Subarachnoid hemorrhage differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Subarachnoid hemorrhage}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Subarachnoid_hemorrhage]]
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{{CMG}}; {{AE}} {{SAH}} {{SaraM}}
 
==Overview==
 
==Differential diagnosis==
It is clinically difficult to distinguish subarchnoid hemorrhage from an [[ischemic stroke]]. However, the symptoms like [[headache]], [[nausea]], [[vomiting]], and depressed level of consciousness should raise the suspicion for a hemorrhagic event compared to [[ischemic stroke]].<ref name="pmid9810961">{{cite journal| author=Linn FH, Rinkel GJ, Algra A, van Gijn J| title=Headache characteristics in subarachnoid haemorrhage and benign thunderclap headache. | journal=J Neurol Neurosurg Psychiatry | year= 1998 | volume= 65 | issue= 5 | pages= 791-3 | pmid=9810961 | doi= | pmc=2170334 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9810961  }} </ref><ref name="pmid1783930">{{cite journal| author=Markus HS| title=A prospective follow up of thunderclap headache mimicking subarachnoid haemorrhage. | journal=J Neurol Neurosurg Psychiatry | year= 1991 | volume= 54 | issue= 12 | pages= 1117-8 | pmid=1783930 | doi= | pmc=1014694 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1783930  }} </ref>
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! style="background: #4479BA; width: 220px;" | {{fontcolor|#FFF|Disease}}
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Findings}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Ischemic stroke]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Occurs when a clot or a mass clogs a blood vessel and cutting off the blood flow to the brain
*Present as a
**Thrombotic stroke (thrombus develops at the clogged part of the vessel)
**Embolic strokes (blood clot that forms at another locations usually the heart and large arteries of the upper chest and neck, and travels to the brain)
*Urgent evaluation with brain / neurovascular imaging (such as [[MRI]], [[CT]], [[CTA]], [[MRA]]), cardiac, and metabolic evaluation is often necessary
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''[[transient ischemic attack| transient ischemic attack (TIA)]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Caused by a temporary clot which often called a “mini stroke”
*Occurs rapidly and  presents as a sudden onset of a focal neurologic symptom/sign lasting less than 24 hours
*Urgent evaluation with brain / neurovascular imaging (such as [[MRI]], [[CT]], [[CTA]], [[MRA]]), cardiac, and metabolic evaluation is often necessary
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Acute hypertensive crisis]]/[[Malignant hypertension]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Presents as significantly elevated blood pressure (systolic pressure ≥180 and/or diastolic pressure ≥120 mmHg) with or wihout acute end-organ injury
*Urgent evaluation with  [[MRI]] and [[CT]] of the brain, serum [[creatinine]], [[urinalysis]], cardiac ([[EKG]], [[chest x ray]], and c[[ardiac enzymes]]) and metabolic evaluation is often necessary
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Sentinel headache'''<ref name="pmid14984225">{{cite journal| author=Polmear A| title=Sentinel headaches in aneurysmal subarachnoid haemorrhage: what is the true incidence? A systematic review. | journal=Cephalalgia | year= 2003 | volume= 23 | issue= 10 | pages= 935-41 | pmid=14984225 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14984225  }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
*Caused by small aneurysmal leaks into the subarachnoid space
*Presents as a episode of headache similar to that accompanying [[subarachnoid hemorrhage]] (days to weeks prior to [[aneurysm]] rupture) and focal neurologic symptoms and signs are usually absent
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Sinusitis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Presents with acute and subacute headaches and facial pain
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Hypoglycemia]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Pituitary apoplexy]]'''<ref name="pmid9596029">{{cite journal| author=Dodick DW, Wijdicks EF| title=Pituitary apoplexy presenting as a thunderclap headache. | journal=Neurology | year= 1998 | volume= 50 | issue= 5 | pages= 1510-1 | pmid=9596029 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9596029  }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
*Caused by pituitary gland infarct or hemorrhage secondary to [[pitutiery adenoma]]
