Sandbox:Akshun

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, cerebral hemorrhage, intracranial mass, infarction, intracranial venous thrombosis, migraine, cavernous sinus thrombosis, cerebellar hemorrhage and midbrain infarction.

Differentiating Pituitary apoplexy From Other Diseases

Pituitary apoplexy should be differentiated from other diseases causing severe headache for example:

Disease	Symptoms	Findings
Subarachnoid hemorrhage	Severe headache (as a worst headache of the life) Headache is the main symptom (often starts suddenly and starts after a popping or snapping feeling in the head) Double vision Nausea and vomiting Symptoms of meningeal irritation Nuchal rigidity and pain Back pain Bilateral leg pain Numbness Weakness Sudden decreased level of consciousness Rapid progression of symptoms Speech disturbance	Lumbar puncture (LP) Lumbar puncture (LP) seems necessary when there is a strong suspicion of subarachnoid hemorrhage. Lumbar puncture (LP) is the most sensitive techniques to detect the blood in CSF especially 12 hours after onset of symptoms.[1][2] The classic findings of subarachnoid hemorrhage may include:[3][4][5][6][7] Elevated opening pressure Elevated red blood cell (RBC) RBC count does not diminish from CSF tube one to tube four and it helps to differentiate bleeding in SAH from traumatic spinal tap. However, decrease in the number of RBCs in later tubes can also happen in subarachnoid hemorrhage CSF samples taken within 24 hours of the ictus usually show a WBC-to-RBC ratio of 1:1000 that is consistent with the normal conditions. After 24 hours, secondary to chemical meningitis the CSF samples may demonstrate a polymorphonuclear and mononuclear polycytosis. Xanthochromia (represents Hemoglobin degradation products) Indicates that blood has been in the CSF for at least two hour and can last for two weeks or more Spectrophotometry It detects blood breakdown products (oxyhemoglobin to methemoglobin to bilirubin) More sensitivity compare to xanthochromia but not widely used
Meningitis	Fever,  neck stiffness headache. Other symptoms include photophobia (inability to tolerate bright light) phonophobia (inability to tolerate loud noises)  irritability, altered mental status (in small children) seizure.	Diagnosis of meningitis, is based on clinical presentation in combination with CSF analysis. CSF analysis has major role for diagnosis and rule out other possibilities.
Intracranial Mass	Headache Nausea Vomiting Change in mental status Seizures Focal symptoms of brain damage Associated co-morbid conditions like tuberculosis, etc
Cerebral hemorrhage	Increased intracranial pressure (ICP) (headache, vomiting, and depressed level of consciousness)  progression of focal neurological deficits over periods of hours
Infarction
Intracranial venous thrombosis
Severe headache with decreased visual acuity, ocular palsies, or visual field changes
Complicated migraine
Midbrain infarction
Cavernous sinus thrombosis
Cerebellar hemorrhage
Signs of hypopituitarism (hypogonadism, hypoadrenalism, or hypothyroidism)
Head injury
Lymphocytic hypophysitis
Iatrogenic surgical
Radiation injury
Infections (particularly tuberculosis and mycotic infections)

Cerebrospinal fluid level	Normal level	Bacterial meningitis	Viral meningitis	Fungal meningitis	Tuberculous meningitis	Neoplastic meningitis
Cells/ul	< 5	>300	10-1000	10-500	50-500	>4
Cells	Lymphocyte	Leukocyte > Lymphocyte	Lymphocyte > Leukocyte	Lymphocyte > Leukocyte	Lymphocyte > Leukocyte	Lymphocyte > Leukocyte
Total protein (mg/dl)	45-60	Typically 100-500	Normal or slightly high	High	Typically 100-200	>50
Glucose ratio (CSF/plasma)	> 0.5	< 0.3	> 0.6	<0.3	< 0.5	<0.5
Lactate (mmols/l)	< 2.1	> 2.1	< 2.1	>3.2	> 2.1	>2.1
Others	Intra-cranial pressure (ICP) = 6-12 (cm H2O)	CSF gram stain, CSF culture, CSF bacterial antigen	PCR of HSV-DNA, VZV	CSF gram stain, CSF india ink	PCR of TB-DNA	CSF tumour markers such as alpha fetoprotein, CEA