Pituitary apoplexy differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Pituitary apoplexy}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Pituitary_apoplexy]]
{{CMG}}; {{AE}}{{Akshun}}
{{CMG}}; {{AE}}{{Akshun}}
==Overview==
==Overview==
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  | doi = 10.1111/aas.12927
  | doi = 10.1111/aas.12927
  | pmid = 28635146
  | pmid = 28635146
}}</ref><ref>{{cite journal |vauthors=Johnston PC, Chew LS, Hamrahian AH, Kennedy L |title=Lymphocytic infundibulo-neurohypophysitis: a clinical overview |journal=Endocrine |volume=50 |issue=3 |pages=531–6 |year=2015 |pmid=26219407 |doi=10.1007/s12020-015-0707-6 |url=}}</ref><ref>{{cite journal |vauthors=Makale MT, McDonald CR, Hattangadi-Gluth JA, Kesari S |title=Mechanisms of radiotherapy-associated cognitive disability in patients with brain tumours |journal=Nat Rev Neurol |volume=13 |issue=1 |pages=52–64 |year=2017 |pmid=27982041 |doi=10.1038/nrneurol.2016.185 |url=}}</ref><ref name="pmid9541295">{{cite journal| author=Sato N, Sze G, Endo K| title=Hypophysitis: endocrinologic and dynamic MR findings. | journal=AJNR Am J Neuroradiol | year= 1998 | volume= 19 | issue= 3 | pages= 439-44 | pmid=9541295 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9541295  }} </ref>
}}</ref><ref>{{cite journal |vauthors=Johnston PC, Chew LS, Hamrahian AH, Kennedy L |title=Lymphocytic infundibulo-neurohypophysitis: a clinical overview |journal=Endocrine |volume=50 |issue=3 |pages=531–6 |year=2015 |pmid=26219407 |doi=10.1007/s12020-015-0707-6 |url=}}</ref><ref>{{cite journal |vauthors=Makale MT, McDonald CR, Hattangadi-Gluth JA, Kesari S |title=Mechanisms of radiotherapy-associated cognitive disability in patients with brain tumours |journal=Nat Rev Neurol |volume=13 |issue=1 |pages=52–64 |year=2017 |pmid=27982041 |doi=10.1038/nrneurol.2016.185 |url=}}</ref><ref name="pmid9541295">{{cite journal| author=Sato N, Sze G, Endo K| title=Hypophysitis: endocrinologic and dynamic MR findings. | journal=AJNR Am J Neuroradiol | year= 1998 | volume= 19 | issue= 3 | pages= 439-44 | pmid=9541295 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9541295  }} </ref><ref name="pmid11779895">{{cite journal |vauthors=Kidwell CS, Saver JL, Villablanca JP, Duckwiler G, Fredieu A, Gough K, Leary MC, Starkman S, Gobin YP, Jahan R, Vespa P, Liebeskind DS, Alger JR, Vinuela F |title=Magnetic resonance imaging detection of microbleeds before thrombolysis: an emerging application |journal=Stroke |volume=33 |issue=1 |pages=95–8 |year=2002 |pmid=11779895 |doi= |url=}}</ref>
 
<small>
{| class="wikitable"
{|
! rowspan="3" |Onset
! rowspan="2" style="background: #4479BA; text-align: center;" |{{fontcolor|#FFF|Onset}}
! rowspan="3" |Disease
! rowspan="2" style="background: #4479BA; text-align: center;" |{{fontcolor|#FFF|Disease}}
! colspan="2" |Symptoms
! colspan="2" style="background: #4479BA; text-align: center;" |{{fontcolor|#FFF|Symptoms}}
! rowspan="3" |Gold Standard
! rowspan="2" style="background: #4479BA; text-align: center;" |{{fontcolor|#FFF|Gold Standard Test}}
! rowspan="3" |CT/MRI
! rowspan="2" style="background: #4479BA; text-align: center;" |{{fontcolor|#FFF|CT/MRI Findings}}
! rowspan="3" |Other Investigation Findings
! rowspan="2" style="background: #4479BA; text-align: center;" |{{fontcolor|#FFF|Other Investigation Findings}}
|-
|-
!'''Headache'''
! style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|'''Headache''' Characteristics}}
! rowspan="2" |Other features
! style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Associated Features}}
|-
|-
!Characteristics
| rowspan="7" style="background: #DCDCDC; text-align: center;" |'''Sudden'''
|-
| style="background: #DCDCDC; text-align: center;" |'''Pituitary apoplexy'''
| rowspan="7" |[[Sudden]]
| style="background: #F5F5F5;" |Severe [[headache]]
|Pituitary apoplexy
| style="background: #F5F5F5;" |
|Severe [[headache]]
|
* [[Nausea and vomiting]]
* [[Nausea and vomiting]]
* Paralysis of eye muscles ([[diplopia]])
* Paralysis of eye muscles ([[diplopia]])
* Changes in vision
* Changes in vision
|[[MRI]]
| style="background: #F5F5F5;" |[[MRI]]
|
| style="background: #F5F5F5;" |
* [[CT]] scan without [[Contrast medium|contrast]] is the initial test of choice. [[Pituitary hemorrhage|Pituitary hemorrhag]]<nowiki/>e on [[CT]] presents as a hyper-dense lesion.
* [[CT]] scan without [[Contrast medium|contrast]] is the initial test of choice. [[Pituitary hemorrhage|Pituitary hemorrhag]]<nowiki/>e on [[CT]] presents as a hyper-dense lesion
 
