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) 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. For more information on CSF analysis in meningitis please click here.
Intracranial Mass	Headache Nausea Vomiting Change in mental status Seizures Focal symptoms of brain damage Associated co-morbid conditions like tuberculosis, etc	CT and MRI These tests are of higher value to detect intracranial lesions. They have higher sensitivity and specificity compared to X-rays. Biopsy Biopsy of the lesion is needed to know the nature of the lesion. X ray X- ray skull is quite a non specific test, but useful if any of the lesions are calcified. X- ray chest may be warranted if any metastatic tumor is suspected. Blood tests Serum BNP (Brain natriuretic peptide)
Cerebral hemorrhage	Increased intracranial pressure (ICP) (headache, vomiting, and depressed level of consciousness)  progression of focal neurological deficits over periods of hours	Diagnosis is based on history of symptoms development, physical examination and imaging findings. CT is very sensitive for identifying acute hemorrhage and is considered the gold standard. CT scan without contrast is the initial test performed to diagnose ischemic stroke and rule out hemorrhagic stroke. 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.
Cerebral Infarction	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.	Diagnosis is based on history of symptoms development, physical examination and imaging findings. CT scan without contrast is the initial test performed to diagnose ischemic stroke and rule out hemorrhagic stroke. 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. It may also help differentiate viable tissue from infarct area if combined with MR perfusion. For diagnosing ischemic stroke in the emergency setting, MRI scan has the sensitivity and specificity of 83% and 98% respectively.[45] MRI scan is superior to CT scan for being more sensitive and specific in detection of lacunar and posterior fossa infarcts, differentiation between acute and chronic stroke and detection of microbleeds. Another additional advantage is absence of ionising radiation compared to CT scan. Some of the disadvantages of MRI scan may include lack of availability in acute setting, higher cost, inability to use it in patients with metallic implants. MRI with contrast cannot be used in patients with renal failure.[46][47]
Intracranial venous thrombosis	Headache: It is a common presentation (present in 90% of cases); it tends to worsen over a period of several days, but may also develop suddenly (thunderclap headache).[1] The headache may be the only symptom of cerebral venous sinus thrombosis.[2] Inability to move one or more limbs Weakness on one side of the face Aphasia Seizures: 40% of all patients have seizure. It is more in women before and after birth.[3] Focal seizures Tonic-clonic seizure Status epilepticus[1] Depressed level of consciousness and otherwise unexplained changes in mental status are common symptoms in the elderly.[4]	CT and MRI Cerebral edema and venous infarction may be apparent. The classic finding of sinus thrombosis on unenhanced CT images is a hyperattenuating thrombus in the occluded sinus; however, hyperattenuation is present in only 25% of sinus thrombosis cases. Increased attenuation in the venous sinuses also may be seen in patients with dehydration, an elevated hematocrit level, or a subjacent subarachnoid hemorrhage or subdural hematoma. CT venography For the detection of the thrombus itself, the most commonly used tests are computed tomography (CT) and magnetic resonance imaging (MRI), both using various types of radiocontrast to perform a venogram. Computed tomography, with radiocontrast in the venous phase (CT venography or CTV), has a detection rate that in some regards exceeds that of MRI. The test involves injection into a vein (usually in the arm) of a radioopaque substance, and time is allowed for the bloodstream to carry it to the cerebral veins - at which point the scan is performed. It has a sensitivity of 75-100% (it detects 75-100% of all clots present), and a specificity of 81-100% (it would be incorrectly positive in 0-19%). In the first two weeks, the "empty delta sign" may be observed (in later stages, this sign may disappear). Cerebral angiography Cerebral angiography may demonstrate smaller clots, and obstructed veins may give the "corkscrew appearance".
Severe headache with decreased visual acuity, ocular palsies, or visual field changes
migraine	Migraine can present in the following four phases Prodrome Phase This phase is characterized by the occurrence of vegetative or affective symptoms as early as 24 to 48 hours prior the beginning of the migraine attacks. The typical symptoms include altered mood, irritability, depression or euphoria, fatigue, yawning, excessive sleepiness, craving for certain food (e.g., chocolate), muscle stiffness (especially in the neck), constipation, diarrhea or increased urination. The prodrome phase helps the patient or observant family to predict the occurrence of a new migraine episode.[1] Aura Phase[edit | edit source] For the 20-30%[2][3] of migraineurs who suffer migraine with aura, this aura comprises focal neurological phenomena that precede or accompany the attack. They appear gradually over 5 to 20 minutes and generally last fewer than 60 minutes. Pain Phase The headache of migraine is often but not always unilateral and tends to have a throbbing or pulsatile quality, especially as the intensity increases. The pain may be bilateral at the onset or may start on one side then becomes generalized. The headache usually alternates sides from one attack to the next. The onset is usually gradual. The pain peaks and then subsides, and usually lasts between 4 and 72 hours in adults and 1 and 48 hours in children. The pain of migraine is invariably accompanied by other features. Nausea occurs in almost 90 percent of patients, while vomiting occurs in about one third of patients. Many patients experience sensory hyperexcitability manifested by photophobia, phonophobia, osmophobia and seek a dark and quiet room. Blurred vision, nasal stuffiness, diarrhea, polyuria, pallor or sweating may be noted during the headache phase. There may be localized edema of the scalp or face, scalp tenderness, prominence of a vein or artery in the temple, or stiffness and tenderness of the neck. Impairment of concentration and mood are common. Lightheadedness, rather than true vertigo and a feeling of faintness may occur. The extremities tend to be cold and moist. Postdrome Phase The effects of migraine may persist for some days after the main headache has ended; this is called the migraine postdrome. Many report a sore feeling in the area where the migraine was, and some report impaired thinking for a few days after the headache has passed.
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)