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. 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.[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. CT venography For the detection of the thrombus itself, 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 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. Other symptoms include gastrointestinal upsets, such as nausea and vomiting, and a heightened sensitivity to bright lights (photophobia) and noise (phonophobia). Approximately one third of people who experience migraine get a preceding aura.[4]	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	Common symptoms of head injury include those indicative of traumatic brain injury: Headache Confusion Drowsiness Personality change Seizures Nausea and vomiting Loss of consciousness A lucid interval, during which a patient appears conscious only to deteriorate later	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	Lymphocytic hypophysitis is most often seen in late pregnancy or the postpartum period with the following symptoms: Hypopituitarism Mass lesion effect such as headache or visual field defects	CT & MRI typically reveal features of a pituitary mass. The most accurate test is pituitary biopsy which will show lymphocytic infiltration.
Radiation injury	Headache 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.	CT & MRI will show Focal radiation necrosis Diffuse white matter injury Contrast-enhancing mass surrounded by edema and mass effect.