* [[MRI]] is done in cases of inconclusive [[CT]]. An [[MRI]] is more [[Sensitivity (tests)|sensitive]] in identifying [[intrasellar]] mass and [[soft tissue]] changes  
* [[MRI]] is done in cases of inconclusive [[CT]]. An [[MRI]] is more sensitive in identifying [[intrasellar]] mass and soft tissue changes.
| style="background: #F5F5F5;" |[[Blood tests]] may be done to check:
|[[Blood tests]] may be done to check:
* [[PT]]/[[INR]] and [[aPTT]]
* [[PT]]/[[INR]] and [[aPTT]]
* [[Pituitary gland|Pituitary]] [[hormonal]] assay
* [[Pituitary gland|Pituitary]] [[hormonal]] assay
|-
|-
|[[Subarachnoid hemorrhage]]  
| style="background: #DCDCDC; text-align: center;" |[[Subarachnoid hemorrhage|'''Subarachnoid hemorrhage''']]  
|
| style="background: #F5F5F5;" |
* [[Headache|Severe headache]]
* [[Headache|Severe headache]]
* <nowiki/>[[Thunderclap headache|Thunderclap]]
* <nowiki/>[[Thunderclap headache|Thunderclap]]
* Described as the worst [[headache]] of life
* Described as the worst [[headache]] of life
|
| style="background: #F5F5F5;" |
* [[Double vision]]
* [[Double vision]]
* [[Nausea]] and [[vomiting]]
* [[Nausea]] and [[vomiting]]
* Symptoms of [[meningeal irritation]]
* [[Symptoms]] of [[meningeal irritation]]
* Sudden [[Loss of consciousness|decreased level of consciousness]]
* Sudden [[Loss of consciousness|decreased level of consciousness]]
|[[Digital subtraction angiography]]
| style="background: #F5F5F5;" |[[Digital subtraction angiography]]
|
| style="background: #F5F5F5;" |
* The [[modality]] of choice for [[diagnosis]] of [[subarachnoid hemorrhage]] is noncontrast head [[Computed tomography|computed tomography (CT)]], with or without [[lumbar puncture]].<sup>[[Subarachnoid hemorrhage CT#cite note-pmid7897421-1|[1]]]</sup>
* The [[modality]] of choice for [[diagnosis]] of [[subarachnoid hemorrhage]] is non-contrast head [[Computed tomography|computed tomography (CT)]], with or without [[lumbar puncture]].<sup>[[Subarachnoid hemorrhage CT#cite note-pmid7897421-1|[1]]]</sup>
* [[Computed tomography|CT]] shows hyperattenuating material filling the [[subarachnoid space]].
* [[Computed tomography|CT]] shows hyperattenuating material filling the [[subarachnoid space]]
|
| style="background: #F5F5F5;" |
* [[Lumbar puncture|Lumbar puncture (LP)]] is necessary when there is a strong suspicion of [[subarachnoid hemorrhage]]. LP will show:
* [[Lumbar puncture|Lumbar puncture (LP)]] is necessary when there is a strong suspicion of [[subarachnoid hemorrhage]]. LP will show:
** Elevated opening [[pressure]]
** Elevated opening [[pressure]]
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** [[Xanthochromic|Xanthochromia]]
** [[Xanthochromic|Xanthochromia]]
|-
|-
|[[Meningitis]]
| style="background: #DCDCDC; text-align: center;" |[[Meningitis|'''Meningitis''']]
|[[Headache]] is associated with:
| style="background: #F5F5F5;" |[[Headache]] is associated with:
* [[Fever]]  
* [[Fever]]  
* [[Neck stiffness]]
* [[Neck stiffness]]
|
| style="background: #F5F5F5;" |
* [[Photophobia]]   
* [[Photophobia]]   
* [[Phonophobia]] 
* [[Phonophobia]] 
* [[Irritability]]
* [[Irritability]]
* [[Altered mental status]]
* [[Altered mental status]]
|[[Lumbar puncture]] for [[CSF]]
| style="background: #F5F5F5;" |[[Lumbar puncture]] for [[CSF]]
|
| style="background: #F5F5F5;" |
* [[CT]] scan of the [[head]] may be performed before [[Lumbar puncture|LP]] to determine the risk of [[herniation]].
* [[CT]] scan of the [[head]] may be performed before [[Lumbar puncture|LP]] to determine the risk of [[herniation]]
|
| style="background: #F5F5F5;" |
* [[Diagnosis]] is based on [[clinical]] presentation in combination with [[CSF]] analysis.
* [[Diagnosis]] is based on [[clinical]] presentation in combination with [[CSF]] analysis  
* [[CSF]] analysis is the investigation of choice.
* [[CSF]] analysis is the investigation of choice
* For more information on [[CSF]] analysis in meningitis please [[Meningitis#Diagnosis|click here.]]
* For more information on [[CSF]] analysis in [[meningitis]] please [[Meningitis#Diagnosis|click here]]
|-
|-
|[[Cerebral hemorrhage]]
| style="background: #DCDCDC; text-align: center;" |[[Cerebral hemorrhage|'''Cerebral hemorrhage''']]
|Rapidly progressing [[headache]]  
| style="background: #F5F5F5;" |Rapidly progressing [[headache]]  
|
| style="background: #F5F5F5;" |
* Symptoms of [[increased intracranial pressure]] (ICP)
* [[Nausea]]
 