*Presents with  acute headache, change in mental status, ophthalmoplegia, and decreased visual acuity
**Brain CT and MRI are the preferred imaging techniques
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Cerebral venous thrombosis]]'''<ref name="pmid8961993">{{cite journal| author=de Bruijn SF, Stam J, Kappelle LJ| title=Thunderclap headache as first symptom of cerebral venous sinus thrombosis. CVST Study Group. | journal=Lancet | year= 1996 | volume= 348 | issue= 9042 | pages= 1623-5 | pmid=8961993 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8961993  }} </ref><ref name="pmid3975957">{{cite journal| author=Bousser MG, Chiras J, Bories J, Castaigne P| title=Cerebral venous thrombosis--a review of 38 cases. | journal=Stroke | year= 1985 | volume= 16 | issue= 2 | pages= 199-213 | pmid=3975957 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3975957  }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
*Presents with isolated gradual onset headache or in combination with [[papilledema]], [[seizures]], bilateral focal deficits, and change in mental status
*Brain MRI with venography should be considered
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Colloid cyst|Colloid cyst of the third ventricle]]'''<ref name="pmid14830663">{{cite journal| author=KELLY R| title=Colloid cysts of the third ventricle; analysis of twenty-nine cases. | journal=Brain | year= 1951 | volume= 74 | issue= 1 | pages= 23-65 | pmid=14830663 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14830663  }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
*Caused by an acute [[obstructive hydrocephalus]] secondary to sudden obstruction in cerebrospinal fluid flow by the cyst
*Presents with an acute onset fronto-parietal or fronto-occipital headache which relieved by taking the supine position and may be associated with nausea, vomiting, mental status changes, seizures, coma
*Head CT or MRI of the brain are usually diagnostic
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[dissection|Cervical artery dissection]]'''<ref name="pmid1423556">{{cite journal| author=Mitsias P, Ramadan NM| title=Headache in ischemic cerebrovascular disease. Part I: Clinical features. | journal=Cephalalgia | year= 1992 | volume= 12 | issue= 5 | pages= 269-74 | pmid=1423556 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1423556  }} </ref><ref name="pmid14638953">{{cite journal| author=Touzé E, Gauvrit JY, Moulin T, Meder JF, Bracard S, Mas JL et al.| title=Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study. | journal=Neurology | year= 2003 | volume= 61 | issue= 10 | pages= 1347-51 | pmid=14638953 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14638953 }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
*It usulay occurs spontaneously or after head and neck injury
*Presents with gradual onset head and neck pain with a local manifestations (such as [[Horner syndrome]], pulsatile [[tinnitus]], bruit, or cranial [[neuropathies]])
*Neuroimagings are usually preferred  (brain MRI with MRA and cranial CT with CTA)
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Reversible cerebral vasoconstriction syndrome'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Occurs spontaneously and trigerred by sexual activity, exertion, emotion, and constriction of the cerebral arteries
*Presents with acute severe headache with or without focal deficits or seizures that resolves spontaneously within 12 weeks
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[intracranial hypotension|Spontaneous intracranial hypotension]]'''<ref name="pmid1549206">{{cite journal| author=Rando TA, Fishman RA| title=Spontaneous intracranial hypotension: report of two cases and review of the literature. | journal=Neurology | year= 1992 | volume= 42 | issue= 3 Pt 1 | pages= 481-7 | pmid=1549206 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1549206  }} </ref><ref name="pmid11270540">{{cite journal| author=Schievink WI, Wijdicks EF, Meyer FB, Sonntag VK| title=Spontaneous intracranial hypotension mimicking aneurysmal subarachnoid hemorrhage. | journal=Neurosurgery | year= 2001 | volume= 48 | issue= 3 | pages= 513-6; discussion 516-7 | pmid=11270540 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11270540  }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
*Presents with orthostatic headaches, nausea, vomiting, dizziness,  diplopia, interscapular pain
*Caused by [[cerebrospinal fluid|cerebrospinal fluid (CSF)]] leakage from spinal meningeal defects or [[dural]] tears
*Brain MRI is the preferred imaging techniques
|}
 
