Pituitary apoplexy differential diagnosis: Difference between revisions

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{| class="wikitable"
{| class="wikitable"
! rowspan="3" |Onset
! rowspan="3" |Disease
! rowspan="3" |Disease
! colspan="3" |Symptoms
! colspan="2" |Symptoms
! rowspan="3" |Gold Standard
! rowspan="3" |Gold Standard
! rowspan="3" |CT/MRI
! rowspan="3" |CT/MRI
! rowspan="3" |Other Investigation Findings
! rowspan="3" |Other Investigation Findings
|-
|-
! colspan="2" |'''Headache'''
!'''Headache'''
! rowspan="2" |Other features
! rowspan="2" |Other features
|-
|-
!Onset
!Characteristics
!Characteristics
|-
|-
| rowspan="7" |Sudden
|Pituitary apoplexy
|Pituitary apoplexy
|Sudden
|Severe [[headache]]
|Severe [[headache]]
|
|
Line 98: Line 98:
|-
|-
|[[Subarachnoid hemorrhage]]  
|[[Subarachnoid hemorrhage]]  
|Sudden
|
|
* [[Headache|Severe headache]]
* [[Headache|Severe headache]]
Line 119: Line 118:
|-
|-
|[[Meningitis]]
|[[Meningitis]]
|Sudden
|[[Headache]] is associated with:
|[[Headache]] is associated with:
* [[Fever]]  
* [[Fever]]  
Line 136: Line 134:
* [[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.]]
|-
|[[Intracranial mass]]
|Gradual
|[[Morning headache]]
|
* [[Nausea]]
* [[Vomiting]]
* [[Change in mental status]]
* [[Seizures]]
* Focal neurological deficits
|[[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]].
|
* [[Biopsy]] of the lesion may be done 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 lesion|calcified]]
|-
|-
|[[Cerebral hemorrhage]]
|[[Cerebral hemorrhage]]
|Sudden
|Rapidly progressing headache  
|Rapidly progressing headache  
|
|
Line 171: Line 148:
|
|
* [[PT]]/[[INR]] and [[aPTT]] should be checked to rule out [[coagulopathy]].
* [[PT]]/[[INR]] and [[aPTT]] should be checked to rule out [[coagulopathy]].
|-
|[[Intracranial venous thrombosis]]
|Gradual
|
* Diffuse [[headache]]
* [[Headache]] can be the only symptom of [[Cerebral venous sinus thrombosis|cerebral venous thrombosis]]
|
* Focal neurological deficits
* [[Seizure|Seizures]]
* [[Coma|Depressed level of consciousness]] 
|[[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]]
|[[Migraine]]
|Sudden
|
|
* Severe to moderate [[headache]]  
* Severe to moderate [[headache]]  
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|-
|-
|[[Head injury]]
|[[Head injury]]
|Sudden
|
|
* Dull  
* Dull  
Line 237: Line 191:
|-
|-
|[[Lymphocytic hypophysitis]]
|[[Lymphocytic hypophysitis]]
|Sudden
|
|
* Generalized
* Generalized
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|[[CT]] & [[MRI]] typically reveal features of a pituitary mass.
|[[CT]] & [[MRI]] typically reveal features of a pituitary mass.
|The most accurate test is a pituitary [[biopsy]] which will show [[lymphocytic]] [[Infiltration (medical)|infiltration]].
|The most accurate test is a pituitary [[biopsy]] which will show [[lymphocytic]] [[Infiltration (medical)|infiltration]].
|-
| rowspan="2" |Gradual
|[[Intracranial mass]]
|[[Morning headache]]
|
* [[Nausea]]
* [[Vomiting]]
* [[Change in mental status]]
* [[Seizures]]
* Focal neurological deficits
|[[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]].
|
* [[Biopsy]] of the lesion may be done 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 lesion|calcified]]
|-
|[[Intracranial venous thrombosis]]
|
* Diffuse [[headache]]
* [[Headache]] can be the only symptom of [[Cerebral venous sinus thrombosis|cerebral venous thrombosis]]
|
* Focal neurological deficits
* [[Seizure|Seizures]]
* [[Coma|Depressed level of consciousness]] 
|[[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."
|}
|}


Revision as of 18:29, 10 August 2017

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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, 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]

Onset Disease Symptoms Gold Standard CT/MRI Other Investigation Findings
Headache Other features
Characteristics
Sudden Pituitary apoplexy Severe headache MRI
  • CT scan without contrast is the initial test of choice. Pituitary hemorrhage on CT presents as a hyper-dense lesion.
  • MRI is done in cases of inconclusive CT. An MRI is more sensitive in identifying intrasellar mass and soft tissue changes.
 Blood tests may be done to check:
  • PT/INR and aPTT
  • Pituitary hormonal assay
Subarachnoid hemorrhage Digital subtraction angiography
Meningitis Headache is associated with: 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.
Cerebral hemorrhage Rapidly progressing headache
  • Focal neurological deficits
 CT without contrast

(differentiate ischemic stroke from hemorrhagic stroke)

  • CT is very sensitive for identifying acute hemorrhage which appears as a 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.
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.
  • 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.
Head injury
  • Dull
  • Throbbing
  • One sided or all around
 CT scan without contrast
  • CT scan is the first test performed and identifies cerebral hemorrhage (appears as a hyperattenuating clot) following head injury.
  • MRI is more sensitive, takes more time, and is done in patients with symptoms unexplained by CT scan.
Lymphocytic hypophysitis
  • Generalized
  • Retro-orbital or Bitemporal
  • Most often seen in late pregnancy or the postpartum period
 Pituitary biopsy CT & MRI typically reveal features of a pituitary mass. The most accurate test is a pituitary biopsy which will show lymphocytic infiltration.
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.
  • Biopsy of the lesion may be done to identify the nature of the lesion such as:
  • X-ray of the skull is a non specific test, but useful if any of the lesions are calcified
Intracranial venous thrombosis Digital subtraction angiography
  • The classic finding of sinus thrombosis on unenhanced CT images is a hyperattenuating thrombus in the occluded sinus.
  • Cerebral angiography may demonstrate smaller clots, and obstructed veins may give the "corkscrew appearance."

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. ↑ Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.

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