Subdural hematoma differential diagnosis: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Subdural_hematoma]] | |||
== Overview == | |||
Subdural hematoma must be differentiated from other disease that causes headache,seizures and loss of consciousness such as Meningitis, encephalitis, brain tumor, hemorrhagic stroke, neurosyphilis, migrain, hypertensive encephalopathy, wernicke’s encephalopathy, brain abscess, drug toxicity, conversion disorders, metabolic disturbance, multiple sclerosis, and seizure. | |||
==Differential diagnosis== | ==Differential diagnosis== | ||
Subdural hematoma must be differentiated from other causes of headache,seizures and loss of consciousness. | Subdural hematoma must be differentiated from other disease that causes headache,seizures and loss of consciousness such as Meningitis, encephalitis, brain tumor, hemorrhagic stroke, neurosyphilis, migrain, hypertensive encephalopathy, wernicke’s encephalopathy, brain abscess, drug toxicity, conversion disorders, metabolic disturbance, multiple sclerosis, and seizure. | ||
=== '''Differentiating subdural hematoma from other diseases on the basis of headache,seizures and loss of consciousness.''' === | |||
{| | {| | ||
|-style="background: #4479BA; color: #FFFFFF; text-align: center;" | |- style="background: #4479BA; color: #FFFFFF; text-align: center;" | ||
! rowspan="2" |<small>Diseases</small> | ! rowspan="2" |<small>Diseases</small> | ||
! colspan="4" |<small>Symptoms | ! colspan="4" |<small>Symptoms | ||
| Line 25: | Line 30: | ||
!<small>CSF Findings</small> | !<small>CSF Findings</small> | ||
!<small>Gold standard test</small> | !<small>Gold standard test</small> | ||
|- | |||
| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Subdural hematoma|Subdural hemorrhage]] | |||
| 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" | + | |||
| style="background: #F5F5F5; padding: 5px text-align:center" |[[Trauma]], fall | |||
| 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;" |[[Confusion]], [[dizziness]], [[nausea]], [[vomiting]] | |||
|- | |- | ||
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Meningitis]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Meningitis]] | ||
| Line 63: | Line 84: | ||
| style="background: #F5F5F5; padding: 5px text-align:center" |[[Fever]], [[Seizure|seizures]], [[Focal neurologic signs|focal neurologic abnormalities]] | | style="background: #F5F5F5; padding: 5px text-align:center" |[[Fever]], [[Seizure|seizures]], [[Focal neurologic signs|focal neurologic abnormalities]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Brain tumor]]<ref name="pmid10582668">{{cite journal| author=Morgenstern LB, Frankowski RF| title=Brain tumor masquerading as stroke. | journal=J Neurooncol | year= 1999 | volume= 44 | issue= 1 | pages= 47-52 | pmid=10582668 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10582668 }} </ref> | | style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Brain tumor]]<ref name="pmid10582668">{{cite journal| author=Morgenstern LB, Frankowski RF| title=Brain tumor masquerading as stroke. | journal=J Neurooncol | year= 1999 | volume= 44 | issue= 1 | pages= 47-52 | pmid=10582668 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10582668 }} </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 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" | + | | style="background: #F5F5F5; padding: 5px text-align:center" | + | ||
|style="background: #F5F5F5; padding: 5px text-align:center" |[[Weight loss]], [[fatigue]] | | style="background: #F5F5F5; padding: 5px text-align:center" |[[Weight loss]], [[fatigue]] | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"| + | | 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 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;" |MRI | ||
|style="background: #F5F5F5; padding: 5px;" |[[Cachexia]], gradual progression of symptoms | | style="background: #F5F5F5; padding: 5px;" |[[Cachexia]], gradual progression of symptoms | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Hemorrhagic stroke]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Hemorrhagic 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" | + | | 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" | + | ||
|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" |[[Hypertension]] | | style="background: #F5F5F5; padding: 5px text-align:center" |[[Hypertension]] | ||
|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;" |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;" |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;" |[[Neck stiffness]] | | style="background: #F5F5F5; padding: 5px;" |[[Neck stiffness]] | ||
|- | |- | ||
| 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 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" | - | |||
| style="background: #F5F5F5; padding: 5px text-align:center" |[[Sexually transmitted disease|STI]]<nowiki/>s | |||
| style="background: #F5F5F5; padding: 5px; text-align:center" | + | |||
| style="background: #F5F5F5; padding: 5px;" |'''↑''' [[Leukocytes]] and [[protein]] | |||
| style="background: #F5F5F5; padding: 5px;" |CSF [[VDRL]]-specifc | |||
|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 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" | - | |||
|style="background: #F5F5F5; padding: 5px text-align:center" |[[Sexually transmitted disease|STI]]<nowiki/>s | |||
|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> | 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;" |[[Blindness]], [[confusion]], [[depression]], | | style="background: #F5F5F5; padding: 5px;" |[[Blindness]], [[confusion]], [[depression]], | ||
