Pituitary apoplexy differential diagnosis

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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, lymphocytic hypophysitis and radiation injury.

Differentiating Pituitary apoplexy From Other Diseases

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

Disease	Symptoms		Diagnosis
			Gold Standard	CT/MRI	Other Investigation Findings
	Headache	Other features
Subarachnoid hemorrhage	Severe headacheas the worst headache of life Headache starts suddenly and after a popping or snapping feeling in the head	Double vision Nausea and vomiting Symptoms of meningeal irritation Sudden decreased level of consciousness Rapid progression of symptoms	Digital subtraction angiography	The modality of choice for diagnosis of subarachnoid hemorrhage is noncontrast head computed tomography (CT), with or without lumbar puncture.[1] CT shows hyperattenuating material filling the subarachnoid space.	Lumbar puncture (LP) is necessary when there is a strong suspicion of subarachnoid hemorrhage. LP will show: Elevated opening pressure Elevated red blood cell (RBC) Xanthochromia
Meningitis	Headache with fever and neck stiffness	Photophobia (inability to tolerate bright light)   Phonophobia (inability to tolerate loud noises)  Irritability, altered mental status (in small children)	Lumbar puncture for CSF	CT scan of the head may be performed before LP to determine the risk of herniation.	Diagnosis is based on clinical presentation in combination with CSF analysis. CSF analysis is the investigation of choice. For more information on CSF analysis in meningitis please click here.
Intracranial mass	Headache with focal neurological deficits	Nausea Vomiting Change in mental status Seizures Can be associated comorbid conditions like tuberculosis, etc	MRI	CT or MRI is the initial test to detect intracranial lesions. These imaging tests determine the location of intracranial mass lesion(s) and help in guiding therapy.	Biopsy of the lesion is needed to identify the nature of the lesion such as: Tumor Abscess X- ray of the skull is a non specific test, but useful if any of the lesions are calcified.
Cerebral hemorrhage	Rapidly worsening headache with focal neurological deficits	Headache, vomiting, and depressed level of consciousness from increased intracranial pressure (ICP)   Progression of focal neurological deficits over periods of hours	CT scan without contrast	CT scan without contrast is the initial test performed to differentiate ischemic stroke and rule out hemorrhagic stroke. CT is very sensitive for identifying acute hemorrhage which appears as hyperattenuating clot. 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.	PT/ INR and aPTT should be checked to rule out coagulopathy.
Cerebral Infarction	Headache with tightness around the forehead and focal neurological deficits	The symptoms of an ischemic stroke vary widely depending on the site and blood supply of the area involved. For more information on symptoms of ischemic stroke based on area involved please click here.	Cerebral angiography	CT scan without contrast is the initial test performed to diagnose ischemic stroke and rule out hemorrhagic stroke. CT may show hypo-attenuation and swelling of involved area. MR diffusion weighted imaging is the most sensitive and specific test for diagnosing ischemic stroke and may help detect presence of infarction in few minutes of onset of symptoms.	Carotid doppler may be done to check for patency of carotid arteries and blood supply to the brain. Cerebral angiography is an invasive test and detect abnormalities of the blood vessels, including narrowing, blockage, or malformations (such as aneurysms or arterio-venous malformations).
Intracranial venous thrombosis	Diffuse headache that progresses over several days to weeks Headache can be the only symptom of cerebral venous thrombosis	Inability to move one or more limbs. Weakness on one side of the face. Seizures: 40% of all patients have seizure. Depressed level of consciousness and otherwise unexplained changes in mental status are common symptoms in the elderly.[4]	Digital subtraction angiography	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.	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".
Migraine	Severe or moderate headache (which is often one-sided and pulsating) lasts between several hours to three days.	Gastrointestinal upset such as nausea and vomiting Preceding aura (in 35% pts) Heightened sensitivity to: Bright lights (photophobia) Noise (phonophobia).	---	CT and MRI may be needed to rule out other suspected possible causes of headache.	Migraine is a clinical diagnosis that does not require any laboratory tests. Laboratory tests can be ordered to rule out any suspected coexistent metabolic problems or to determine the baseline status of the patient before initiation of migraine therapy.
Head injury	Headache: Dull Throbbing can be on one side or all around the forehead	Confusion Drowsiness Personality change Seizures Nausea and vomiting Loss of consciousness lucid interval	CT scan without contrast	CT scan is the first test performed and identifies cerebral hemorrhage (appears as hyperattenuating clot) following head injury. CT scan is also less time consuming. MRI is more sensitive, takes more time and is done in patients with symptoms unexplained by CT scan.	The Glasgow Coma Scale is a tool for measuring degree of unconsciousness and is thus a useful tool for determining severity of injury. The Pediatric Glasgow Coma Scale is used in young children.
Lymphocytic hypophysitis	Headache: Generalized Retro-orbital or Bitemporal	Lymphocytic hypophysitis is most often seen in late pregnancy or the postpartum period with the following symptoms: Mass lesion effect such as headache or visual field defects Hypopituitarism	Pituitary biopsy	CT & MRI typically reveal features of a pituitary mass.	The most accurate test is pituitary biopsy which will show lymphocytic infiltration.
Radiation injury	Headache develops gradually	Impairment of mental function is the most prominent feature such as personality change, impairment of memory, confusion, learning difficulties Focal neurological abnormalities and evidence of raised intracranial pressure	Surgical exploration including biopsy (histological confirmation)	CT & MRI will show: Focal radiation necrosis Diffuse white matter injury Contrast-enhancing mass surrounded by edema and mass effect	PET scan Radiation necrosis is hypo metabolic and will have decreased uptake of fluorodeoxyglucose.