* [[Vomiting]]
* Focal neurological deficits
* [[Diplopia]]
|[[CT]] without [[Contrast medium|contrast]]
* [[Focal neurologic signs|Focal neurological deficits]]
(differentiate [[ischemic stroke]] from [[hemorrhagic stroke|hemorrhagic stroke]])
| style="background: #F5F5F5;" |[[CT]] without [[Contrast medium|contrast]]
|
(differentiates [[ischemic stroke]] from [[hemorrhagic stroke|hemorrhagic stroke]])
* [[CT]] is very sensitive for identifying acute [[hemorrhage]] which appears as a hyperattenuating clot.
| style="background: #F5F5F5;" |
* Gradient echo and T2 susceptibility-weighted [[MRI]] are as sensitive as [[CT]] for detection of acute [[hemorrhage]] and are more sensitive for identification of prior [[hemorrhage]].
* [[CT]] is highly [[Sensitivity (tests)|sensitive]] for identifying acute [[hemorrhage]] which appears as a hyperattenuating [[clot]].
|
* Gradient echo and T2 susceptibility-weighted [[MRI]] are as [[Sensitivity (tests)|sensitive]] as [[CT]] for detection of acute [[hemorrhage]] and are more [[Sensitivity (tests)|sensitive]] for identification of prior [[hemorrhage]]
* [[PT]]/[[INR]] and [[aPTT]] should be checked to rule out [[coagulopathy]].
| style="background: #F5F5F5;" |
* [[PT]]/[[INR]] and [[aPTT]] should be checked to rule out [[coagulopathy]]
|-
|-
|[[Migraine]]
| style="background: #DCDCDC; text-align: center;" |[[Migraine|'''Migraine''']]
|
| style="background: #F5F5F5;" |
* Severe to moderate [[headache]]  
* Severe to moderate [[headache]]  
* One-sided  
* One-sided  
* Pulsating
* [[Pulsatility|Pulsating]]
* Lasts between several hours to three days.
* Lasts between several hours to three days
|
| style="background: #F5F5F5;" |
* [[Nausea and vomiting]]
* [[Nausea and vomiting]]
* Preceding [[Aura (symptom)|aura]]  
* Preceding [[Aura (symptom)|aura]]  
* [[Photophobia]]
* [[Photophobia]]
* [[Phonophobia]]
* [[Phonophobia]]
|'''---'''
| style="background: #F5F5F5;" |'''---'''
|
| style="background: #F5F5F5;" |
* [[CT]] and [[MRI]] may be needed to rule out other suspected possible causes of [[headache]].
* [[CT]] and [[MRI]] may be needed to rule out other suspected possible causes of [[headache]]
 
| style="background: #F5F5F5;" |
|
* [[Migraine]] is a [[clinical]] [[diagnosis]] that does not require any [[laboratory]] tests.
* [[Migraine]] is a clinical [[diagnosis]] that does not require any [[laboratory]] tests.
* [[Laboratory]] tests may be ordered to rule out any suspected coexistent [[metabolic]] problems
* [[Laboratory]] tests may be ordered to rule out any suspected coexistent [[metabolic]] problems.
|-
|-
|[[Head injury]]
| style="background: #DCDCDC; text-align: center;" |'''[[Head injury]] ([[Epidural hematoma]])'''
|
| style="background: #F5F5F5;" |
* Dull  
* Dull  
* Throbbing
* Throbbing
* One sided or all around
* One sided or all around
|
| style="background: #F5F5F5;" |
* [[Confusion]]
* [[Confusion]]
* [[Drowsiness]]
* [[Drowsiness]]
Line 181: Line 176:
* [[Headache|Loss of consciousness]]
* [[Headache|Loss of consciousness]]
* [[Lucid interval]]
* [[Lucid interval]]
|[[CT]] scan without [[Contrast medium|contrast]]
| style="background: #F5F5F5;" |[[Computed tomography|CT scan]] without [[Contrast medium|contrast]]
|
| style="background: #F5F5F5;" |
* [[CT]] scan is the first test performed and identifies [[cerebral hemorrhage]] (appears as a hyperattenuating clot) following [[head injury]].
* [[Computed tomography|CT scan]] is the first test performed and identifies [[cerebral hemorrhage]] (appears as a hyperattenuating [[clot]]) following [[head injury]]  
 