Abnormal [[gait]] | Abnormal [[gait]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |Complex or atypical [[migraine]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |Complex or atypical [[migraine]] | ||
|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" | - | | 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" | - | ||
|style="background: #F5F5F5; padding: 5px text-align:center" |Family history of [[migraine]] | | style="background: #F5F5F5; padding: 5px text-align:center" |Family history of [[migraine]] | ||
| 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;" |Clinical assesment | | style="background: #F5F5F5; padding: 5px;" |Clinical assesment | ||
|style="background: #F5F5F5; padding: 5px;" |Presence of aura, [[nausea]], [[vomiting]] | | style="background: #F5F5F5; padding: 5px;" |Presence of aura, [[nausea]], [[vomiting]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Hypertensive encephalopathy]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Hypertensive encephalopathy]] | ||
|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" | - | | 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" | - | ||
|style="background: #F5F5F5; padding: 5px text-align:center" |[[Hypertension]] | | style="background: #F5F5F5; padding: 5px text-align:center" |[[Hypertension]] | ||
|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;" |Clinical assesment | | style="background: #F5F5F5; padding: 5px;" |Clinical assesment | ||
|style="background: #F5F5F5; padding: 5px;" |[[Delirium]], [[cortical blindness]], [[cerebral edema]], [[seizure]] | | style="background: #F5F5F5; padding: 5px;" |[[Delirium]], [[cortical blindness]], [[cerebral edema]], [[seizure]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Wernicke's encephalopathy|Wernicke’s encephalopathy]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Wernicke's encephalopathy|Wernicke’s encephalopathy]] | ||
|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" | - | | 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" | + | ||
|style="background: #F5F5F5; padding: 5px text-align:center" |History of alcohal abuse | | style="background: #F5F5F5; padding: 5px text-align:center" |History of alcohal abuse | ||
| 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;" |Clinical assesment and lab findings | | style="background: #F5F5F5; padding: 5px;" |Clinical assesment and lab findings | ||
|style="background: #F5F5F5; padding: 5px;" |[[Ophthalmoplegia]], [[confusion]] | | style="background: #F5F5F5; padding: 5px;" |[[Ophthalmoplegia]], [[confusion]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Brain abscess|CNS abscess]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Brain abscess|CNS abscess]] | ||
|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" | + | | 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" | - | ||
|style="background: #F5F5F5; padding: 5px text-align:center" |History of [[drug abuse]], [[endocarditis]], [[immunosupression]] | | style="background: #F5F5F5; padding: 5px text-align:center" |History of [[drug abuse]], [[endocarditis]], [[immunosupression]] | ||
|style="background: #F5F5F5; padding: 5px;" | + | | style="background: #F5F5F5; padding: 5px;" | + | ||
|style="background: #F5F5F5; padding: 5px;" |'''↑''' leukocytes, '''↓''' glucose and '''↑''' protien | | style="background: #F5F5F5; padding: 5px;" |'''↑''' leukocytes, '''↓''' glucose and '''↑''' protien | ||
|style="background: #F5F5F5; padding: 5px;" |MRI is more sensitive and specific | | style="background: #F5F5F5; padding: 5px;" |MRI is more sensitive and specific | ||
|style="background: #F5F5F5; padding: 5px;" |High grade [[fever]], [[fatigue]],[[nausea]], [[vomiting]] | | style="background: #F5F5F5; padding: 5px;" |High grade [[fever]], [[fatigue]],[[nausea]], [[vomiting]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Drug toxicity]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Drug toxicity]] | ||
|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" | + | | 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" | - | ||
|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;" | - | ||
| style="background: #F5F5F5; padding: 5px;" |Drug screen test | | style="background: #F5F5F5; padding: 5px;" |Drug screen test | ||
|style="background: #F5F5F5; padding: 5px;" |[[Lithium]], [[Sedatives]], [[phenytoin]], [[carbamazepine]] | | style="background: #F5F5F5; padding: 5px;" |[[Lithium]], [[Sedatives]], [[phenytoin]], [[carbamazepine]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Conversion disorder]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Conversion disorder]] | ||
|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" | + | | 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" | | ||
|style="background: #F5F5F5; padding: 5px text-align:center" |History of [[emotional stress]] | | style="background: #F5F5F5; padding: 5px text-align:center" |History of [[emotional stress]] | ||
| 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;" |Diagnosis of exclusion | | style="background: #F5F5F5; padding: 5px;" |Diagnosis of exclusion | ||
|style="background: #F5F5F5; padding: 5px;" |[[Tremor|Tremors]], [[blindness]], difficulty [[swallowing]] | | style="background: #F5F5F5; padding: 5px;" |[[Tremor|Tremors]], [[blindness]], difficulty [[swallowing]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |Metabolic disturbances ([[electrolyte imbalance]], [[hypoglycemia]]) | | style="background: #DCDCDC; padding: 5px; text-align: center;" |Metabolic disturbances ([[electrolyte imbalance]], [[hypoglycemia]]) | ||
