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 |
|
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]
|
|
| Meningitis |
|
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 |
|
||
| Cerebral hemorrhage |
|
||
| 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[1] | Viral meningitis[1] | Fungal meningitis | Tuberculous meningitis[2] | Neoplastic meningitis[3] |
|---|---|---|---|---|---|---|
| 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)[4] | > 0.5 | < 0.3 | > 0.6 | <0.3 | < 0.5 | <0.5 |
| Lactate (mmols/l)[5] | < 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 |
- ↑ 1.0 1.1 Negrini B, Kelleher KJ, Wald ER (2000). "Cerebrospinal fluid findings in aseptic versus bacterial meningitis". Pediatrics. 105 (2): 316–9. PMID 10654948.
- ↑ Caudie C, Tholance Y, Quadrio I, Peysson S (2010). "[Contribution of CSF analysis to diagnosis and follow-up of tuberculous meningitis]". Ann Biol Clin (Paris). 68 (1): 107–11. doi:10.1684/abc.2010.0407. PMID 20146981.
- ↑ Le Rhun E, Taillibert S, Chamberlain MC (2013). "Carcinomatous meningitis: Leptomeningeal metastases in solid tumors". Surg Neurol Int. 4 (Suppl 4): S265–88. doi:10.4103/2152-7806.111304. PMC 3656567. PMID 23717798.
- ↑ Chow E, Troy SB (2014). "The differential diagnosis of hypoglycorrhachia in adult patients". Am J Med Sci. 348 (3): 186–90. doi:10.1097/MAJ.0000000000000217. PMC 4065645. PMID 24326618.
- ↑ Leen WG, Willemsen MA, Wevers RA, Verbeek MM (2012). "Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice". PLoS One. 7 (8): e42745. doi:10.1371/journal.pone.0042745. PMC 3412827. PMID 22880096.