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="2" |<small>Diseases</small>
! colspan="4" |<small>Diagnostic tests</small>
! colspan="5" |<small>Physical Examination</small>
! colspan="3" |<small>Symptoms
! colspan="1" rowspan="2" |<small>Past medical history</small>
! rowspan="2" |<small>Other Findings</small>
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!<small>Na+, K+, Ca2+</small>
!<small>CT /MRI</small>
!<small>CSF Findings</small>
!<small>Gold standard test</small>
!<small>Neck stiffness</small>
!<small>Motor or Sensory deficit</small>
!<small>Papilledema</small>
!<small>Bulging fontanelle</small>
!<small>Cranial nerves</small>
!<small>Headache</small>
!<small>Fever</small>
!<small>Altered mental status</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Brain tumour]]<ref name="pmid1278192">Soffer D (1976) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1278192 Brain tumors simulating purulent meningitis.] ''Eur Neurol'' 14 (3):192-7. PMID: [http://pubmed.gov/1278192 1278192]</ref><ref name="pmid3883130" />
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px text-align:center" |Cancer cells<ref name="pmid21371327">{{cite journal| author=Weston CL, Glantz MJ, Connor JR| title=Detection of cancer cells in the cerebrospinal fluid: current methods and future directions. | journal=Fluids Barriers CNS | year= 2011 | volume= 8 | issue= 1 | pages= 14 | pmid=21371327 | doi=10.1186/2045-8118-8-14 | pmc=3059292 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21371327  }}</ref>
| style="background: #F5F5F5; padding: 5px;" |MRI
| style="background: #F5F5F5; padding: 5px; text-align:center" |     
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |      ✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |[[Cachexia]], gradual progression of symptoms
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Delirium tremens]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |Clinical diagnosis
| style="background: #F5F5F5; padding: 5px; text-align:center" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;text-align:center" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |      ✔
| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |[[Alcohol]] intake, sudden witdrawl or reduction in consumption
| style="background: #F5F5F5; padding: 5px;" |[[Tachycardia]], [[diaphoresis]], [[hypertension]], [[tremors]], [[mydriasis]], [[positional nystagmus]],
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Subarachnoid hemorrhage|Subarachnoid  hemorrhage]]<ref name="pmid14585453">Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14585453 Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases.] ''J Emerg Med'' 25 (3):265-70. PMID: [http://pubmed.gov/14585453 14585453]</ref>
 
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |Xanthochromia<ref name="pmid1198628">{{cite journal| author=Lee MC, Heaney LM, Jacobson RL, Klassen AC| title=Cerebrospinal fluid in cerebral hemorrhage and infarction. | journal=Stroke | year= 1975 | volume= 6 | issue= 6 | pages= 638-41 | pmid=1198628 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1198628  }}</ref>
| style="background: #F5F5F5; padding: 5px;" |CT scan  without contrast<ref name="pmid21694755">{{cite journal| author=Birenbaum D, Bancroft LW, Felsberg GJ| title=Imaging in acute stroke. | journal=West J Emerg Med | year= 2011 | volume= 12 | issue= 1 | pages= 67-76 | pmid=21694755 | doi= | pmc=3088377 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21694755  }}</ref><ref name="pmid21807345">{{cite journal| author=DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF et al.| title=ACR Appropriateness Criteria® on cerebrovascular disease. | journal=J Am Coll Radiol | year= 2011 | volume= 8 | issue= 8 | pages= 532-8 | pmid=21807345 | doi=10.1016/j.jacr.2011.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21807345  }}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |    ✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |Trauma/fall
| style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[dizziness]], [[Nausea and vomiting|nausea]], [[Nausea and vomiting|vomiting]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Stroke]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" | Normal
| style="background: #F5F5F5; padding: 5px; text-align:center" | CT scan  without contrast
| style="background: #F5F5F5; padding: 5px; text-align:center" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |TIAs, [[hypertension]], [[diabetes mellitus]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |Speech difficulty, gait abnormality
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Neurosyphilis]]<ref name="pmid22482824">{{cite journal| author=Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG et al.| title=Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients. | journal=J Neurol Sci | year= 2012 | volume= 317 | issue= 1-2 | pages= 35-9 | pmid=22482824 | doi=10.1016/j.jns.2012.03.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22482824  }} </ref><ref name="pmid24365430">{{cite journal |vauthors=Berger JR, Dean D |title=Neurosyphilis |journal=Handb Clin Neurol |volume=121 |issue= |pages=1461–72 |year=2014 |pmid=24365430 |doi=10.1016/B978-0-7020-4088-7.00098-5 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |'''↑''' [[Leukocytes]] and [[protein]]
| style="background: #F5F5F5; padding: 5px;" |CSF [[VDRL]]-specifc
CSF FTA-Ab -sensitive<ref name="pmid22421697">{{cite journal| author=Ho EL, Marra CM| title=Treponemal tests for neurosyphilis--less accurate than what we thought? | journal=Sex Transm Dis | year= 2012 | volume= 39 | issue= 4 | pages= 298-9 | pmid=22421697 | doi=10.1097/OLQ.0b013e31824ee574 | pmc=3746559 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22421697  }}</ref>
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;text-align:center" |✔
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| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |Unprotected sexual intercourse, [[STI]]<nowiki/>s
| style="background: #F5F5F5; padding: 5px;" |[[Blindness]], [[confusion]], [[depression]],
 