* [[MRI]] is more [[Sensitivity (tests)|sensitive]], takes more time, and is done in patients with [[Symptom|symptoms]] unexplained by [[Computed tomography|CT scan]]  
* [[MRI]] is more sensitive, takes more time, and is done in patients with [[Symptom|symptoms]] unexplained by [[Computed tomography|CT]] scan.
| style="background: #F5F5F5;" |
|
* The [[Glasgow Coma Scale]] is a tool for measuring degree of [[unconsciousness]] and is a useful tool for determining severity of [[injury]]  
* The [[Glasgow Coma Scale]] is a tool for measuring degree of [[unconsciousness]] and is a useful tool for determining severity of [[injury]].
* The [[Pediatric Glasgow Coma Scale]] is used in young [[children]]
* The [[Pediatric Glasgow Coma Scale]] is used in young [[children]].
|-
|-
|[[Lymphocytic hypophysitis]]
| style="background: #DCDCDC; text-align: center;" |[[Lymphocytic hypophysitis|'''Lymphocytic hypophysitis''']]
|
| style="background: #F5F5F5;" |
* Generalized [[headache]]
* Generalized [[headache]]
* Retro-orbital or Bitemporal [[pain]]
* Retro-orbital or Bitemporal [[pain]]
|
| style="background: #F5F5F5;" |
* Most often seen in late [[pregnancy]] or the [[postpartum]] period  
* Most often seen in late [[pregnancy]] or the [[postpartum]] period  
* Mass lesion effect such as [[Visual field defect|visual field defects]]
* Mass lesion effect such as [[Visual field defect|visual field defects]]
* [[Hypopituitarism]]
* [[Hypopituitarism]]
|[[Pituitary]] [[biopsy]]
| style="background: #F5F5F5;" |[[Pituitary]] [[biopsy]]
|[[CT]] & [[MRI]] typically reveal features of a [[Pituitary gland|pituitary]] [[mass]].
| style="background: #F5F5F5;" |[[CT]] & [[MRI]] typically reveal features of a [[Pituitary gland|pituitary]] [[mass]]
|The most accurate test is a [[Pituitary gland|pituitary]] [[biopsy]] which will show [[lymphocytic]] [[Infiltration (medical)|infiltration]].
| style="background: #F5F5F5;" |
* The most accurate test is a [[Pituitary gland|pituitary]] [[biopsy]] which will show [[lymphocytic]] [[Infiltration (medical)|infiltration]]
|-
|-
| rowspan="2" |Gradual
| rowspan="2" style="background: #DCDCDC; text-align: center;" |'''Gradual'''
|[[Intracranial mass]]
| style="background: #DCDCDC; text-align: center;" |[[Intracranial mass|'''Intracranial mass''']]
|[[Morning headache]]
| style="background: #F5F5F5;" |[[Morning headache]]
|
| style="background: #F5F5F5;" |
* [[Nausea]]
* [[Nausea]]
* [[Vomiting]]
* [[Vomiting]]
* [[Change in mental status]]
* [[Change in mental status]]
* [[Seizures]]
* [[Seizures]]
* Focal [[neurological]] deficits
* [[Focal neurologic signs|Focal neurological deficits]]
|[[MRI]]
| style="background: #F5F5F5;" |[[MRI]]
|
| style="background: #F5F5F5;" |
* [[CT]] or [[MRI]] is the initial test to detect intracranial lesions (ring enhancing lesions).
* [[CT]] or [[MRI]] is the initial test to detect intracranial lesions (ring enhancing lesions)  
* These [[imaging]] tests determine the location of [[intracranial mass]] lesion(s) and help in guiding [[therapy]].
* These [[imaging]] tests determine the location of [[intracranial mass]] lesion(s) and help in guiding [[therapy]]
|
| style="background: #F5F5F5;" |
* [[Biopsy]] of the [[lesion]] may be done to identify the nature of the lesion such as:
* [[Biopsy]] of the [[lesion]] may be done to identify the nature of the lesion such as:
** [[Tumor]]  
** [[Tumor]]  
** [[Abscess]]
** [[Abscess]]
* [[X-rays|X-ray]] of the [[skull]] is a non specific test, but useful if any of the lesions are [[Calcified lesion|calcified]]
* [[X-rays|X-ray]] of the [[skull]] is a non specific test, but useful if any of the lesions are [[Calcified lesion|calcified]]
|-
|-
|[[Intracranial venous thrombosis]]
| style="background: #DCDCDC; text-align: center;" |[[Intracranial venous thrombosis|'''Intracranial venous thrombosis''']]
|
| style="background: #F5F5F5;" |
* Diffuse [[headache]]  
* Diffuse [[headache]]  
* [[Headache]] can be the only symptom of [[Cerebral venous sinus thrombosis|cerebral venous thrombosis]]
* [[Headache]] can be the only symptom of [[Cerebral venous sinus thrombosis|cerebral venous thrombosis]]
|
| style="background: #F5F5F5;" |
* Focal neurological deficits
* Focal neurological deficits
* [[Seizure|Seizures]]  
* [[Seizure|Seizures]]  
* [[Coma|Depressed level of consciousness]] 
* [[Coma|Depressed level of consciousness]] 
|[[Digital subtraction angiography]]
| style="background: #F5F5F5;" |[[Digital subtraction angiography]]
|
| style="background: #F5F5F5;" |
* The classic finding of sinus thrombosis on unenhanced [[CT]] images is a hyperattenuating thrombus in the occluded sinus.
* The classic finding of sinus thrombosis on unenhanced [[CT]] images is a hyperattenuating [[thrombus]] in the occluded [[sinus]]
* [[CT]] and [[MRI]] may identify [[Cerebral edema]] and [[venous]] [[infarction]] may be apparent
| style="background: #F5F5F5;" |
* CT [[venography]] detects the [[thrombus]], [[computed tomography]] with [[radiocontrast]] in the [[venous]] phase (CT [[venography]] or CTV) has a detection rate that in some regards exceeds that of [[MRI]]
* [[Cerebral angiography]] may demonstrate smaller clots, and obstructed [[veins]] may give the "corkscrew appearance"
|}
</small>


* [[CT]] and [[MRI]] may identify [[Cerebral edema]] and venous [[infarction]] may be apparent.
<br><br>
|
Pituitary apoplexy should be differentiated from other [[diseases]] causing [[hypopituitarism]].<ref name="pmid9541295">{{cite journal |vauthors=Sato N, Sze G, Endo K |title=Hypophysitis: endocrinologic and dynamic MR findings |journal=AJNR Am J Neuroradiol |volume=19 |issue=3 |pages=439–44 |year=1998 |pmid=9541295 |doi= |url=}}</ref><ref name="pmid7758238">{{cite journal |vauthors=Powrie JK, Powell M, Ayers AB, Lowy C, Sönksen PH |title=Lymphocytic adenohypophysitis: magnetic resonance imaging features of two new cases and a review of the literature |journal=Clin. Endocrinol. (Oxf) |volume=42 |issue=3 |pages=315–22 |year=1995 |pmid=7758238 |doi= |url=}}</ref><ref name="pmid26262437">{{cite journal |vauthors=Honegger J, Schlaffer S, Menzel C, Droste M, Werner S, Elbelt U, Strasburger C, Störmann S, Küppers A, Streetz-van der Werf C, Deutschbein T, Stieg M, Rotermund R, Milian M, Petersenn S |title=Diagnosis of Primary Hypophysitis in Germany |journal=J. Clin. Endocrinol. Metab. |volume=100 |issue=10 |pages=3841–9 |year=2015 |pmid=26262437 |doi=10.1210/jc.2015-2152 |url=}}</ref><ref name="pmid7629223">{{cite journal |vauthors=Thodou E, Asa SL, Kontogeorgos G, Kovacs K, Horvath E, Ezzat S |title=Clinical case seminar: lymphocytic hypophysitis: clinicopathological findings |journal=J. Clin. Endocrinol. Metab. |volume=80 |issue=8 |pages=2302–11 |year=1995 |pmid=7629223 |doi=10.1210/jcem.80.8.7629223 |url=}}</ref><ref name="pmid8345854">{{cite journal |vauthors=Imura H, Nakao K, Shimatsu A, Ogawa Y, Sando T, Fujisawa I, Yamabe H |title=Lymphocytic infundibuloneurohypophysitis as a cause of central diabetes insipidus |journal=N. Engl. J. Med. |volume=329 |issue=10 |pages=683–9 |year=1993 |pmid=8345854 |doi=10.1056/NEJM199309023291002 |url=}}</ref><ref name="pmid21668725">{{cite journal |vauthors=Hsieh CY, Liu BY, Yang YN, Yin WH, Young MS |title=Massive pericardial effusion with diastolic right ventricular compression secondary to hypothyroidism in a 73-year-old woman |journal=Emerg Med Australas |volume=23 |issue=3 |pages=372–5 |year=2011 |pmid=21668725 |doi=10.1111/j.1742-6723.2011.01425.x |url=}}</ref><ref name="pmid9747750">{{cite journal |vauthors=Dejager S, Gerber S, Foubert L, Turpin G |title=Sheehan's syndrome: differential diagnosis in the acute phase |journal=J. Intern. Med. |volume=244 |issue=3 |pages=261–6 |year=1998 |pmid=9747750 |doi= |url=}}</ref>
* CT [[venography]] detects the [[thrombus]], [[computed tomography]] with [[radiocontrast]] in the venous phase (CT [[venography]] or CTV) has a detection rate that in some regards exceeds that of [[MRI]].
<small>
 
