---
title: "Empty Sella"
docid: "39a0d2d1-1439-4558-8f5d-86a2a6d93e3a"
authors:
- key: "5cff4116-3654-4b3a-bb75-5ebe0b8c9850"
value: "Anne G. Osborn, MD, FACR"
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name: "Brain"
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slug: "diagnosis"
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slug: "anatomy-based-diagnoses"
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slug: "sella-and-pituitary"
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slug: "miscellaneous"
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name: "Empty Sella"
slug: "empty-sella"
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documentVersionId: "91612570-e8d2-417b-8345-8226e2028fbf"
imageCount: 18
lastUpdated: "08/10/20"
pageDescription: "Empty Sella"
pageKeywords: "Brain, Diagnosis, Anatomy-Based Diagnoses, Sella and Pituitary, Miscellaneous, Empty Sella"
pageTitle: "Empty Sella | STATdx"
enhancedTitle: "Empty Sella"
type: "DX"
references: true
breadcrumbs:
- "Brain"
- "Diagnosis"
- "Anatomy-Based Diagnoses"
- "Sella and Pituitary"
- "Miscellaneous"
- "Empty Sella"
---
# KEY FACTS
- ## Terminology
- Sella partially filled with arachnoid-lined CSF collection
- Primary empty sella
- Common normal variant (15% of brain MRs), incidental finding
- Normal or increased CSF pressure
- Near-normal volume of compressed pituitary tissue
- Secondary empty sella
- Prior pituitary surgery, radiation, or injury
- ## Imaging
- Intrasellar CSF, pituitary flattened against sellar floor
- Bony sella may be normal or moderately enlarged (secondary to pulsatile CSF)
- Bony margins intact, not eroded/demineralized
- Infundibular stalk, pituitary gland enhance normally
- Fluid exactly like CSF
- Suppresses completely on FLAIR
- Does not restrict on DWI
- ## Top Differential Diagnoses
- Idiopathic intracranial hypertension
- Secondary intracranial hypertension
- Arachnoid cyst
- Pituitary apoplexy
- Pituitary anomalies
- ## Pathology
- "Deficient" diaphragma sellae
- Dural covering of sella is incomplete (widened)
- Leaves large opening for infundibular stalk
- Allows intrasellar herniation of arachnoid with CSF from suprasellar subarachnoid cistern above
- ## Clinical Issues
- Mostly incidental, asymptomatic (adults)
- F:M = 5:1
- Headache, visual disturbances if related to intracranial hypertension
- Frequent endocrine abnormalities in children
# TERMINOLOGY
- ## Abbreviations
- Empty sella (ES)
- ## Definitions
- Herniation of suprasellar arachnoid and cerebrospinal fluid (CSF) through wide diaphragma sellae into bony sella turcica
- Sella turcica is partially filled with CSF
- Rarely completely empty
- Pituitary gland
- Almost never completely absent
- Thin, flattened rim of residual pituitary tissue
- Generally at posteroinferior sellar floor
- Primary or secondary
- Primary empty sella
- Common normal variant (15% of brain MRs), incidental finding
- Normal or increased CSF pressure
- Near-normal volume of compressed pituitary tissue
- No history of trauma, surgery, radiation
- Patients typically endocrinologically normal
- Secondary empty sella
- Many etiologies
- Surgery
- Radiation
- Bromocriptine therapy
- Trauma
- Sheehan syndrome (postpartum pituitary necrosis)
- Pituitary apoplexy
- Pituitary abscess
# IMAGING
- ## General Features
- ### Best diagnostic clue
- Intrasellar CSF with pituitary gland flattened against sellar floor
- Bony sella may be normal or large
- ### Location
- Intrasellar CSF
- ### Size
- Variable
- ## Imaging Recommendations
- ### Best imaging tool
- Sagittal T1WI
- Coronal T2WI
- ## CT Findings
- ### NECT
- CSF-like herniation of CSF into bony sella
- Bony sella typically appears normal
- May also be moderately enlarged (secondary to pulsatile CSF)
- Bony margins intact, not eroded/demineralized
- ### CECT
- Infundibular stalk and pituitary gland enhance normally
- Occasionally intrasellar CSF collection may be asymmetric
- Stalk may appear tilted to one side
- ## MR Findings
- ### T1WI
- Primary empty sella
- Fluid looks exactly like CSF
- Stalk usually midline
- Gland + stalk = anchor sign on coronal imaging
- Stalk may be tilted to one side if intrasellar CSF herniation is asymmetric
- 3rd ventricle, hypothalamus usually normal
- Rare: Herniation of optic chiasm, anterior 3rd ventricle into sella
- Secondary empty sella
- Look for changes of transsphenoidal hypophysectomy
- Defect in sellar floor
- Fat packing
- May cause distortion of stalk, chiasm
- Stalk and pituitary remnant(s) may be scarred/adhesed to side or bottom of sella turcica
- ### T2WI
- Fluid exactly like CSF
- ### FLAIR
- Intrasellar fluid suppresses completely on FLAIR
- ### DWI
- No restriction
- ### T1WI C+
- Primary empty sella
- Stalk, gland enhance normally
- No other abnormalities
- Secondary empty sella
- Gland and stalk may be adhesed/distorted
# DIFFERENTIAL DIAGNOSIS
- [Idiopathic Intracranial Hypertension](/document/idiopathic-intracranial-hypertensi-/d7a0a1b6-1d94-473c-9fe9-021443969f9f)
- Often not truly "idiopathic" (e.g., dural venous sinus stenosis)
- Usually obese female, 20-40 years
- Headache, papilledema
- Intraoptic protrusion of optic nerve head
- Enlarged optic nerve sheaths ± empty sella
- Ventricles may appear slit-like
- Subarachnoid spaces (cisterns, surface sulci) may be small
- ## Secondary Intracranial Hypertension
- Increased intracranial pressure caused by
- Obstructive hydrocephalus (intra-/extraventricular)
- Mass (neoplasm, etc.)
