Context: An empty sella is a relatively common condition, often being an
incidental finding at MRI or CT scan. It can develop because of the intrasellar
herniation of Cerebro-spinal Fluid (CSF) and arachnoid membrane through an absent
or rudimentary diaphragm sellae in concomitance of a sudden and even transient
increment of intracranial pressure, leading to a picture in which the pituitary is
flattened along the floor of the sella.
Case Description: A young female with headache, nausea, dizziness, diplopia and
visual impairment showed an empty sella on MRI and increased CSF pressure at the
lumbar puncture. After an initial improvement, there was a progressive worsening of
the headache, especially in orthostatic position, with transient relief after bed rest and
hydration. At MRI the empty sella was no longer evident, cerebellar tonsils were displaced in the occipital
foramen and there was an impregnation of the meninges after contrast medium, a picture of CSF
hypotension, probably due to the previously performed lumbar puncture causing a fistula with leak of
CSF and consequent disappearance of the empty sella. The patient gradually improved after being
submitted to epidural blood patch.
Conclusions: The case here reported demonstrates that an empty sella can be a reversible condition in
rare cases. Its disappearance can be due to the reduction in intracranial pressure caused by the lumbar
puncture itself. The changes in the characteristics of the headache, in particular its worsening in the
orthostatic position, should lead to the suspicion of CSF leak through a fistula and consequent intracranial
hypotension, a dangerous and sometimes life-threatening condition.