{|
* [[Cerebral angiography]] may demonstrate smaller clots, and obstructed [[veins]] may give the "corkscrew appearance."
! rowspan="3" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Diseases}}
! rowspan="3" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Onset}}
! colspan="5" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Manifestations}}
! colspan="4" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Diagnosis}}
|-
! colspan="4" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|History and Symptoms}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Physical examination}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Laboratory findings}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Gold standard}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Imaging}}
! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Other investigation findings}}
|-
! style="background: #7d7d7d; width: 200px;" | {{fontcolor|#FFF| Traumatic delivery}}
! style="background: #7d7d7d; width: 200px;" | {{fontcolor|#FFF| Lactation failure}}
! style="background: #7d7d7d; width: 200px;" | {{fontcolor|#FFF| Menstrual irregularities}}
! style="background: #7d7d7d; width: 200px;" | {{fontcolor|#FFF| Other features}}
|-
! style="background: #DCDCDC; text-align: center;" |[[Sheehan's syndrome]]
| style="background: #F5F5F5;" |Acute
| style="background: #F5F5F5;" |<nowiki>++</nowiki>
| style="background: #F5F5F5;" | ++
| style="background: #F5F5F5;" |[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
| style="background: #F5F5F5;" |Symptoms of:
* [[Adrenal insufficiency]]
* [[Hypothyroidism]]
| style="background: #F5F5F5;" |
* [[Breast tissue]] [[atrophy]]
* Decreased [[axillary]] and [[pubic]] hair growth
| style="background: #F5F5F5;" |
* [[Pancytopenia]]
* [[Eosinophilia]]
* [[Hyponatremia]]
* Low [[fasting plasma glucose]]
* Decreased levels of [[anterior pituitary]] [[hormones]] in blood
| style="background: #F5F5F5;" |
* Clinical diagnosis 
* Most senitive test: Low baseline [[prolactin]] levels w/o response to [[Thyrotropin-releasing hormone|TRH]]
| style="background: #F5F5F5;" |CT/MRI:
* Sequential changes of pituitary enlargement followed by:
* Shrinkage and [[necrosis]] leading to decreased sellar volume or [[empty sella]]
| style="background: #F5F5F5;" |
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
! style="background: #DCDCDC; text-align: center;" |[[Lymphocytic hypophysitis]]
| style="background: #F5F5F5;" |Acute
| style="background: #F5F5F5;" |<nowiki>+/-</nowiki>
| style="background: #F5F5F5;" |<nowiki>+</nowiki>
| style="background: #F5F5F5;" |[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
| style="background: #F5F5F5;" |
* Associated with [[autoimmune]] conditions
* Generalized [[headache]]
* Retro-orbital or Bitemporal [[pain]]
* Mass lesion effect such as [[Visual field defect|visual field defects]]
| style="background: #F5F5F5;" |
* [[Diabetes insipidus|DI]]
* [[Autoimmune]] [[thyroiditis]]
| style="background: #F5F5F5;" |
* Decreased pituitary hormones([[Gonadotropins]] most common)
* [[Hyperprolactinemia]](40%)
* [[Growth hormone|GH]] excess
| style="background: #F5F5F5;" |
* [[Pituitary gland|Pituitary]] [[biopsy]]: [[lymphocytic]] [[Infiltration (medical)|infiltration]]
| style="background: #F5F5F5;" |
* [[CT]] & [[MRI]]: Features of a [[Pituitary gland|pituitary]] [[mass]]
* Diffuse and homogeneous contrast enhancement
| style="background: #F5F5F5;" |[[Assay|Assays]] for:
* Anti-TPO 
* Anti-Tg Ab
|-
! style="background: #DCDCDC; text-align: center;" |[[Pituitary apoplexy]]
| style="background: #F5F5F5;" |Acute
| style="background: #F5F5F5;" |<nowiki>+/-</nowiki>
| style="background: #F5F5F5;" |<nowiki>++</nowiki>
| style="background: #F5F5F5;" |[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
| style="background: #F5F5F5;" |
*Severe [[headache]]
* [[Nausea and vomiting]]
* Paralysis of eye muscles ([[diplopia]])
* Changes in vision
| style="background: #F5F5F5;" |
* [[Visual acuity]] defects
* [[Cranial nerve palsies|CN palsies]] (nerves III, IV, V , and VI)
| style="background: #F5F5F5;" |
* Decreased levels of [[anterior]] pituitary hormones in blood.
| style="background: #F5F5F5;" |
* [[Magnetic resonance imaging|MRI]]
| style="background: #F5F5F5;" |
* [[CT]] scan without [[Contrast medium|contrast]]: Hemorrhag<nowiki/>e on [[CT]] presents as a hyperdense lesion
* [[MRI]]: If inconclusive [[CT]]
| style="background: #F5F5F5;" |
[[Blood tests]] may be done to check:
* [[PT]]/[[INR]] and [[aPTT]]
* [[Pituitary gland|Pituitary]] [[hormonal]] assay
|-
! style="background: #DCDCDC; text-align: center;" |[[Empty sella syndrome]]
| style="background: #F5F5F5;" |Chronic
| style="background: #F5F5F5;" |<nowiki>-</nowiki>
| style="background: #F5F5F5;" |<nowiki>+</nowiki>
| style="background: #F5F5F5;" |[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
| style="background: #F5F5F5;" |
* [[Erectile dysfunction]]
* [[Headache]]
* Low [[libido]]
| style="background: #F5F5F5;" |
* Signs of raised [[intracranial pressure]] may be present
* [[Nipple discharge|Nipple]] discharge
| style="background: #F5F5F5;" |
* Decreased levels of  pituitary hormones in blood.
| style="background: #F5F5F5;" |
* [[MRI]]
| style="background: #F5F5F5;" |
* [[Empty sella]] containing [[Cerebrospinal fluid|CSF]]
| style="background: #F5F5F5;" |
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
! style="background: #DCDCDC; text-align: center;" |[[Simmond's Disease|Simmonds' disease]]/[[Pituitary]] [[cachexia]]
| style="background: #F5F5F5;" |Chronic
| style="background: #F5F5F5;" |<nowiki>+/-</nowiki>
| style="background: #F5F5F5;" | +
