Differentials
Intracerebral hemorrhage
SIGNS / SYMPTOMS
No symptoms or signs reliably distinguish hemorrhagic stroke from ischemic stroke.
Hemorrhagic stroke is more often associated with reduced level of consciousness and signs of increased intracranial pressure than ischemic stroke.
INVESTIGATIONS
CT or MRI demonstrates hemorrhage (hyperattenuation).
Transient ischemic attack
SIGNS / SYMPTOMS
The definition of TIA is now "tissue-based" rather than defined by the duration of neurological dysfunction: there is no ischemic lesion visible on brain imaging in a patient with TIA. An ischemic brain lesion on brain imaging, even if a patient’s episode of focal neurological dysfunction rapidly resolves, signifies an ischemic stroke.[142]
INVESTIGATIONS
CT or MRI may be normal or may reveal evidence of older infarcts.
Transient global amnesia
SIGNS / SYMPTOMS
Transient global amnesia lasts 24-48 hours, with no evidence of acute infarct.
Patients may have a history of migraine.
INVESTIGATIONS
CT or MRI may be normal.
EEG is normal.
Cerebral amyloid angiopathy-related transient focal neurologic episodes
SIGNS / SYMPTOMS
Transient neurologic symptoms are typically recurrent, stereotyped, transient episodes of paresthesias, numbness, or weakness; onset spreading over seconds to minutes; usually resolves over a similar period.
INVESTIGATIONS
Magnetic resonance scan with T2*-weighted imaging or susceptibility-weighted imaging might suggest cerebral amyloid angiopathy.[143]
Hypertensive encephalopathy
SIGNS / SYMPTOMS
The combination of headache, cognitive abnormalities or decreased level of consciousness, and hypertension significantly above the patient's baseline blood pressure indicates hypertensive encephalopathy. Other possible signs/symptoms include visual changes or loss, or signs of increased intracranial pressure.[117]
INVESTIGATIONS
Cerebral edema on CT or MRI.
Hypoglycemia
SIGNS / SYMPTOMS
There may be a history of diabetes with use of insulin or insulin secretagogues.
Decreased level of consciousness.
INVESTIGATIONS
Low serum glucose at time of symptoms.
Complicated migraine
SIGNS / SYMPTOMS
Repetitive history of similar events: preceding aura, headache in a marching pattern differentiates complicated migraine.[117]
Stroke often presents with negative symptoms (e.g., visual loss, numbness, or weakness).
Positive symptoms (e.g., marching paresthesias, visual hallucinations, and abnormal motor manifestations) are more likely with complicated migraine.
INVESTIGATIONS
MRI shows no evidence of infarction.
Seizure and postictal deficits
SIGNS / SYMPTOMS
History of seizures; witnessed seizure followed by postictal deficits: for example, drowsiness and tongue-biting.[117]
Wrong-way eye deviation (i.e., gaze deviation away from the side of the brain lesion, toward the hemiparetic side) should prompt consideration of seizure but can also occur with strokes affecting the pons or thalamus.
INVESTIGATIONS
Electroencephalogram confirms evidence of seizure.
MRI shows no evidence of infarction.
Functional neurologic and somatic symptom disorders
SIGNS / SYMPTOMS
Neurologic signs and symptoms do not fit a vascular territory.
No cranial nerve deficits.
Additionally, conversion disorder displays multiple signs that are neurologically inconsistent.
INVESTIGATIONS
MRI shows no evidence of infarction.
Wernicke encephalopathy
SIGNS / SYMPTOMS
History of alcohol abuse.
Irritability, confusion, and delirium are common presenting features.
INVESTIGATIONS
Decreased blood thiamine level and successful therapeutic trial of thiamine.
Brain tumor
SIGNS / SYMPTOMS
Symptoms and signs more likely to have been ongoing.
May be history of cancer if metastatic lesion is causing symptoms.
INVESTIGATIONS
CT head demonstrates lesion or lesions.
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