Abnormal [[gait]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Viral encephalitis]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |Increased [[RBC]]S or xanthochromia, [[Mononuclear cells|mononuclear]] [[lymphocytosis]], high protein content, normal [[glucose]]
| style="background: #F5F5F5; padding: 5px;" |Clinical assesment
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |    ✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |Tick bite/mosquito bite/ viral prodome for several days
| style="background: #F5F5F5; padding: 5px;" |Extreme lethargy, rash [[hepatosplenomegaly]], [[lymphadenopathy]], [[behavioural]] changes
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Herpes simplex encephalitis]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |Clinical assesment
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |History of [[hypertension]]
| style="background: #F5F5F5; padding: 5px;" |[[Delirium]], cortical [[blindness]], [[cerebral edema]], [[seizure]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Wernicke’s encephalopathy
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |Normal
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |History of alcohal abuse
| style="background: #F5F5F5; padding: 5px;" |[[Ophthalmoplegia]], [[confusion]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[CNS abscess]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |'''↑''' [[leukocytes]] >100,000/ul, '''↓''' [[glucose]] and '''↑''' protien, '''↑''' red blood cells, [[lactic acid]] >500mg
| style="background: #F5F5F5; padding: 5px;" |Contrast enhanced MRI is more sensitive and specific,
[[Histopathological]] examination of brain tissue
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |History of [[drug abuse]], [[endocarditis]], '''↓''' [[immune]] status
| style="background: #F5F5F5; padding: 5px;" |High grade [[fever]], [[fatigue]],[[Nausea and vomiting|nausea]], [[vomiting]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Drug toxicity]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |[[Lithium]], Sedatives, [[phenytoin]], [[carbamazepine]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Conversion disorder]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |Diagnosis of exclusion
| style="background: #F5F5F5; padding: 5px; text-align:center" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;text-align:center" |
| style="background: #F5F5F5; padding: 5px;text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |[[Tremor|Tremors]], [[blindness]], difficulty [[swallowing]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Electrolyte disturbance]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |'''↓''' or '''↑'''
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |Depends on the cause
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[Seizure|seizures]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Febrile convulsion]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |Not performed in first simple febrile [[seizures]]
| style="background: #F5F5F5; padding: 5px;" |Clinical diagnosis and EEG
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |  ✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |Family history of [[febrile]] [[seizures]], [[viral]] illness or [[gastroenteritis]]
| style="background: #F5F5F5; padding: 5px;" |Age > 1 month,
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Subdural empyema]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |
| style="background: #F5F5F5; padding: 5px;" |Clinical assesment and [[MRI]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" |History of relapses and remissions
| style="background: #F5F5F5; padding: 5px;" |Blurry vision, [[urinary incontinence]], [[fatigue]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Hypoglycemia]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |↓ or '''↑'''
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |Serum blood [[Glucose-1-phosphate adenylyltransferase|glucose]]
[[HbA1c]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;text-align:center" |
| style="background: #F5F5F5; padding: 5px;text-align:center" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |  ✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |History of [[Diabetes mellitus|diabetes]]
| style="background: #F5F5F5; padding: 5px;" |[[Palpitation|Palpitations]], [[sweating]], [[dizziness]], low serum, [[glucose]]
|}
Subarachnoid hemorrhage should be differentiated from other [[diseases]] causing severe [[headache]] for example: <ref>{{Cite journal
| author = [[Endrit Ziu]] & [[Fassil Mesfin]]
| title = Subarachnoid Hemorrhage
| year = 2017
| pmid = 28722987
}}</ref><ref>{{Cite journal
| author = [[Benedikt Schwermer]], [[Daniel Eschle]] & [[Constantine Bloch-Infanger]]
| title = &#91;Fever and Headache after a Vacation in Thailand&#93;
| journal = [[Deutsche medizinische Wochenschrift (1946)]]
| volume = 142
| issue = 14
| pages = 1063–1066
| year = 2017
| doi = 10.1055/s-0043-106282
| pmid = 28728201
}}</ref><ref>{{Cite journal
| author = [[Otto Rapalino]] & [[Mark E. Mullins]]
| title = Intracranial Infectious and Inflammatory Diseases Presenting as Neurosurgical Pathologies
| journal = [[Neurosurgery]]
| year = 2017
| doi = 10.1093/neuros/nyx201
| pmid = 28575459
}}</ref><ref>{{Cite journal
| author = [[I. B. Komarova]], [[V. P. Zykov]], [[L. V. Ushakova]], [[E. K. Nazarova]], [[E. B. Novikova]], [[O. V. Shuleshko]] & [[M. G. Samigulina]]
| title = &#91;Clinical and neuroimaging signs of cardioembolic stroke laboratory in children&#93;
| journal = [[Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova]]
| volume = 117
| issue = 3. Vyp. 2
| pages = 11–19
| year = 2017
| doi = 10.17116/jnevro20171173211-19
| pmid = 28665364
}}</ref><ref>{{Cite journal
| author = [[Sanjay Konakondla]], [[Clemens M. Schirmer]], [[Fengwu Li]], [[Xiaogun Geng]] & [[Yuchuan Ding]]
| title = New Developments in the Pathophysiology, Workup, and Diagnosis of Dural Venous Sinus Thrombosis (DVST) and a Systematic Review of Endovascular Treatments
| journal = [[Aging and disease]]
| volume = 8
| issue = 2
| pages = 136–148
| year = 2017
| doi = 10.14336/AD.2016.0915
| pmid = 28400981
}}</ref><ref>{{Cite journal
| author = [[Priyanka Yadav]], [[Alec L. Bradley]] & [[Jonathan H. Smith]]
| title = Recognition of Chronic Migraine by Medicine Trainees: A Cross-Sectional Survey
| journal = [[Headache]]
| year = 2017
| doi = 10.1111/head.13133
| pmid = 28653369
}}</ref><ref>{{Cite journal
| author = [[S. Wulffeld]], [[L. S. Rasmussen]], [[B. Hojlund Bech]] & [[J. Steinmetz]]
  | title = The effect of CT scanners in the trauma room - an observational study
  | journal = [[Acta anaesthesiologica Scandinavica]]
| volume = 61
| issue = 7
| pages = 832–840
| year = 2017
| doi = 10.1111/aas.12927
| pmid = 28635146
}}</ref><ref>{{cite journal |vauthors=Johnston PC, Chew LS, Hamrahian AH, Kennedy L |title=Lymphocytic infundibulo-neurohypophysitis: a clinical overview |journal=Endocrine |volume=50 |issue=3 |pages=531–6 |year=2015 |pmid=26219407 |doi=10.1007/s12020-015-0707-6 |url=}}</ref><ref>{{cite journal |vauthors=Makale MT, McDonald CR, Hattangadi-Gluth JA, Kesari S |title=Mechanisms of radiotherapy-associated cognitive disability in patients with brain tumours |journal=Nat Rev Neurol |volume=13 |issue=1 |pages=52–64 |year=2017 |pmid=27982041 |doi=10.1038/nrneurol.2016.185 |url=}}</ref><ref name="pmid9541295">{{cite journal| author=Sato N, Sze G, Endo K| title=Hypophysitis: endocrinologic and dynamic MR findings. | journal=AJNR Am J Neuroradiol | year= 1998 | volume= 19 | issue= 3 | pages= 439-44 | pmid=9541295 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9541295  }} </ref>
 
