Sandbox:Akshun: Difference between revisions

Jump to navigation Jump to search
No edit summary
No edit summary
Line 39: Line 39:
* [[Phonophobia]] (inability to tolerate loud noises) 
* [[Phonophobia]] (inability to tolerate loud noises) 
* [[Irritability]], [[altered mental status]] (in small children).
* [[Irritability]], [[altered mental status]] (in small children).
|
|CT scan of the head may be performed before LP to determine the risk of herniation.
|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 [[Meningitis#Diagnosis|click here.]]
|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 [[Meningitis#Diagnosis|click here.]]
|-
|-
Line 52: Line 52:
* Associated co-morbid conditions like tuberculosis, etc
* Associated co-morbid conditions like tuberculosis, etc
|
|
 
CT & MRI are the initial test to detect intracranial lesions. These imaging test determine the location of intracranial mass lesion(s) and help in guiding therapy.
CT & MRI are of higher value to detect intracranial lesions.
|Biopsy
|Biopsy
* Biopsy of the lesion is needed to know the nature of the lesion.
* Biopsy of the lesion is needed to know the nature of the lesion.
Line 68: Line 67:
* [[CT scan]] without contrast is the initial test performed to diagnose [[ischemic stroke]] and rule out [[hemorrhagic stroke]].
* [[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.
* 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.
|
|PT/ INR and aPTT should be checked to rule out any coagulopathy.


|-
|-
Line 77: Line 76:
* 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.  
* 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.  
|
|
* Carotid doppler can be done to check for patency of carotid arteries and blood supply to the brain.
* Cerebral angiogram is an invasive test and detect abnormalities of the blood vessels, including narrowing, blockage, or malformations (such as aneurysms or arterio-venous malformations). 


|-
|-
Line 88: Line 90:
* [[Coma|Depressed level of consciousness]] and otherwise unexplained changes in [[mental status]] are common symptoms in the elderly.<sup>[[Cerebral venous sinus thrombosis history and symptoms#cite note-4|[4]]]</sup>
* [[Coma|Depressed level of consciousness]] and otherwise unexplained changes in [[mental status]] are common symptoms in the elderly.<sup>[[Cerebral venous sinus thrombosis history and symptoms#cite note-4|[4]]]</sup>
|
|
 
CT and MRI identify
CT and MRI
* [[Cerebral edema]] and venous infarction may be apparent.
* [[Cerebral edema]] and venous infarction may be apparent.


Line 117: Line 118:
* [[Headache|Loss of consciousness]]
* [[Headache|Loss of consciousness]]
* A [[lucid interval]], during which a patient appears conscious only to deteriorate later
* A [[lucid interval]], during which a patient appears conscious only to deteriorate later
|
|CT scan take less time and are intially the first test done.
 
MRI is more sensitive but takes more time. They are
|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.
|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.
|-
|-
Line 133: Line 136:
* Focal neurological abnormalities and evidence of raised intracranial pressure.
* Focal neurological abnormalities and evidence of raised intracranial pressure.
|
|
CT & MRI will show
CT & MRI will show
* Focal radiation necrosis
* Focal radiation necrosis
* Diffuse white matter injury  
* Diffuse white matter injury  
* Contrast-enhancing mass surrounded by edema and mass effect.
* Contrast-enhancing mass surrounded by edema and mass effect.
|
|PET scan
* Radiation necrosis is hypo metabolic and will have decreased uptake of fluorodeoxyglucose.


|}
|}
<references />
<references />

Revision as of 13:19, 21 July 2017


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 and other conditions.

Differentiating Pituitary apoplexy From Other Diseases

Pituitary apoplexy should be differentiated from other diseases causing severe headache for example:

Disease Symptoms Diagnosis
CT/MRI Other Investigation Findings
Subarachnoid hemorrhage The modality of choice for diagnosis of subarachnoid hemorrhage is noncontrast head computed tomography (CT), with or without lumbar puncture.[1]

Lumbar puncture (LP) seems necessary when there is a strong suspicion of subarachnoid hemorrhage.

Meningitis CT scan of the head may be performed before LP to determine the risk of herniation. 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 & MRI are the initial test to detect intracranial lesions. These imaging test determine the location of intracranial mass lesion(s) and help in guiding therapy.

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.
Cerebral hemorrhage
  • Headache, vomiting, and depressed level of consciousness from increased intracranial pressure (ICP)  
  • Progression of focal neurological deficits over periods of hours
  • 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.
PT/ INR and aPTT should be checked to rule out any coagulopathy.
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.
  • Carotid doppler can be done to check for patency of carotid arteries and blood supply to the brain.
  • Cerebral angiogram is an invasive test and detect abnormalities of the blood vessels, including narrowing, blockage, or malformations (such as aneurysms or arterio-venous malformations). 
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.
  • Depressed level of consciousness and otherwise unexplained changes in mental status are common symptoms in the elderly.[4]

CT and MRI identify

  • The classic finding of sinus thrombosis on unenhanced CT images is a hyperattenuating thrombus in the occluded sinus.
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] 
CT and MRI might 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 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:

CT scan take less time and are intially the first test done.

MRI is more sensitive but takes more time. They are

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.
PET scan
  • Radiation necrosis is hypo metabolic and will have decreased uptake of fluorodeoxyglucose.