- Dilated anterior recesses of 3rd ventricle herniate into sella
- Look for mass, evidence for transependymal CSF migration
- [Arachnoid Cyst](/document/arachnoid-cyst/d25aaeb3-5b3c-4483-99dc-2757468eedb9)
- Suprasellar arachnoid cyst may herniate into bony sella
- Bony sella often enlarged, eroded/expanded
- Look for 3rd ventricle or optic chiasm displaced by CSF-containing mass
- Cyst walls may be visible on thin-section imaging
- [Pituitary Apoplexy](/document/pituitary-apoplexy/43efc995-d33c-4ac1-be70-e3237eec9fc9)
- Acute: Pituitary gland usually enlarged, not small
- Usually hemorrhagic
- Look for rim enhancement around periphery of enlarged, nonenhancing gland
- Chronic: May cause empty sella
- [Pituitary Anomalies](/document/pituitary-anomalies/09ca9b54-a3d9-43fd-a9cc-4c0212b578a1)
- Ectopic posterior pituitary "bright spot"
- May cause small pituitary gland
- Infundibular stalk short, "stubby"
- Bony sella often small, shallow appearing
- Sella can appear partially empty
- Persisting embryonal infundibular recess of 3rd ventricle
- Can mimic empty sella (rare)
- Pituitary stalk duplication
- Rare
- Look for 2 thin stalks
- Sella may appear partially empty
- [Sheehan Syndrome](/document/pituitary-apoplexy/43efc995-d33c-4ac1-be70-e3237eec9fc9)
- Original clinical description
- Postpartum hemorrhage
- Pituitary necrosis
- Lactation failure
- Hypopituitarism
- Anterior pituitary necrosis
- Leaves small residual pituitary gland
- Result = empty sella
- May occur years after pregnancy
- Slow clinical progression over years suggests factors other than ischemia may be involved
- Necrosis may be caused by antihypothalamus, antipituitary antibodies
- Pituitary autoimmunity may perpetuate hypopituitarism
- [Epidermoid Cyst](/document/epidermoid-cyst/704c5ddf-e1f7-4a5d-a1b8-5b0e603170d9)
- True intrasellar epidermoid cyst very rare
- Off midline > midline
- Usually extension from cerebellopontine angle epidermoid
# PATHOLOGY
- ## General Features
- ### Etiology
- Primary empty sella
- Deficient diaphragma sellae
- Dural covering of sella is incomplete (widened)
- Leaves widened dural opening for infundibular stalk
- Allows intrasellar herniation of arachnoid with CSF from suprasellar subarachnoid cistern above
- Compresses pituitary gland against sellar floor
- Traction on infundibular stalk may cause alteration in visual system
- Pulsatile CSF may gradually enlarge sella
- Secondary empty sella
- Common: Surgery, bromocriptine therapy, radiation
- Less common: Pituitary apoplexy, pituitary abscess
- Rare: Pituitary necrosis in viral hemorrhagic fever (e.g., hanta)
- ## Gross Pathologic & Surgical Features
- Diaphragma sellae appears widened, gaping
- Intrasellar herniation of arachnoid-containing CSF
# CLINICAL ISSUES
- ## Presentation
- ### Most common signs/symptoms
- Incidental, usually asymptomatic
- Headache
- Visual disturbances 1-15%
- Idiopathic intracranial hypertension (IIH)
- Optic chiasm herniation into ES may cause visual symptoms
- Endocrine disturbances
- 20% of adults have subtle laboratory abnormalities
- Majority (70%) of children with ES have endocrine abnormalities
- ## Demographics
- ### Age
- Peak incidence between 50-60 years
- Increased CSF pressure presents earlier (30-40 years)
- ### Sex
- F:M = 5:1
- ### Epidemiology
- 10-15% found incidentally on imaging
- ## Natural History & Prognosis
- Both primary and secondary empty sella usually benign, do not require treatment
- If related to IIH, can result in vision loss or CSF leak
- Hormonal replacement therapy may be required in some cases
- Surgery (rare)
- "Chiasmapexy" to elevate optic chiasm if severe visual disturbances caused by inferior displacement of optic chiasm into empty sella
- CSF rhinorrhea may require surgical intervention
# DIAGNOSTIC CHECKLIST
- ## Consider
- Incidental, normal variant in older adults
- Additional findings of IIH in younger females (e.g., dilated optic nerve sheaths, papilledema, dural venous sinus narrowing)