{| class="wikitable"
! rowspan="2" |Disease
! rowspan="2" |Symptoms
! colspan="2" |Diagnosis
|-
!CT/MRI
!Other Investigation Findings
|-
|[[Subarachnoid hemorrhage]]
|
* [[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)
* [[Double vision]]
* [[Nausea]] and [[vomiting]]
* Symptoms of [[meningeal irritation]]
* Sudden [[Loss of consciousness|decreased level of consciousness]]
* Rapid progression of symptoms
|
* The modality of choice for diagnosis of [[subarachnoid hemorrhage]] is noncontrast head [[Computed tomography|computed tomography (CT)]], with or without [[lumbar puncture]].<sup>[[Subarachnoid hemorrhage CT#cite note-pmid7897421-1|[1]]]</sup>
* [[Computed tomography|CT]] shows hyperattenuating material filling the subarachnoid space.
|
* [[Lumbar puncture|Lumbar puncture (LP)]] is necessary when there is a strong suspicion of [[subarachnoid hemorrhage]]. LP will show:
** Elevated opening pressure
** Elevated [[Red blood cell|red blood cell (RBC)]]
** [[Xanthochromic|Xanthochromia]]
|-
|[[Meningitis]]
|
* [[Headache]]  
* [[Neck stiffness]]
* [[Fever]]
 
