Pituitary adenoma differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D.

Overview

On the basis of seizure, visual disturbance, and constitutional symptoms, pituitary adenoma must be differentiated from oligodendroglioma, meningioma, hemangioblastoma, astrocytoma, schwannoma, primary CNS lymphoma, medulloblastoma, ependymoma, craniopharyngioma, pinealoma, AV malformation, brain aneurysm, bacterial brain abscess, tuberculosis, toxoplasmosis, hydatid cyst, CNS cryptococcosis, CNS aspergillosis, and brain metastasis.

Differential Diagnosis

Differentiating pituitary adenoma from other diseases on the basis of seizure, visual disturbance, and constitutional symptoms

On the basis of seizure, visual disturbance, and constitutional symptoms, pituitary adenoma must be differentiated from oligodendroglioma, meningioma, hemangioblastoma, astrocytoma, schwannoma, primary CNS lymphoma, medulloblastoma, ependymoma, craniopharyngioma, pinealoma, AV malformation, brain aneurysm, bacterial brain abscess, tuberculosis, toxoplasmosis, hydatid cyst, CNS cryptococcosis, CNS aspergillosis, and brain metastasis.

Diseases Clinical manifestations Para-clinical findings Gold
standard
Additional findings
Symptoms Physical examination
Lab Findings MRI Immunohistopathology
Head-
ache
Seizure Visual disturbance Constitutional Focal neurological deficit
Adult primary brain tumors Pituitary adenoma
[1][2][3]
+ Bitemporal hemianopia
  • It is associated with MEN1 disease.
Glioblastoma multiforme
[4][5][3]
+ +/− +/− +
  • Pseudopalisading appearance
oligodendroglioma
[6][7][8]
+ + +/− +
  • Chicken wire capillary pattern
  • Fried egg cell appearance
Meningioma
[9][10][11]
+ +/− +/− +
  • Well circumscribed
  • Extra-axial mass
  • Whorled spindle cell pattern
  • May be associated with NF-2
Hemangioblastoma
[12][13][14][15]
+ +/− +/− +
Schwannoma
[16][17][18][19]
+
  • Split-fat sign
  • Fascicular sign
  • Often have areas of hemosiderin
  • S100+
Primary CNS lymphoma
[20][21]
+ +/− +/− +
  • Single mass with ring enhancement
Childhood primary brain tumors Pilocytic astrocytoma
[22][23][24]
+ +/− +/− +
Medulloblastoma
[25][26][27]
+ +/− +/− +
  • Homer wright rosettes
Ependymoma
[28][3]
+ +/− +/− +
  • Hydrocephalus
  • Causes an unusually persistent, continuous headache in children.
Craniopharyngioma
[29][30][31][3]
+ +/− + Bitemporal hemianopia +
Pinealoma
[32][33][34]
+ +/− +/− + vertical gaze palsy
  • May cause prinaud syndrome (vertical gaze palsy, pupillary light-near dissociation, lid retraction and convergence-retraction nystagmus
Vascular AV malformation
[35][36][3]
+ + +/− +/−
Brain aneurysm
[37][38][39][40][41]
+ +/− +/− +/−
Infectious Bacterial brain abscess
[42][43]
+ +/− +/− + +
  • Central hypodense signal and surrounding ring-enhancement in T1
  • Central hyperintense area surrounded by a well-defined hypointense capsule with surrounding edema in T2
  • Clinical presentation/ imaging
Tuberculosis
[44][3][45]
+ +/− +/− + +
  • CSF analysis/ Imaging
Toxoplasmosis
[46][47]
+ +/− +/− +
  • Clinical presentation/ imaging
Hydatid cyst
[48][3]
+ +/− +/− +/− +
  • Imaging
CNS cryptococcosis
[49]
+ +/− +/− + +
  • We may see numerous acutely branching septate hyphae
CNS aspergillosis
[50]
+ +/− +/− + +
  • Multiple abscesses
  • Ring enhancement
  • Peripheral low signal intensity on T2
  • We may see numerous acutely branching septate hyphae
Other Brain metastasis
[51][3]
+ +/− +/− + +
  • Based on the primary cancer type we may have different immunohistopathology findings.
  • History/ imaging
  • If there is any uncertainty about etiology, biopsy should be performed

ABBREVIATIONS

CNS=Central nervous system, AV=Arteriovenous, CSF=Cerebrospinal fluid, NF-2=Neurofibromatosis type 2, MEN-1=Multiple endocrine neoplasia, GFAP=Glial fibrillary acidic protein, HIV=Human immunodeficiency virus, BhCG=Human chorionic gonadotropin, ESR=Erythrocyte sedimentation rate, AFB=Acid fast bacilli

References

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