Diagnostic Considerations

A number of other intracranial neoplasms can present as intrasellar tumors. These include craniopharyngiomas, meningiomas, neurofibromas, ectopic germinomas, and, rarely, metastatic tumors.

Granulomatous and infectious disorders can localize to the sellar region or the hypothalamus (eg, sarcoid, tuberculomas).

Carotid artery aneurysm can occur in the intrasellar region.

Lesions in the sphenoid sinus, such as a mucocele, can mimic the clinical picture of a pituitary adenoma.

Hypothalamus compression can cause increased prolactin levels because of a decrease in the prolactin inhibitory factor. Thus, hyperprolactinemia may be seen with non–prolactin-secreting pituitary adenomas and other sellar lesions with hypothalamic compression.

An unusual postpartum lymphocytic inflammatory pituitary lesion can be associated a mass lesion. This is known as lymphocytic hypophysitis.

Acromegaly can result from a nonpituitary source of increased growth hormone.

Differentiating between Cushing disease and Cushing syndrome, which is related to adrenal hyperplasia or tumor, is important.

Other causes of hyperprolactinemia that are unrelated to mass lesions in the pituitary or the hypothalamus include the following:

Intracranial - Empty sella syndrome, pseudotumor cerebri, status post cranial irradiation
Pharmacological - Antipsychotics (and other dopamine receptor antagonists), methyldopa, reserpine, verapamil, estrogen, opiates, cimetidine, sulpiride
Endocrine - Primary hypothyroidism
Metabolic - Chronic renal failure, cirrhosis
Other unusual causes - Breast manipulation, chest wall lesions, spinal cord lesions, stress
In some cases, a specific cause cannot be established.

Differential Diagnoses

Basilar Artery Thrombosis
Brainstem Gliomas
Cavernous Sinus Syndromes
Cerebral Venous Thrombosis
Dizziness, Vertigo, and Imbalance
Glioblastoma Multiforme
Intracranial Hemorrhage
Leptomeningeal Carcinomatosis (Metastasis) Imaging
Low-Grade Astrocytoma
Meningioma
Pediatric Craniopharyngioma
Pediatric Ependymoma
Primary CNS Lymphoma
Tuberculous Meningitis

