VLOG: NeuroOp Guru: Isolated empty sella is not a sign of elevated ICP

Andrew Lee, MD, and Andrew Carey, MD, sit down on another episode of the NeuroOp Guru to discuss how isolated empty sella is not a sign of elevated ICP

Video Transcript

Editor's note - This transcript has been edited for clarity.

Andy Lee, MD:

Hello and welcome to another edition of NeuroOp Guru. I'm here with my good friend, Dr. Drew Carey. Hi, Drew.

Drew Carey, MD:

Hi Andy.

Andy Lee, MD:

And today we're going to be talking about isolated empty sella is not a sign of increased ICP. And Drew, I thought it was a sign of ICP. It's not?

Drew Carey, MD:

No, no, it's not. So very common finding among patients in classic literature. It's more associated with age in folks over age 50, maybe 30% of them have empty sella with no other concerns. But the radiologist always put in the report, empty sella, and may be a sign of IIH and please correlate clinically. So I think the big question for this paper was well, do we see it in patients who are not elderly, and do we have to be concerned about if we see it in the young person?

Andy Lee, MD:

And what was the answer?

Drew Carey, MD:

Well, so what they did is they included 613 consecutive patients seen in a neurophthalmology clinic who underwent an MRI and at their neuroophthalmic visit, they had no papilledema and no other concerns for elevated intracranial pressure. And they got two neuroradiologist who were masked to patients diagnoses to review the MRIs, and they used a pretty standard validated grading system. Category one through five, where one is normal, and five is no visible pituitary tissue, or really big sella. And in these patients, they categorize them by age as well to take a look, you know, young versus older patients. And while the mean age did increase among the patients as their category or empty sulla-ness increased, it was very common to see patients with empty sella at all categories, among all the age groups,. Category one in our our pie chart is this blue group. Category Two was the most common, which is this orange slice,. Category three, category four, and category five. So category five, which is, you know, no visible pituitary tissue was the least common, which you would expect for the most severe grading scale, it still could be present among these patients who had normal neurophthlamic exams and no signs or symptoms of elevated intracranial pressure.

Andy Lee, MD:

So do you think that the severity matters, or is this study showing it doesn't matter whether it's moderate, severe or no tissue? It's so common, don't use that?

Drew Carey, MD:

I think as an isolated finding, it does not matter. And we've seen this in other papers, you know, where they they looked at how many findings suggested of elevated ICP do you need, you know, to have specificity? And the answer is, you know, three out of four, four out of five, depending on what you're looking at. Including, and other papers have said, well, what's the most specific or most concerning finding, and that's vertical optic nerve sheath tortuosity. Posterior globe flattening, you know, is also very highly specific, although not in isolation. And you really need multiple findings, the empty sella is a big one, and [inaudible] of stenosis, particularly at the transverse sphenoid sigmoid junction. So I think in isolation, nobody should be freaking out about any of those findings. If you're seeing multiple findings, you know, three or four, you could throw in, you know, dissent of the cerebellar tonsils.

Andy Lee, MD:

You think we should be telling the radiology, don't put that anymore? Or don't send us these anymore? Or what should we be telling him?

Drew Carey, MD:

You know, I think that's a really hard question, because you definitely don't want to miss a patient who has papilledema from IIH, because that can be vision threatening, and in a small group of patients leads to blindness. So we do want them, the neuroradiologist, to think about it. It would be nice if they could say, you know, this is an isolated finding this is low risk, you know, or if they said, you know, there were other associated findings. And in this patient, you know, you really do have to think about that. I also think it's a different scenario if somebody's getting an outpatient MRI for migraine, versus somebody's in the emergency room.

Andy Lee, MD:

So what we've been doing is we don't refuse these consults, but I'm letting general ophthalmology see them to rule out papilledema and I personally have said they don't need a neuro-oph exam just for this.

Drew Carey, MD:

I agree. 100%. With that, I don't think we have enough neuro-ophthalmologists in the country to be doing eye exams for this and I think a regular eye doctor, you know, somebody who's you know, used to doing dilated eye exams and you know, an optometrist and ophthalmologist can look at a patient and say normal or not normal and and if there's a question they can get an OCT and ask for help. And that's what we're here for.

Andy Lee, MD:

So what do you think the take home message from this paper is for our audience?

Drew Carey, MD:

So for our audience, so if you're a general ophthalmologist, and you've ordered an MRI, for any, any reason, other than papilledema, you think the patient has proptosis, you're looking for an orbital tumor, your patient has a headache and you wanted to order an MRI. You know, patient had transient vision changes and you wanted to order an MRI and but their dilated fundus exam was normal, if it comes back with an empty sella and your radiologist says, you know, could be a sign of IIH please correlate clinically, you don't have to send that to a neuro-ophthalmologist. They don't have papilledema. It's not something that we have to worry about. And it's a very common finding, and it does increase with age, and you can reassure your patients.

Andy Lee, MD:

Well, I think that's a really good message. That concludes another edition of the NeuroOp Guru. Thanks again, Dr. Carey.

Drew Carey, MD:

Thanks for having me Dr. Lee.