Empty Sella Syndrome (ESS) is a radiographical finding characterized by the apparent absence of the pituitary gland within the sella turcica, often accompanied by the herniation of the suprasellar cistern into the sella. This condition can have significant implications for hypothalamic function due to the close anatomical relationship between the pituitary gland and the hypothalamic regulatory centers.
Related Conditions: Pituitary adenomas, Craniopharyngioma, Hypothalamic dysfunction, Hypopituitarism
The hypothalamus and pituitary gland maintain intimate structural and functional relationships:
- The median eminence serves as the interface between hypothalamic neurons and the pituitary portal system
- Releasing hormones from hypothalamic neurons travel via the portal circulation to the anterior pituitary
- The posterior pituitary is directly contiguous with hypothalamic nuclei (supraoptic and paraventricular)
Hypothalamic neurons regulate:
- Anterior pituitary hormone secretion via releasing/inhibiting hormones
- Posterior pituitary function through direct axonal projections
- Autonomic nervous system coordination
- Homeostatic mechanisms including temperature, hunger, thirst, and circadian rhythms
- Congenital defect in the diaphragma sellae
- May allow CSF pulsation to remodel the sella
- Often incidental finding with normal pituitary function
- Prior surgery or radiation therapy
- Pituitary infarction or necrosis
- Tumor-related gland destruction
- Sheehan syndrome (postpartum pituitary necrosis)
When pituitary function is compromised:
- Loss of negative feedback from peripheral hormones
- Dysregulation of hypothalamic releasing hormone secretion
- Potential hypothalamic neuronal changes due to altered hormonal environment
- Growth hormone deficiency: Fatigue, decreased muscle mass, increased adiposity
- Hypothyroidism: Cold intolerance, weight gain, fatigue
- Adrenal insufficiency: Orthostatic hypotension, fatigue, hypoglycemia
- Gonadal dysfunction: Infertility, decreased libido, menstrual irregularities
- Prolactin abnormalities: Galactorrhea or hypoprolactinemia
- Headaches (due to CSF dynamics)
- Visual disturbances (optic chiasm involvement)
- Cranial nerve palsies (rare)
- Cognitive difficulties
- Mood changes
- Reduced exercise tolerance
- MRI shows herniation of suprasellar cistern into sella
- Pituitary gland appears flattened against the sella floor
- May show partially empty sella with residual tissue
- Comprehensive pituitary hormone panel
- Dynamic testing (e.g., ACTH stimulation test)
- Evaluation of hypothalamic function
- Cortisol replacement (hydrocortisone)
- Thyroid hormone replacement
- Sex steroid therapy
- Growth hormone therapy (in selected cases)
- Rarely required for primary ESS
- Indicated for progressive visual loss
- CSF leak repair when present
- Regular endocrine follow-up
- Visual field testing when indicated
- MRI surveillance for structural changes
- Studies on hypothalamic neuronal plasticity in hypopituitarism
- Investigation of hypothalamic involvement in post-surgical syndromes
- Markers of hypothalamic dysfunction
- Predictors of endocrine recovery
- Empty sella syndrome: a review (Endocrine, 2019)
- Hypothalamic-pituitary axis dysfunction in ESS (Pituitary, 2020)
- Primary empty sella: clinical manifestations (JCEM, 2018)
- Management of hypopituitarism (Nature Reviews Endocrinology, 2021)
- Empty sella and quality of life (Endocrine-Related Cancer, 2019)