| style="background: #F5F5F5;" |[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
| style="background: #F5F5F5;" |
* [[Cachexia]]
* [[Premature aging|Premature]] aging
| style="background: #F5F5F5;" |
* Progressive [[emaciation]]
* Loss of body hair
| style="background: #F5F5F5;" |
* Decreased levels of anterior pituitary hormones in blood.
| style="background: #F5F5F5;" |
* [[Magnetic resonance imaging|MRI]]
| style="background: #F5F5F5;" |
* Done to rule out any pituitary cause
| style="background: #F5F5F5;" |
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
! style="background: #DCDCDC; text-align: center;" |[[Primary hypothyroidism|Hypothyroidism]]
| style="background: #F5F5F5;" |Chronic
| style="background: #F5F5F5;" |<nowiki>+/-</nowiki>
| style="background: #F5F5F5;" |<nowiki>-</nowiki>
| style="background: #F5F5F5;" |[[Oligomenorrhea]]/[[menorrhagia]]
| style="background: #F5F5F5;" |
* Cold intolerance
* [[Constipation]]
| style="background: #F5F5F5;" |
* Dry skin
* [[Bradycardia]]
* Hair loss
* [[Myxedema]]
* Delayed relaxation phase of deep [[Tendon reflex|tendon reflexes]]
| style="background: #F5F5F5;" |
* Low [[T3]],[[T4]]
* Normal/ low [[Thyroid-stimulating hormone|TSH]]
* Rest of pituitary hormone levels WNL
| style="background: #F5F5F5;" |
* [[TSH]] levels
| style="background: #F5F5F5;" |
* Done to rule out any pituitary cause
| style="background: #F5F5F5;" |
*Assays for anti-TPO and anti-Tg Ab
*FNA biopsy
|-
! style="background: #DCDCDC; text-align: center;" |[[Hypogonadotropic hypogonadism]]
| style="background: #F5F5F5;" |Chronic
| style="background: #F5F5F5;" |<nowiki>-</nowiki>
| style="background: #F5F5F5;" |<nowiki>-</nowiki>
| style="background: #F5F5F5;" |[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
| style="background: #F5F5F5;" |
* [[Hot flushes]]
* Energy and mood changes
* Decreased [[libido]]
| style="background: #F5F5F5;" |
* [[Breast tissue]] [[atrophy]]
* Decreased [[maturation]] of [[vaginal]] [[mucosa]]
| style="background: #F5F5F5;" |
* Low [[estrogen]], [[testosterone]]
* High [[FSH]]/[[Luteinizing hormone|LH]]
| style="background: #F5F5F5;" |
* [[FSH]]
* [[Luteinizing hormone|LH]]
| style="background: #F5F5F5;" |
* Done to rule out any pituitary cause
| style="background: #F5F5F5;" |
* Genetic tests  ([[karyotype]])
* Measurement of total and free [[testosterone]] and [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] concentrations
|-
! style="background: #DCDCDC; text-align: center;" |Hypoprolactinemia
| style="background: #F5F5F5;" |Chronic
| style="background: #F5F5F5;" |<nowiki>-</nowiki>
| style="background: #F5F5F5;" |<nowiki>+</nowiki>
| style="background: #F5F5F5;" |<nowiki>-</nowiki>
| style="background: #F5F5F5;" |
* [[Infertility]]
* Subfertiliy
| style="background: #F5F5F5;" |
* Puerperal agalactogenesis
| style="background: #F5F5F5;" |
* No workup is necessary
| style="background: #F5F5F5;" |
* Decreased prolactin levels
| style="background: #F5F5F5;" |
* Done to rule out any pituitary cause
| style="background: #F5F5F5;" |
* [[Prolactin]] assay in [[3rd trimester]]
* [[Luteinizing hormone|LH]], [[Follicle-stimulating hormone|FSH]]
* [[Thyrotropin]] and free [[thyroxine]]
|-
! style="background: #DCDCDC; text-align: center;" |[[Panhypopituitarism]]
| style="background: #F5F5F5;" |Chronic
| style="background: #F5F5F5;" |<nowiki>-</nowiki>
| style="background: #F5F5F5;" |<nowiki>+</nowiki>
| style="background: #F5F5F5;" |[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
| style="background: #F5F5F5;" |
* [[Polyuria]]
* [[Polydipsia]]
* Features of [[hypothyroidism]] and [[hypoadrenalism]]
| style="background: #F5F5F5;" |
* [[Growth failure]]
* B/L [[hemianopsia]]
* [[Papilledema]]
| style="background: #F5F5F5;" |
* All pituitary hormones decreased
| style="background: #F5F5F5;" |
* [[Magnetic resonance imaging|MRI]]
| style="background: #F5F5F5;" |
* Done to rule out any pituitary cause
| style="background: #F5F5F5;" |
* Left hand and wrist [[radiograph]] for [[bone age]]
|-
! style="background: #DCDCDC; text-align: center;" |[[Primary adrenal insufficiency]]/[[Addison's disease]]
| style="background: #F5F5F5;" |Chronic
| style="background: #F5F5F5;" |<nowiki>-</nowiki>
| style="background: #F5F5F5;" | -
| style="background: #F5F5F5;" |<nowiki>-</nowiki>
| style="background: #F5F5F5;" |
* [[Hypoglycemia]]
* [[Hypotension]]
| style="background: #F5F5F5;" |
* [[Dehydration]]
* [[Hyperpigmentation]]
* loss of [[pubic]] and [[axillary]] hair
| style="background: #F5F5F5;" |
* [[Hyponatremia]] with/without [[hyperkalemia]]
* [[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
| style="background: #F5F5F5;" |
* Abdominal [[Computed tomography|CT]]
| style="background: #F5F5F5;" |
* Abdominal [[Computed tomography|CT]]
| style="background: #F5F5F5;" |
* Serum [[cortisol]] testing
* Serum [[ACTH]] testing
* Anti-adrenal [[Antibody|Ab]] testing
|-
! style="background: #DCDCDC; text-align: center;" |[[Menopause]]
| style="background: #F5F5F5;" |Chronic
| style="background: #F5F5F5;" |<nowiki>-</nowiki>
| style="background: #F5F5F5;" |<nowiki>+/-</nowiki>
| style="background: #F5F5F5;" |[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
| style="background: #F5F5F5;" |
* [[Hot flashes]]
* [[Insomnia]]
* [[Weight gain]] and [[bloating]]
* Mood changes
| style="background: #F5F5F5;" |
* [[Vaginal atrophy]]
* Loss of pelvic [[muscle tone]]
| style="background: #F5F5F5;" |
* ↑ [[FSH]]
* [[Estradiol]] and [[inhibin]]
| style="background: #F5F5F5;" |
* [[FSH]] > [[LH]]
| style="background: #F5F5F5;" |Normal
| style="background: #F5F5F5;" |
* [[Endometrial biopsy]]
|}
|}
</small>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


