the abnormal appearance of the pituitary gland), but in some cases (around 20%), any, or all, of the pituitary hormone levels can be affected. Testing of the entire pituitary axis is appropriate and highly recommended in patients with empty sella syndrome after diagnosis however, there is currently a lack of society-based guidelines. In recent case reports, there have been rare patient presentations with unusual symptoms and signs, like hyponatremia, acromegaly, and mental problems like dementia. ![]() If the pituitary function is compromised, history and physical exam can be consistent with any or all pituitary hormone deficiencies. Įndocrine abnormalities are present in less than 20% of cases of empty sella. Spontaneous cerebrospinal fluid rhinorrhea is possible, as is visual field impairment however, both of these presentations are rare. Other authors consider the possibility that increased intracranial pressure and possible herniation cause headaches however, no confirmation of this theory exists either. Many experts believe that the association exists because the headache of any unrelated cause prompted imaging of the head, leading to the incidental discovery of the empty sella. There is a lack of evidence to support ESS as the cause of the headache. The most common symptom associated with ESS is a headache. History and physical exam are typically normal in patients with empty sella syndrome because the endocrine function is usually intact. It could be the result of treating a pituitary adenoma (by either drugs, surgery, or radiotherapy), spontaneous regression of the pituitary gland under different circumstances, postpartum pituitary necrosis (also known as Sheehan syndrome), or lymphocytic hypophysitis. SES, on the other hand, is much more common than PES. Examples include a normal increase in pituitary volume during pregnancy and lactation and then spontaneous regression in pituitary volume during menopause in women. The last proposed mechanism causing empty sella involves an initial enlargement of the pituitary gland followed by a later decrease in gland size, creating an empty space where CSF can accumulate. The resolution of empty sella on imaging after treatment of intracranial hypertension illustrated further evidence that intracranial hypertension can cause empty sella. Many different pathologies causing increased CSF pressures have correlations with PES, including brain tumors, idiopathic intracranial hypertension (pseudotumor cerebri), intracranial thrombosis, and hydrocephalus. The most common neuroimaging finding in patients with idiopathic intracranial hypertension (also known as pseudotumor cerebri) is empty sella. Intracranial hypertension is also thought to increase the likelihood of herniation of CSF into the sella turcica, especially if the diaphragma sellae is already compromised. ![]() The anomalous diaphragma sellae allows the accumulation of cerebrospinal fluid (CSF) into the sella turcica, causing remodeling and enlargement of the sella turcica as well as flattening of the pituitary gland. Incompetent diaphragma sellae has been the finding in the vast majority of PES in autopsy reports. Currently, its cause is not entirely understood, but researchers have proposed several mechanisms, including incompetence or complete absence of the diaphragma sellae, chronic intracranial hypertension, small vessel disease, and temporary expansion followed by regression of the pituitary gland. PES is the less common of the two entities. As stated above, empty sella syndrome falls into two categories: primary empty sella syndrome and secondary empty sella syndrome. ![]()
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