Empty Sella Syndrome

What It Is, Causes, Signs and Symptoms, and More

Author: Emily Miao, MD, PharmD

Editor: Alyssa Haag, MD

Editor: Ian Mannarino, MD, MBA

Editor: Kelsey LaFayette, DNP, ARNP, FNP-C

Illustrator: Abbey Richard, MSc

Copyeditor: David G. Walker

Modified: Mar 30, 2026

What is empty sella syndrome?

Empty sella syndrome (ESS) is a radiologic finding in which the sella turcica, a bony structure at the base of the brain that holds and protects the pituitary gland, appears abnormally filled with cerebrospinal fluid originating from the subarachnoid space. This can result in flattening and compression of the pituitary gland, potentially leading to loss of pituitary function.

There are two types of ESS: primary and secondary. Primary empty sella syndrome is characterized by a structural defect in the sella turcica with no identifiable underlying cause. Secondary ESS occurs as a consequence of another medical condition (e.g. pituitary surgery, radiation).

An infographic detailing empty sella syndrome.

What causes empty sella syndrome?

The causes of primary empty sella syndrome are poorly understood, though it is thought to occur due to an anatomical defect that causes CSF to leak into the sella turcica and flatten the pituitary gland, potentially causing deficiencies in one or more pituitary hormones (e.g. growth hormone). Primary empty sella syndrome most frequently occurs in adult genetic females and is associated with obesity and high blood pressure. Secondary ESS is thought to be caused by pre-existing conditions or external factors, including prior neurosurgery, prior radiation therapy to the head, or infarction. Neurosurgical interventions may damage or compromise nearby pituitary structures, leading to the accumulation of cerebrospinal fluid within the sella turcica and compression of pituitary tissue. Prior radiation therapy can also damage the pituitary tissue if these structures are within the radiation field. Radiation can cause partial or complete atrophy of the pituitary gland and subsequent loss of function. Additionally, infarction secondary to hypertensive disorders of pregnancy, such as eclampsia, can lead to ESS. Eclampsia is a life-threatening pregnancy-related complication characterized by the onset of seizures, high blood pressure, and evidence of end-organ damage (e.g. proteinuria) after the 20th week of gestation. Eclampsia causes vascular dysfunction and endothelial damage, which increases the risk of infarcts in the arteries supplying the pituitary gland.

What are the signs and symptoms of empty sella syndrome

Most people with empty sella syndrome are asymptomatic, meaning they do not experience any signs or symptoms. Among those who are symptomatic, symptoms of empty sella syndrome include headaches, vision changes, fatigue, unexplained changes in weight, and hormonal imbalances due to loss of pituitary function (e.g. irregular menstrual cycles, decreased libido).

How is empty sella syndrome diagnosed?

Diagnosis of empty sella syndrome is confirmed with brain imaging studies, such as computed tomography (CT scan) or magnetic resonance imaging (MRI). ESS is confirmed radiologically when imaging consists of cerebrospinal fluid filling the sella turcica and the remaining pituitary gland is flattened. On imaging, the total pituitary volume may be reduced while the sella turcica appears enlarged. The diagnosis of ESS is usually incidental, meaning diagnostic imaging was not initially performed for issues related to the pituitary gland. When ESS is detected on imaging, further review of symptoms and medical and surgical history is warranted. Adjunctive laboratory blood tests can provide information regarding pituitary hormones (e.g. growth hormone, prolactin), adrenal (e.g. cortisol), and thyroid function (e.g. free T4, TSH).

How is empty sella syndrome treated?

Treatment for ESS consists of supportive care measures aimed at reducing symptoms and improving the individual’s quality of life. A referral to an endocrinologist may be helpful for a comprehensive endocrine evaluation. If hormone imbalances are identified on blood tests, treatment is tailored to each individual using hormone or hormone analogue replacements. For example, individuals with adrenal insufficiency may receive cortisol replacement therapy, hyperprolactinemia can be treated with dopamine agonists (e.g. bromocriptine, cabergoline), and hypothyroidism is managed with thyroid hormone replacement therapy (e.g. levothyroxine). The prognosis of ESS is excellent with supportive treatment and individuals can expect to have a normal life expectancy comparable to that of the general population.

What are the most important facts to know about empty sella syndrome?

Empty sella syndrome is a radiologic finding characterized by the abnormal appearance of the sella turcica, which is a bony structure where the pituitary gland sits at the base of the brain. ESS is categorized into primary and secondary ESS. Primary empty sella syndrome is a condition characterized by a defect in the sella turcica that allows cerebrospinal fluid originating from the subarachnoid space to fill the sella turcica. Secondary ESS occurs secondary to another medical condition. Regardless of etiology, the pituitary gland is flattened and compressed, which results in loss of pituitary function. Symptoms of empty sella syndrome include headaches, vision changes, fatigue, unexplained weight changes, and hormonal imbalances. Diagnosis of empty sella syndrome is confirmed with computed tomography (CT scan) or magnetic resonance imaging (MRI). Treatment for ESS consists of supportive care measures and/or hormone replacement aimed at reducing symptoms and improving the individual’s quality of life.

Key Takeaways

Definition	Empty sella syndrome (ESS) is a radiologic finding in which the sella turcica, a bony structure at the base of the brain that holds and protects the pituitary gland, appears abnormally filled with cerebrospinal fluid originating from the subarachnoid space, which can result in compression of the pituitary gland.
Types	- Primary ESS → no identifiable underlying cause - Secondary ESS → underlying cause (e.g., pituitary surgery, radiation)
Causes	- Primary: probably anatomical defect → CSF leakage into sella turcica - Most common in: adult genetic females - Associated with obesity and hypertension - Secondary: pre-existing conditions or factors - Neurosurgery - Radiation therapy - Infarction
Signs and Symptoms	Mostly asymptomatic. If symptoms occur: - Headache - Vision changes - Fatigue - Unexplained changes in weight - Hormonal imbalances from loss of pituitary function
Diagnosis	- Brain imaging – usually incidental diagnosis - Reduced total pituitary volume + enlarged sella turcica - Review of symptoms and medical history - Blood tests (e.g., adrenal and thyroid function)
Treatment	- Supportive care - Endocrinological evaluation - Management of hormonal imbalances, e.g.: - Adrenal insufficiency → cortisol replacement therapy - Hyperprolactinemia → dopamine agonists - Hypothyroidism → thyroid hormone replacement therapy

References

Auer MK, Stieg MR, Crispin A, Sievers C, Stalla GK, Kopczak A. Primary empty sella syndrome and the prevalence of hormonal dysregulation. Dtsch Arztebl Int. 2018;115(7):99-105. doi:10.3238/arztebl.2018.0099

De Marinis L, Bonadonna S, Bianchi A, Maira G, Giustina A. Primary empty sella. J Clin Endocrinol Metab. 2005;90(9):5471-5477. doi:10.1210/jc.2005-0288

Kuo M, Maya MM, Bonert V, Melmed S. Prospective evaluation of incidental pituitary imaging findings in the sella turcica. J Endocr Soc. 2020;5(2):bvaa186. Published 2020 Nov 29. doi:10.1210/jendso/bvaa186

Zuhur SS, Kuzu I, Ozturk FY, Uysal E, Altuntas Y. Anterior pituitary hormone deficiency in subjects with total and partial primary empty sella: Do all cases need endocrinological evaluation? Turk Neurosurg. 2014;24(3):374-379. doi:10.5137/1019-5149.JTN.8671-13.0