Workup

Chahal HS, Stals K, Unterländer M, et al. AIP mutation in pituitary adenomas in the 18th century and today. N Engl J Med. 2011 Jan 6. 364(1):43-50. [QxMD MEDLINE Link].
Villwock JA, Villwock M, Deshaies E, Goyal P. Significant increases of pituitary tumors and resections from 1993 to 2011. Int Forum Allergy Rhinol. 2014 Sep. 4(9):767-70. [QxMD MEDLINE Link].
Vlotides G, Eigler T, Melmed S. Pituitary tumor-transforming gene: physiology and implications for tumorigenesis. Endocr Rev. 2007 Apr. 28(2):165-86. [QxMD MEDLINE Link].
Larkin S, Ansorge O, De Groot LJ, Chrousos G, Dungan K, Feingold KR, et al. Pathology and Pathogenesis of Pituitary Adenomas and Other Sellar Lesions. 2000. [QxMD MEDLINE Link]. [Full Text].
Riss D, Jin L, Qian X, et al. Differential expression of galectin-3 in pituitary tumors. Cancer Res. 2003 May 1. 63(9):2251-5. [QxMD MEDLINE Link].
Zhang X, Horwitz GA, Heaney AP, Nakashima M, Prezant TR, Bronstein MD, et al. Pituitary tumor transforming gene (PTTG) expression in pituitary adenomas. J Clin Endocrinol Metab. 1999 Feb. 84(2):761-7. [QxMD MEDLINE Link].
Kosmorsky GS, Dupps WJ Jr, Drake RL. Nonuniform pressure generation in the optic chiasm may explain bitemporal hemianopsia. Ophthalmology. 2008 Mar. 115(3):560-5. [QxMD MEDLINE Link].
Thomas ST. Finite Element Modleing of Chiasmal Compression. J of Undergraduate Engineering Res. 2009. 12:1-30.
Laws ER Jr, Penn DL, Repetti CS. Advances and controversies in the classification and grading of pituitary tumors. J Endocrinol Invest. 2018 Jun 1. [QxMD MEDLINE Link].
Ambrosi B, Dall'Asta C, Cannavo S, et al. Effects of chronic administration of PPAR-gamma ligand rosiglitazone in Cushing's disease. Eur J Endocrinol. 2004 Aug. 151(2):173-8. [QxMD MEDLINE Link].
Talkad AV, Kattah JC, Xu MY, et al. Prolactinoma presenting as painful postganglionic Horner syndrome. Neurology. 2004 Apr 27. 62(8):1440-1. [QxMD MEDLINE Link].
Paterno' V, Fahlbusch R. High-Field iMRI in transsphenoidal pituitary adenoma surgery with special respect to typical localization of residual tumor. Acta Neurochir (Wien). 2014 Mar. 156(3):463-74; discussion 474. [QxMD MEDLINE Link].
Fenstermaker R, Abad A. Imaging of Pituitary and Parasellar Disorders. Continuum (Minneap Minn). 2016 Oct. 22 (5, Neuroimaging):1574-1594. [QxMD MEDLINE Link].
Singh H, Essayed WI, Cohen-Gadol A, Zada G, Schwartz TH. Resection of pituitary tumors: endoscopic versus microscopic. J Neurooncol. 2016 Nov. 130 (2):309-317. [QxMD MEDLINE Link].
Kreutzer J, Fahlbusch R. Diagnosis and treatment of pituitary tumors. Curr Opin Neurol. 2004 Dec. 17(6):693-703. [QxMD MEDLINE Link].
Giustina A, Barkan A, Casanueva FF, et al. Criteria for cure of acromegaly: a consensus statement. J Clin Endocrinol Metab. 2000 Feb. 85(2):526-9. [QxMD MEDLINE Link].
Semple PL, Webb MK, de Villiers JC, Laws ER Jr. Pituitary apoplexy. Neurosurgery. 2005. 56(1):65-72; discussion 72-3. [QxMD MEDLINE Link].
Biousse V, Newman NJ, Oyesiku NM. Precipitating factors in pituitary apoplexy. J Neurol Neurosurg Psychiatry. 2001 Oct. 71(4):542-5. [QxMD MEDLINE Link].
Rotenberg BW, Saunders S, Duggal N. Olfactory outcomes after endoscopic transsphenoidal pituitary surgery. Laryngoscope. 2011 Aug. 121(8):1611-3. [QxMD MEDLINE Link].
Gnanalingham KK, Bhattacharjee S, Pennington R, et al. The time course of visual field recovery following transphenoidal surgery for pituitary adenomas: predictive factors for a good outcome. J Neurol Neurosurg Psychiatry. 2005 Mar. 76(3):415-9. [QxMD MEDLINE Link].
Alameda C, Lucas T, Pineda E, et al. Experience in management of 51 non-functioning pituitary adenomas: indications for post-operative radiotherapy. J Endocrinol Invest. 2005 Jan. 28(1):18-22. [QxMD MEDLINE Link].
Castinetti F, Régis J, Dufour H, Brue T. Role of stereotactic radiosurgery in the management of pituitary adenomas. Nat Rev Endocrinol. 2010 Apr. 6(4):214-23. [QxMD MEDLINE Link].
Ciric I, Zhao JC, Du H, Findling JW, Molitch ME, Weiss RE, et al. Transsphenoidal surgery for Cushing disease: experience with 136 patients. Neurosurgery. 2012 Jan. 70(1):70-80; discussion 80-1. [QxMD MEDLINE Link].
Colin P, Jovenin N, Delemer B, et al. Treatment of pituitary adenomas by fractionated stereotactic radiotherapy: a prospective study of 110 patients. Int J Radiat Oncol Biol Phys. 2005 Jun 1. 62(2):333-41. [QxMD MEDLINE Link].
Conomy JP, Ferguson JH, Brodkey JS, Mitsumoto H. Spontaneous infarction in pituitary tumors: neurologic and therapeutic aspects. Neurology. 1975 Jun. 25(6):580-7. [QxMD MEDLINE Link].
David, NJ, Gargano FP, Glaser JS. Pituitary apoplexy in clinical perspective. Neurophthalmology Symposium. St Louis: CV Mosby; 1975. Vol 8: 140-165.
Dawson BH, Kothandaram P. Acute massive infarction of pituitary adenomas. A study of five patients. J Neurosurg. 1972 Sep. 37(3):275-9. [QxMD MEDLINE Link].
Gharib H, Frey HM, Laws ER, et al. Coexistent primary empty sella syndrome and hyperprolactinemia. Report of 11 cases. Arch Intern Med. 1983 Jul. 143(7):1383-6. [QxMD MEDLINE Link].
Greenberg HS, Chandler WF, Ensminger WD. Radiosensitization with carotid intra-arterial bromodeoxyuridine +/- 5-fluorouracil biomodulation for malignant gliomas. Neurology. 1994 Sep. 44(9):1715-20. [QxMD MEDLINE Link].
Jagannathan J, Yen CP, Pouratian N, Laws ER, Sheehan JP. Stereotactic radiosurgery for pituitary adenomas: a comprehensive review of indications, techniques and long-term results using the Gamma Knife. J Neurooncol. 2009 May. 92(3):345-56. [QxMD MEDLINE Link].
Jho HD. Endoscopic endonasal pituitary surgery: Technical aspects. Contemporary Neurosurgery. 1997. 19:1-8.
Jho HD, Carrau RL, Ko Y, Daly MA. Endoscopic pituitary surgery: an early experience. Surg Neurol. 1997 Mar. 47(3):213-22; discussion 222-3. [QxMD MEDLINE Link].
Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Paluzzi A, Wang EW, Snyderman CH. Endoscopic endonasal surgery for Giant Pituitary adenomas: Advantages and Limitations. J of Neursurg. January/2013. E Pubahead of print:
Levy A, Lightman SL. Diagnosis and management of pituitary tumours. BMJ. 1994 Apr 23. 308(6936):1087-91. [QxMD MEDLINE Link].
Melmed S. Acromegaly. N Engl J Med. 1990 Apr 5. 322(14):966-77. [QxMD MEDLINE Link].
Molitch ME. Pregnancy and the hyperprolactinemic woman. N Engl J Med. 1985 May 23. 312(21):1364-70. [QxMD MEDLINE Link].
Oldfield EH, Doppman JL, Nieman LK, Chrousos GP, Miller DL, Katz DA, et al. Petrosal sinus sampling with and without corticotropin-releasing hormone for the differential diagnosis of Cushing's syndrome. N Engl J Med. 1991 Sep 26. 325(13):897-905. [QxMD MEDLINE Link].
Orth DN. Cushing's syndrome. N Engl J Med. 1995 Mar 23. 332(12):791-803. [QxMD MEDLINE Link].
Rotenberg BW, Saunders S, Duggal N. Olfactory outcomes after Endoscopic Transphenoidal Pituitary surgery. The Laryngoscope. 2011. 121:1611-1613.
Thorner MO, Vance ML, Laws ER. The anterior pituitary. Williams, ed. Textbook of Endocrinology. Philadelphia: WB Saunders; 1998. 249-340.
Zhang X, Horwitz GA, Heaney AP, Nakashima M, Prezant TR, Bronstein MD, et al. Pituitary tumor transforming gene (PTTG) expression in pituitary adenomas. J Clin Endocrinol Metab. 1999 Feb. 84(2):761-7. [QxMD MEDLINE Link].