- Look for endocrine abnormalities in children
- ## Image Interpretation Pearls
- Intrasellar fluid follows CSF **exactly**on all sequences
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## References
# Selected References
1. [Byrne N et al: Symptomatic primary tethered optic chiasm: Technical case report. Oper Neurosurg (Hagerstown). ePub, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32386310%5Bpmid%5D)
1. [Chen H et al: A case report of empty Sella syndrome secondary to Hantaan virus infection and review of the literature. Medicine (Baltimore). 99(14):e19734, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32243412%5Bpmid%5D)
1. [Guinto G et al: Osseous remodeling technique of the sella turcica: a new surgical option for primary empty sella syndrome. World Neurosurg. 126:e953-8, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30877013%5Bpmid%5D)
1. [Kirigin Biloš LS et al: Empty sella in the making. World Neurosurg. 128:366-70, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31128314%5Bpmid%5D)
1. [Rehder D: Idiopathic intracranial hypertension: Review of clinical syndrome, imaging findings, and treatment. Curr Probl Diagn Radiol. ePub, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31056359%5Bpmid%5D)
1. [Seo YS et al: Bitemporal hemianopsia associated with empty sella syndrome. J Craniofac Surg. 30(8):2660-1, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31449212%5Bpmid%5D)
1. [Atci IB et al: Prognosis of hormonal deficits in empty sella syndrome using neuroimaging. Asian J Neurosurg. 13(3):737-41, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=30283536%5Bpmid%5D)
1. [Auer MK et al: Primary empty sella syndrome and the prevalence of hormonal dysregulation. Dtsch Arztebl Int. 115(7):99-105, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29510819%5Bpmid%5D)
1. [Barzaghi LR et al: Treatment of empty sella associated with visual impairment: a systematic review of chiasmapexy techniques. Pituitary. 21(1):98-106, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29027644%5Bpmid%5D)
1. [Chiloiro S et al: Diagnosis of endocrine disease: Primary empty sella: A comprehensive review. Eur J Endocrinol. ePub, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28780516%5Bpmid%5D)
1. [Kyung SE et al: Enlargement of the sella turcica in pseudotumor cerebri. J Neurosurg. 120(2):538-42, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24313606%5Bpmid%5D)
1. [Saindane AM et al: Factors determining the clinical significance of an "empty" sella turcica. AJR Am J Roentgenol. 200(5):1125-31, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23617499%5Bpmid%5D)
## Images
### Selected Images
flattens and displaces the pituitary gland 
posteroinferiorly against the sellar floor.](images/app.statdx.com_image_thumbnail_6004ed79-2fa0-49f7-940c-bd93c8468a05_size_168_quality_85_f648e337_20251014T204947Z.jpg)
*Sagittal graphic shows an empty sella (ES). The extension of arachnoid with CSF through the diaphragma sellae flattens and displaces the pituitary gland posteroinferiorly against the sellar floor.*
*Sagittal graphic shows an empty sella (ES). The extension of arachnoid with CSF through the diaphragma sellae flattens and displaces the pituitary gland posteroinferiorly against the sellar floor.*
. The pituitary gland appears flattened along the sellar floor and a posterior pituitary "bright spot" is absent.](images/app.statdx.com_image_thumbnail_f16f23ba-0444-41be-a643-31d4421376f1_size_168_quality_85_17ebc893_20251014T204947Z.jpg)
*Sagittal T1 MR in a 59-year-old woman with blurry vision and a primary hypopituitarism shows an enlarged, mostly CSF-filled sella turcica . The pituitary gland appears flattened along the sellar floor and a posterior pituitary "bright spot" is absent.*
compressed against the expanded sellar floor. The infundibulum is kinked over the dorsum sellae .](images/app.statdx.com_image_thumbnail_497bac8b-b19c-47fb-9f2e-73b3c20c7db8_size_168_quality_85_287c11b8_20251014T204947Z.jpg)