* [[Photophobia]] (inability to tolerate bright light)
* [[Phonophobia]] (inability to tolerate loud noises) 
* [[Irritability]], [[altered mental status]] (in small children)
|
* [[CT]] scan of the head may be performed before [[Lumbar puncture|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 [[Meningitis#Diagnosis|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]].
|
* [[Biopsy]] of the lesion is needed to identify the nature of the lesion such as:
** [[Tumor]]
** [[Abscess]]
 
* X- ray of the skull is a non specific test, but useful if any of the lesions are [[Calcified lesion|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 scan]] without contrast is the initial test performed to diagnose [[ischemic stroke]] and rule out [[hemorrhagic stroke|hemorrhagic stroke.]]
* [[CT]] is very sensitive for identifying acute [[hemorrhage]] which appears as hyperattenuating clot.
* 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 [[Ischemic stroke#Diagnosis#History and symptoms|click here]].
|
* [[CT scan]] without contrast is the initial test performed to diagnose [[ischemic stroke]] and rule out [[hemorrhagic stroke|hemorrhagic stroke.]] CT may show hypo-attenuation and swelling of involved area.
* [[MRI|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]] may be done to check for patency of [[carotid arteries]] and blood supply to the [[brain]].
 
* Cerebral [[angiogram]] is an [[Invasive (medical)|invasive]] test and detect [[abnormalities]] of the [[blood vessels]], including narrowing, blockage, or [[malformations]] (such as [[Aneurysm|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]]).<sup>[[Cerebral venous sinus thrombosis history and symptoms#cite note-Stam2005-1|[1]]]</sup> The [[headache]] may be the only [[symptom]] of [[cerebral venous sinus thrombosis]].<sup>[[Cerebral venous sinus thrombosis history and symptoms#cite note-Cumurciuc2005-2|[2]]]</sup>
* Inability to move one or more limbs.
* Weakness on one side of the face.
* [[Seizure|Seizures]]: 40% of all patients have seizure.
* [[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>
|
* 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 (symptom)|aura]].<sup>[[Migraine overview#cite note-4|[4]]]</sup> 
|
* [[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]]
|
* [[Headache]]
* [[Confusion]]
* [[Drowsiness]]
* Personality change
* [[Seizure|Seizures]]
* [[Nausea]] and [[vomiting]]
* [[Headache|Loss of consciousness]]
* [[lucid interval]]
|
* [[CT]] scan is the first test performed and identifies [[cerebral hemorrhage]] (appears as hyperattenuating clot) 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 [[Computed tomography|CT]] scan.
|
* 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 defect|visual field defects]]
|
* [[CT]] & [[MRI]] typically reveal features of a pituitary mass.
|
* The most accurate test is pituitary [[biopsy]] which will show [[lymphocytic]] [[Infiltration (medical)|infiltration]].
|-
|[[Radiation injury]]
|
* [[Headache]]
* Impairment of [[mental function]] is the most prominent feature such as [[Personality change due to another medical condition|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==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 21:40, 8 March 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Ahsan Hussain, M.D.[2] Sara Mehrsefat, M.D. [3]

Overview

Differential diagnosis

It is clinically difficult to distinguish subarchnoid hemorrhage from an ischemic stroke. However, the symptoms like headache, nausea, vomiting, and depressed level of consciousness should raise the suspicion for a hemorrhagic event compared to ischemic stroke.[1][2]

Disease Findings
Ischemic stroke
  • Occurs when a clot or a mass clogs a blood vessel and cutting off the blood flow to the brain
  • Present as a
    • Thrombotic stroke (thrombus develops at the clogged part of the vessel)