Media Gallery

This is a characteristic bitemporal hemianopic visual field defect.
This contrast-enhanced coronal MRI was obtained in a patient who complained of visual loss.
This visual field was plotted using a Goldman perimeter (ie, kinetic perimetry). It was obtained from a patient who reported visual loss and had a normal endocrine workup. The dark areas correspond to the impaired peripheral visual field. This visual field defect is consistent with an intrasellar lesion.
Coronal T1 precontrast MRI A (left panel), B postcontrast (middle panel) and T2 (right panel) showing a sellar mass causing obvious left and upward displacement of the optic chiasm. The mass is a histologically proven pituitary macroadenoma, which presented initially with a large cystic subfrontal extension that was successfully resected in April of 2006. This patient has been observed closely for 2.5 years and despite obvious mass effect, he has no visual complaints and the neuro-ophthalmologic evaluation is normal. Although infrequent, clinicians should be aware of this possibility. Close follow-up is required.
Axial, sagittal, and coronal MRI of the sellae in a patient with a severe headache, normal neuro-ophthalmologic examination, and no evidence of endocrine failure. A hyperintense mass is observed in the sella with suprasellar extension. This case illustrates the clinical spectrum of pituitary apoplexy. Transsphenoidal resection confirmed the diagnosis of pituitary apoplexy.

of 5

Author

Jorge C Kattah, MD Head, Associate Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria

Jorge C Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, New York Academy of Sciences

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew J Tsung, MD Assistant Professor of Neurosurgery, University of Illinois College of Medicine at Peoria; Director, INI Brain Tumor Center, Director of Neurosurgery Research, Department of Neurosurgery, Illinois Neurological Institute; Physician Director, Intermediate Neuroscience Care Unit, OSF St Francis Medical Center; Attending Physician, Illinois Neurological Institute Physicians, LLC

Andrew J Tsung, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, Illinois State Medical Society, Society for Neuro-Oncology, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Joseph V Hanovnikian University of Illinois College of Medicine

Joseph V Hanovnikian is a member of the following medical societies: Illinois State Medical Society, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Nicholas Lorenzo, MD, CPE, MHCM, FAAPL Co-Founder and Former Chief Publishing Officer, eMedicine and eMedicine Health, Founding Editor-in-Chief, eMedicine Neurology; Founder and Former Chairman and CEO, Pearlsreview; Founder and CEO/CMO, PHLT Consultants; Former Chief Medical Officer, MeMD Inc

Nicholas Lorenzo, MD, CPE, MHCM, FAAPL is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association for Physician Leadership

Disclosure: Nothing to disclose.

Additional Contributors

Robert A Egan, MD NW Neuro-Ophthalmology

Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, Oregon Medical Association

Disclosure: Received honoraria from Biogen Idec and Genentech for participation on Advisory Boards.

Frederick M Vincent, Sr, MD Clinical Professor, Department of Neurology and Ophthalmology, Michigan State University Colleges of Human and Osteopathic Medicine

Frederick M Vincent, Sr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners Institute, American College of Legal Medicine, American College of Physicians

Disclosure: Nothing to disclose.

Sections Pituitary Tumors
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
Questions & Answers
Media Gallery
References

Pituitary Tumors Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

Contributor Information and Disclosures

What would you like to print?