*Sagittal T1 C+ FS MR in the same patient shows a thin rim of enhancing pituitary gland compressed against the expanded sellar floor. The infundibulum is kinked over the dorsum sellae .*
*Coronal T2 MR in the same patient shows the expanded sella has a thin rim of compressed pituitary gland lining the sellar floor . The sella is filled with CSF exactly the same signal intensity as the fluid in Meckel caves and lateral ventricles. The diagnosis was primary ES.*
*Sagittal T1 MR shows an incidental finding of a partially ES .*
*Coronal T1 C+ MR shows the enhancing infundibular stalk and pituitary gland . This configuration with the stalk in the midline and a curvilinear pituitary gland has been called the anchor sign because of its resemblance to a ship's anchor .*
.](images/app.statdx.com_image_thumbnail_b128cfaf-e8be-44d2-bde3-997afb4245e8_size_168_quality_85_e5a5e2b9_20251014T204947Z.jpg)
*Sagittal T1 MR shows a 40-year-old man with an incidentally found partially ES. No endocrine laboratory abnormalities were reported. Notice the enlarged, bony sella with thin rim of pituitary tissue .*
is present in the midline.](images/app.statdx.com_image_thumbnail_d9289536-d0de-4c2b-9553-2983a5375758_size_168_quality_85_97f163d7_20251014T204947Z.jpg)
*Axial T2 MR in the same patient shows the bony sella is expanded and filled with CSF . A normal pituitary infundibulum is present in the midline.*
*Sagittal T1 C+ FS MR shows an ES secondary to surgery for pituitary macroadenoma. There is little pituitary tissue apparent along the enlarged sellar floor .*
retracted downward toward the sella.](images/app.statdx.com_image_thumbnail_adb74bf5-9d6c-4d1a-9d19-a37df5eb661e_size_168_quality_85_9eebf5fc_20251014T204947Z.jpg)
*Coronal T2 MR of a secondary ES in the same patient demonstrates that the sella is filled with CSF . Note the thinned optic chiasm retracted downward toward the sella.*
### Additional Images
*Axial gross pathology shows a primary empty sella found incidentally at autopsy. Note the wide opening of the diaphragma sellae and CSF largely filling the bony sella. (Courtesy M. Sage, MD.)*
into the sella. The pituitary gland is flattened against the sellar floor. (Courtesy W. Kucharczyk, MD.)](images/app.statdx.com_image_thumbnail_064b097f-a1e6-43cb-ace5-1f9286121aef_size_168_quality_85_241b06a6_20251014T204947Z.jpg)
*Low-power micropathology shows primary empty sella with downward herniation of CSF-filled subarachnoid space into the sella. The pituitary gland is flattened against the sellar floor. (Courtesy W. Kucharczyk, MD.)*
. The pituitary gland is flattened against the sellar floor in this patient with a primary empty sella.](images/app.statdx.com_image_thumbnail_48de841a-aa52-4a23-9d05-d3489b4332fd_size_168_quality_85_8d02aadd_20251014T204947Z.jpg)
*Coronal T2 MR at 3T shows CSF within the sella turcica surrounding the infundibular stalk . The pituitary gland is flattened against the sellar floor in this patient with a primary empty sella.*
*Sagittal T1 MR demonstrates a thinned pituitary gland along the floor of the mostly empty sella in a 34-year-old woman who had postpartum anterior pituitary gland necrosis (Sheehan syndrome) 10 years prior to imaging.*
*Coronal T2 MR in the same patient shows a thin, nearly inapparent pituitary gland remnant along the sellar floor . The history distinguishes Sheehan syndrome from an incidental finding of partial empty sella.*
*Sagittal T1 C+ MR shows a 71-year-old woman with a sellar and suprasellar arachnoid cyst mimicking an empty sella. Note the normally enhancing pituitary infundibulum and pituitary tissue displaced anteriorly by the CSF intensity arachnoid cyst.*
*Sagittal T2 MR in the same patient shows the lack of CSF flow artifact within the cyst compared to the flow within the suprasellar and interpeduncular cisterns .*
*Coronal T2 MR shows primary empty sella seen as incidental finding on screening IAC MR. The sella is filled with CSF and the pituitary gland is flattened against the sellar floor.*