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]
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)