{{reflist|2}}
[[Category:Needs content]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Endocrinology]]
[[Category:Endocrinology]]
[[Category:Neurology]]
[[Category:Neurology]]
[[Category:Obstetrics]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Medicine]]
[[Category:Up-To-Date]]


{{WH}}
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Latest revision as of 18:25, 25 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akshun Kalia M.B.B.S.[2]

Overview

Pituitary apoplexy must be differentiated from other diseases that cause severe headache such as subarachnoid hemorrhage, meningitis, intracranial mass, cerebral hemorrhage, cerebral infarction, intracranial venous thrombosis, migraine, head injury, and lymphocytic hypophysitis.

Differentiating Pituitary apoplexy From Other Diseases

Pituitary apoplexy should be differentiated from other diseases causing severe headache for example: [1][2][3][4][5][6][7][8][9][10][11]

Onset Disease Symptoms Gold Standard Test CT/MRI Findings Other Investigation Findings
Headache Characteristics Associated Features
Sudden Pituitary apoplexy Severe headache MRI Blood tests may be done to check:
Subarachnoid hemorrhage Digital subtraction angiography
Meningitis Headache is associated with: Lumbar puncture for CSF
Cerebral hemorrhage Rapidly progressing headache CT without contrast

(differentiates ischemic stroke from hemorrhagic stroke)

Migraine
  • Severe to moderate headache
  • One-sided
  • Pulsating
  • Lasts between several hours to three days
---
  • CT and MRI may be needed to rule out other suspected possible causes of headache
Head injury (Epidural hematoma)
  • Dull
  • Throbbing
  • One sided or all around
CT scan without contrast
Lymphocytic hypophysitis Pituitary biopsy CT & MRI typically reveal features of a pituitary mass
Gradual Intracranial mass Morning headache MRI
  • CT or MRI is the initial test to detect intracranial lesions (ring enhancing lesions)
  • These imaging tests determine the location of intracranial mass lesion(s) and help in guiding therapy
Intracranial venous thrombosis Digital subtraction angiography



Pituitary apoplexy should be differentiated from other diseases causing hypopituitarism.[10][12][13][14][15][16][17]

Diseases Onset Manifestations Diagnosis
History and Symptoms Physical examination Laboratory findings Gold standard Imaging Other investigation findings
Traumatic delivery Lactation failure Menstrual irregularities Other features
Sheehan's syndrome Acute ++ ++ Oligo/amenorrhea Symptoms of:
  • Clinical diagnosis
  • Most senitive test: Low baseline prolactin levels w/o response to TRH
CT/MRI:
  • Sequential changes of pituitary enlargement followed by:
  • Shrinkage and necrosis leading to decreased sellar volume or empty sella
Lymphocytic hypophysitis Acute +/- + Oligo/amenorrhea Assays for:
  • Anti-TPO
  • Anti-Tg Ab
Pituitary apoplexy Acute +/- ++ Oligo/amenorrhea
  • Decreased levels of anterior pituitary hormones in blood.
  • CT scan without contrast: Hemorrhage on CT presents as a hyperdense lesion
  • MRI: If inconclusive CT

Blood tests may be done to check:

