Pituitary apoplexy differential diagnosis: Difference between revisions

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{{Pituitary apoplexy}}
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{{CMG}} {{AE}} {{Akshun}}
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{{CMG}}; {{AE}} {{Akshun}}
==Overview==
==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, head injury, lymphocytic hypophysitis and radiation injury.
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, head injury, lymphocytic hypophysitis and radiation injury.
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* [[Headache|Severe headache]] (as a worst headache of the life)
* [[Headache|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)
** Headache is the main symptom (often starts suddenly and starts after a popping or snapping feeling in the head)
* [[Double vision]]
* [[Double vision]]
* [[Nausea]] and [[vomiting]]
* [[Nausea]] and [[vomiting]]
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{{Reflist|2}}
{{Reflist|2}}


==Differentiating pituitary apoplexy from other diseases==
Pituitary apoplexy must be differentiated from other conditions that cause severe headache, nausea and vomiting such as subarachnoid hemorrhage, bacterial meningitis, cavernous sinus thrombosis.
==References==
{{reflist|2}}
{{reflist|2}}



Revision as of 14:52, 21 July 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Akshun Kalia M.B.B.S.[2]


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]; Associate Editor(s)-in-Chief: Akshun Kalia M.B.B.S.[4]

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, head injury, lymphocytic hypophysitis and radiation injury.

Differentiating Pituitary apoplexy From Other Diseases

Pituitary apoplexy should be differentiated from other diseases causing severe headache for example: [1][2][3][4][5][6][7][8][9][10]

Disease Symptoms Diagnosis
CT/MRI Other Investigation Findings
Subarachnoid hemorrhage
Meningitis
  • CT scan of the head may be performed before LP to determine the risk of herniation.
  • Diagnosis is based on clinical presentation in combination with CSF analysis.
  • CSF analysis is the investigation of choice.
  • 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 or MRI is the initial test to detect intracranial lesions.
  • These imaging tests determine the location of intracranial mass lesion(s) and help in guiding therapy.
  • X- ray of the skull is a non specific test, but useful if any of the lesions are calcified.
Cerebral hemorrhage
  • Progression of focal neurological deficits over periods of hours
  • CT scan without contrast is the initial test performed to diagnose ischemic stroke and rule out hemorrhagic stroke
  • CT is very sensitive for identifying acute hemorrhage and is considered the gold standard.
  • 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 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 may 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]
  • The classic finding of sinus thrombosis on unenhanced CT images is a hyperattenuating thrombus in the occluded sinus.
  • CT and MRI may identify Cerebral edema and venous infarction may be apparent.
  • CT venography detects the thrombus, 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 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 may 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
  • CT scan is the first test performed and checks for cerebral hemorrhage following head injury. CT scan is also less time consuming.
  • MRI is more sensitive, takes more time and is done in patients with symptoms unexplained by CT.
Lymphocytic hypophysitis Lymphocytic hypophysitis is most often seen in late pregnancy or the postpartum period with the following symptoms:
  • 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.

References

  1. Endrit Ziu & Fassil Mesfin (2017). "Subarachnoid Hemorrhage". PMID 28722987.
  2. Benedikt Schwermer, Daniel Eschle & Constantine Bloch-Infanger (2017). "[Fever and Headache after a Vacation in Thailand]". Deutsche medizinische Wochenschrift (1946). 142 (14): 1063–1066. doi:10.1055/s-0043-106282. PMID 28728201.
  3. Otto Rapalino & Mark E. Mullins (2017). "Intracranial Infectious and Inflammatory Diseases Presenting as Neurosurgical Pathologies". Neurosurgery. doi:10.1093/neuros/nyx201. PMID 28575459.
  4. I. B. Komarova, V. P. Zykov, L. V. Ushakova, E. K. Nazarova, E. B. Novikova, O. V. Shuleshko & M. G. Samigulina (2017). "[Clinical and neuroimaging signs of cardioembolic stroke laboratory in children]". Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 117 (3. Vyp. 2): 11–19. doi:10.17116/jnevro20171173211-19. PMID 28665364.
  5. Sanjay Konakondla, Clemens M. Schirmer, Fengwu Li, Xiaogun Geng & Yuchuan Ding (2017). "New Developments in the Pathophysiology, Workup, and Diagnosis of Dural Venous Sinus Thrombosis (DVST) and a Systematic Review of Endovascular Treatments". Aging and disease. 8 (2): 136–148. doi:10.14336/AD.2016.0915. PMID 28400981.
  6. Priyanka Yadav, Alec L. Bradley & Jonathan H. Smith (2017). "Recognition of Chronic Migraine by Medicine Trainees: A Cross-Sectional Survey". Headache. doi:10.1111/head.13133. PMID 28653369.
  7. S. Wulffeld, L. S. Rasmussen, B. Hojlund Bech & J. Steinmetz (2017). "The effect of CT scanners in the trauma room - an observational study". Acta anaesthesiologica Scandinavica. 61 (7): 832–840. doi:10.1111/aas.12927. PMID 28635146.
  8. Johnston PC, Chew LS, Hamrahian AH, Kennedy L (2015). "Lymphocytic infundibulo-neurohypophysitis: a clinical overview". Endocrine. 50 (3): 531–6. doi:10.1007/s12020-015-0707-6. PMID 26219407.
  9. Makale MT, McDonald CR, Hattangadi-Gluth JA, Kesari S (2017). "Mechanisms of radiotherapy-associated cognitive disability in patients with brain tumours". Nat Rev Neurol. 13 (1): 52–64. doi:10.1038/nrneurol.2016.185. PMID 27982041.
  10. Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.

Differentiating pituitary apoplexy from other diseases

Pituitary apoplexy must be differentiated from other conditions that cause severe headache, nausea and vomiting such as subarachnoid hemorrhage, bacterial meningitis, cavernous sinus thrombosis.

References

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