Primary Empty Sella Presenting With Anterior Hypopituitarism: Reframing a Benign Radiologic Finding Through Its Endocrine Consequences.

Background/Objective: Primary empty sella (ES) is typically considered a benign incidental radiologic finding characterized by herniation of the subarachnoid space into the sella turcica and flattening of the pituitary gland. Emerging evidence suggests ES can be associated with varying degrees of clinically significant pituitary dysfunction, which is often underrecognized. We present a case highlighting the endocrine implications of ES and the need for comprehensive evaluation. Case Report: A 53-year-old woman was referred for abnormal thyroid function tests found on routine screening. She reported fatigue, cold intolerance, and cognitive slowing. Laboratory evaluation revealed central hypothyroidism, and a subsequent evaluation of anterior pituitary function revealed central adrenal insufficiency, hypogonadotropic hypogonadism, and growth hormone deficiency. There was no evidence of arginine vasopressin deficiency. Magnetic resonance imaging showed a primary ES with no visualized pituitary gland. Initiation of hormone replacement therapy subsequently resulted in significant clinical improvement. Discussion: This case illustrates that ES may represent a radiologic marker of evolving anterior hypopituitarism, rather than a benign variant. Without appropriate endocrine evaluation, such cases may be misdiagnosed or untreated, leading to worsened morbidity. Given the increasing use of advanced neuroimaging, incidental detection of ES is rising, making awareness of its potential endocrine consequences timely and relevant. Clinical vigilance and comprehensive endocrine assessment are essential to avoid delayed diagnosis and complications. Conclusion: Primary ES may herald progressive pituitary dysfunction. Clinicians should maintain a high index of suspicion and evaluate for central hormonal deficits when primary ES is identified incidentally.