Empty sella syndrome Chronic - + Oligo/amenorrhea
  • Decreased levels of pituitary hormones in blood.
Simmonds' disease/Pituitary cachexia Chronic +/- + Oligo/amenorrhea
  • Decreased levels of anterior pituitary hormones in blood.
  • Done to rule out any pituitary cause
Hypothyroidism Chronic +/- - Oligomenorrhea/menorrhagia
  • Low T3,T4
  • Normal/ low TSH
  • Rest of pituitary hormone levels WNL
  • Done to rule out any pituitary cause
  • Assays for anti-TPO and anti-Tg Ab
  • FNA biopsy
Hypogonadotropic hypogonadism Chronic - - Oligo/amenorrhea
  • Done to rule out any pituitary cause
Hypoprolactinemia Chronic - + -
  • Puerperal agalactogenesis
  • No workup is necessary
  • Decreased prolactin levels
  • Done to rule out any pituitary cause
Panhypopituitarism Chronic - + Oligo/amenorrhea
  • All pituitary hormones decreased
  • Done to rule out any pituitary cause
Primary adrenal insufficiency/Addison's disease Chronic - - -
  • Abdominal CT
  • Abdominal CT
Menopause Chronic - +/- Oligo/amenorrhea Normal

References

  1. Endrit Ziu & Fassil Mesfin (2017). "Subarachnoid Hemorrhage". PMID 28722987.
  2. Benedikt Schwermer, Daniel Eschle & Constantine Bloch-Infanger (2017). "[Fever and Headache after a Vacation in Thailand]". Deutsche medizinische Wochenschrift (1946). 142 (14): 1063–1066. doi:10.1055/s-0043-106282. PMID 28728201.
  3. Otto Rapalino & Mark E. Mullins (2017). "Intracranial Infectious and Inflammatory Diseases Presenting as Neurosurgical Pathologies". Neurosurgery. doi:10.1093/neuros/nyx201. PMID 28575459.
  4. I. B. Komarova, V. P. Zykov, L. V. Ushakova, E. K. Nazarova, E. B. Novikova, O. V. Shuleshko & M. G. Samigulina (2017). "[Clinical and neuroimaging signs of cardioembolic stroke laboratory in children]". Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 117 (3. Vyp. 2): 11–19. doi:10.17116/jnevro20171173211-19. PMID 28665364.
  5. Sanjay Konakondla, Clemens M. Schirmer, Fengwu Li, Xiaogun Geng & Yuchuan Ding (2017). "New Developments in the Pathophysiology, Workup, and Diagnosis of Dural Venous Sinus Thrombosis (DVST) and a Systematic Review of Endovascular Treatments". Aging and disease. 8 (2): 136–148. doi:10.14336/AD.2016.0915. PMID 28400981.
  6. Priyanka Yadav, Alec L. Bradley & Jonathan H. Smith (2017). "Recognition of Chronic Migraine by Medicine Trainees: A Cross-Sectional Survey". Headache. doi:10.1111/head.13133. PMID 28653369.
  7. S. Wulffeld, L. S. Rasmussen, B. Hojlund Bech & J. Steinmetz (2017). "The effect of CT scanners in the trauma room - an observational study". Acta anaesthesiologica Scandinavica. 61 (7): 832–840. doi:10.1111/aas.12927. PMID 28635146.
  8. Johnston PC, Chew LS, Hamrahian AH, Kennedy L (2015). "Lymphocytic infundibulo-neurohypophysitis: a clinical overview". Endocrine. 50 (3): 531–6. doi:10.1007/s12020-015-0707-6. PMID 26219407.
  9. Makale MT, McDonald CR, Hattangadi-Gluth JA, Kesari S (2017). "Mechanisms of radiotherapy-associated cognitive disability in patients with brain tumours". Nat Rev Neurol. 13 (1): 52–64. doi:10.1038/nrneurol.2016.185. PMID 27982041.
  10. 10.0 10.1 Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.
  11. Kidwell CS, Saver JL, Villablanca JP, Duckwiler G, Fredieu A, Gough K, Leary MC, Starkman S, Gobin YP, Jahan R, Vespa P, Liebeskind DS, Alger JR, Vinuela F (2002). "Magnetic resonance imaging detection of microbleeds before thrombolysis: an emerging application". Stroke. 33 (1): 95–8. PMID 11779895.
  12. Powrie JK, Powell M, Ayers AB, Lowy C, Sönksen PH (1995). "Lymphocytic adenohypophysitis: magnetic resonance imaging features of two new cases and a review of the literature". Clin. Endocrinol. (Oxf). 42 (3): 315–22. PMID 7758238.
  13. Honegger J, Schlaffer S, Menzel C, Droste M, Werner S, Elbelt U, Strasburger C, Störmann S, Küppers A, Streetz-van der Werf C, Deutschbein T, Stieg M, Rotermund R, Milian M, Petersenn S (2015). "Diagnosis of Primary Hypophysitis in Germany". J. Clin. Endocrinol. Metab. 100 (10): 3841–9. doi:10.1210/jc.2015-2152. PMID 26262437.
  14. Thodou E, Asa SL, Kontogeorgos G, Kovacs K, Horvath E, Ezzat S (1995). "Clinical case seminar: lymphocytic hypophysitis: clinicopathological findings". J. Clin. Endocrinol. Metab. 80 (8): 2302–11. doi:10.1210/jcem.80.8.7629223. PMID 7629223.
  15. Imura H, Nakao K, Shimatsu A, Ogawa Y, Sando T, Fujisawa I, Yamabe H (1993). "Lymphocytic infundibuloneurohypophysitis as a cause of central diabetes insipidus". N. Engl. J. Med. 329 (10): 683–9. doi:10.1056/NEJM199309023291002. PMID 8345854.
  16. Hsieh CY, Liu BY, Yang YN, Yin WH, Young MS (2011). "Massive pericardial effusion with diastolic right ventricular compression secondary to hypothyroidism in a 73-year-old woman". Emerg Med Australas. 23 (3): 372–5. doi:10.1111/j.1742-6723.2011.01425.x. PMID 21668725.
  17. Dejager S, Gerber S, Foubert L, Turpin G (1998). "Sheehan's syndrome: differential diagnosis in the acute phase". J. Intern. Med. 244 (3): 261–6. PMID 9747750.

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