    • Embolic strokes (blood clot that forms at another locations usually the heart and large arteries of the upper chest and neck, and travels to the brain)
  • Urgent evaluation with brain / neurovascular imaging (such as MRI, CT, CTA, MRA), cardiac, and metabolic evaluation is often necessary
transient ischemic attack (TIA)
  • Caused by a temporary clot which often called a “mini stroke”
  • Occurs rapidly and presents as a sudden onset of a focal neurologic symptom/sign lasting less than 24 hours
  • Urgent evaluation with brain / neurovascular imaging (such as MRI, CT, CTA, MRA), cardiac, and metabolic evaluation is often necessary
Acute hypertensive crisis/Malignant hypertension
  • Presents as significantly elevated blood pressure (systolic pressure ≥180 and/or diastolic pressure ≥120 mmHg) with or wihout acute end-organ injury
  • Urgent evaluation with MRI and CT of the brain, serum creatinine, urinalysis, cardiac (EKG, chest x ray, and cardiac enzymes) and metabolic evaluation is often necessary
Sentinel headache[3]
  • Caused by small aneurysmal leaks into the subarachnoid space
  • Presents as a episode of headache similar to that accompanying subarachnoid hemorrhage (days to weeks prior to aneurysm rupture) and focal neurologic symptoms and signs are usually absent
Sinusitis
  • Presents with acute and subacute headaches and facial pain
Hypoglycemia
Pituitary apoplexy[4]
  • Caused by pituitary gland infarct or hemorrhage secondary to pitutiery adenoma
  • Presents with acute headache, change in mental status, ophthalmoplegia, and decreased visual acuity
    • Brain CT and MRI are the preferred imaging techniques
Cerebral venous thrombosis[5][6]
  • Presents with isolated gradual onset headache or in combination with papilledema, seizures, bilateral focal deficits, and change in mental status
  • Brain MRI with venography should be considered
Colloid cyst of the third ventricle[7]
  • Caused by an acute obstructive hydrocephalus secondary to sudden obstruction in cerebrospinal fluid flow by the cyst
  • Presents with an acute onset fronto-parietal or fronto-occipital headache which relieved by taking the supine position and may be associated with nausea, vomiting, mental status changes, seizures, coma
  • Head CT or MRI of the brain are usually diagnostic
Cervical artery dissection[8][9]
  • It usulay occurs spontaneously or after head and neck injury
  • Presents with gradual onset head and neck pain with a local manifestations (such as Horner syndrome, pulsatile tinnitus, bruit, or cranial neuropathies)
  • Neuroimagings are usually preferred (brain MRI with MRA and cranial CT with CTA)
Reversible cerebral vasoconstriction syndrome
  • Occurs spontaneously and trigerred by sexual activity, exertion, emotion, and constriction of the cerebral arteries
  • Presents with acute severe headache with or without focal deficits or seizures that resolves spontaneously within 12 weeks
Spontaneous intracranial hypotension[10][11]
  • Presents with orthostatic headaches, nausea, vomiting, dizziness, diplopia, interscapular pain
  • Caused by cerebrospinal fluid (CSF) leakage from spinal meningeal defects or dural tears
  • Brain MRI is the preferred imaging techniques
Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
Na+, K+, Ca2+ CT /MRI CSF Findings Gold standard test Neck stiffness Motor or Sensory deficit Papilledema Bulging fontanelle Cranial nerves Headache Fever Altered mental status
Brain tumour[12][13] Cancer cells[14] MRI Cachexia, gradual progression of symptoms
Delirium tremens Clinical diagnosis Alcohol intake, sudden witdrawl or reduction in consumption Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus,
Subarachnoid hemorrhage[15] Xanthochromia[16] CT scan without contrast[17][18] Trauma/fall Confusion, dizziness, nausea, vomiting
Stroke Normal CT scan without contrast TIAs, hypertension, diabetes mellitus Speech difficulty, gait abnormality
Neurosyphilis[19][20] Leukocytes and protein CSF VDRL-specifc

CSF FTA-Ab -sensitive[21]

Unprotected sexual intercourse, STIs Blindness, confusion, depression,

Abnormal gait

Viral encephalitis Increased RBCS or xanthochromia, mononuclear lymphocytosis, high protein content, normal glucose Clinical assesment Tick bite/mosquito bite/ viral prodome for several days Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioural changes
Herpes simplex encephalitis Clinical assesment History of hypertension Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy Normal History of alcohal abuse Ophthalmoplegia, confusion
CNS abscess leukocytes >100,000/ul, glucose and protien, red blood cells, lactic acid >500mg Contrast enhanced MRI is more sensitive and specific,

Histopathological examination of brain tissue

History of drug abuse, endocarditis, immune status High grade fever, fatigue,nausea, vomiting
Drug toxicity Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder Diagnosis of exclusion Tremors, blindness, difficulty swallowing
Electrolyte disturbance or Depends on the cause Confusion, seizures
Febrile convulsion Not performed in first simple febrile seizures Clinical diagnosis and EEG Family history of febrile seizures, viral illness or gastroenteritis Age > 1 month,
Subdural empyema Clinical assesment and MRI History of relapses and remissions Blurry vision, urinary incontinence, fatigue
Hypoglycemia ↓ or Serum blood glucose

HbA1c

History of diabetes Palpitations, sweating, dizziness, low serum, glucose

Subarachnoid hemorrhage should be differentiated from other diseases causing severe headache for example: [22][23][24][25][26][27][28][29][30][31]

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
  • 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.
  • Biopsy of the lesion is needed to identify the nature of the lesion such as:
  • 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 which appears as hyperattenuating clot.
  • 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.
Intracranial venous thrombosis
  • The classic finding of sinus thrombosis on unenhanced CT images is a hyperattenuating thrombus in the occluded sinus.
  • Cerebral angiography may demonstrate smaller clots, and obstructed veins may give the "corkscrew appearance".
Migraine
  • 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 identifies cerebral hemorrhage (appears as hyperattenuating clot) 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 scan.
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.
Radiation injury

CT & MRI will show:

PET scan

References

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