|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" | + | | 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" | + | ||
|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;" |[[Hypoglycemia]], [[Hyponatremia|hypo]] and [[hypernatremia]], [[Hypokalemia|hypo]] and [[hyperkalemia]] | | style="background: #F5F5F5; padding: 5px;" |[[Hypoglycemia]], [[Hyponatremia|hypo]] and [[hypernatremia]], [[Hypokalemia|hypo]] and [[hyperkalemia]] | ||
|style="background: #F5F5F5; padding: 5px;" |Depends on the cause | | style="background: #F5F5F5; padding: 5px;" |Depends on the cause | ||
| style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[seizure]], [[Palpitation|palpitations]], [[sweating]], [[dizziness]], [[hypoglycemia]] | | style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[seizure]], [[Palpitation|palpitations]], [[sweating]], [[dizziness]], [[hypoglycemia]] | ||
|- | |- | ||
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Multiple sclerosis]] exacerbation | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Multiple sclerosis]] exacerbation | ||
|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" | - | | 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" | + | ||
|style="background: #F5F5F5; padding: 5px text-align:center" |History of relapses and remissions | | style="background: #F5F5F5; padding: 5px text-align:center" |History of relapses and remissions | ||
| style="background: #F5F5F5; padding: 5px; text-align:center" | + | | style="background: #F5F5F5; padding: 5px; text-align:center" | + | ||
| style="background: #F5F5F5; padding: 5px; text-align:center" |'''↑''' CSF IgG levels | | style="background: #F5F5F5; padding: 5px; text-align:center" |'''↑''' CSF IgG levels | ||
| Line 260: | Line 265: | ||
|- | |- | ||
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Seizure]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Seizure]] | ||
|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" | + | | 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" | + | ||
|style="background: #F5F5F5; padding: 5px text-align:center" |Previous history of [[seizures]] | | style="background: #F5F5F5; padding: 5px text-align:center" |Previous history of [[seizures]] | ||
| style="background: #F5F5F5; padding: 5px;" | - | | style="background: #F5F5F5; padding: 5px;" | - | ||
| style="background: #F5F5F5; padding: 5px;" |Mass lesion | | style="background: #F5F5F5; padding: 5px;" |Mass lesion | ||
| Line 275: | Line 280: | ||
| style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[apathy]], [[irritability]], | | style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[apathy]], [[irritability]], | ||
|} | |} | ||
==References== | ==References== | ||
Latest revision as of 16:00, 20 May 2019
Overview
Subdural hematoma must be differentiated from other disease that causes headache,seizures and loss of consciousness such as Meningitis, encephalitis, brain tumor, hemorrhagic stroke, neurosyphilis, migrain, hypertensive encephalopathy, wernicke’s encephalopathy, brain abscess, drug toxicity, conversion disorders, metabolic disturbance, multiple sclerosis, and seizure.
Differential diagnosis
Subdural hematoma must be differentiated from other disease that causes headache,seizures and loss of consciousness such as Meningitis, encephalitis, brain tumor, hemorrhagic stroke, neurosyphilis, migrain, hypertensive encephalopathy, wernicke’s encephalopathy, brain abscess, drug toxicity, conversion disorders, metabolic disturbance, multiple sclerosis, and seizure.
Differentiating subdural hematoma from other diseases on the basis of headache,seizures and loss of consciousness.
| Diseases | Symptoms | Physical Examination | Past medical history | Diagnostic tests | Other Findings | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Headache | ↓LOC | Motor weakness | Abnormal sensory | Motor Deficit | Sensory deficit | Speech difficulty | Gait abnormality | Cranial nerves | CT /MRI | CSF Findings | Gold standard test | |||
| Subdural hemorrhage | + | + | + | + | + | - | - | - | + | Trauma, fall | + | Xanthochromia[1] | CT scan without contrast[2][3] | Confusion, dizziness, nausea, vomiting |
| Meningitis | + | - | - | - | - | + | + | - | - | History of fever and malaise | - | ↑ Leukocytes,
↑ Protein ↓ Glucose |
CSF analysis[4] | Fever, neck |
| Encephalitis | + | + | +/- | +/- | - | - | + | +/- | + | History of fever and malaise | + | ↑ Leukocytes, ↓ Glucose | CSF PCR | Fever, seizures, focal neurologic abnormalities |
| Brain tumor[5] | + | - | - | - | + | + | + | - | + | Weight loss, fatigue | + | Cancer cells[6] | MRI | Cachexia, gradual progression of symptoms |
| Hemorrhagic stroke | + | + | + | + | + | + | + | + | - | Hypertension | + | - | CT scan without contrast[2][3] | Neck stiffness |
| Neurosyphilis[7][8] | + | - | + | + | + | + | - | + | - | STIs | + | ↑ Leukocytes and protein | CSF VDRL-specifc
CSF FTA-Ab -sensitive[9] |
Blindness, confusion, depression,
Abnormal gait |
| Complex or atypical migraine | + | - | + | + | - | - | + | - | - | Family history of migraine | - | - | Clinical assesment | Presence of aura, nausea, vomiting |
| Hypertensive encephalopathy | + | + | - | - | - | - | + | + | - | Hypertension | + | - | Clinical assesment | Delirium, cortical blindness, cerebral edema, seizure |
| Wernicke’s encephalopathy | - | + | - | - | - | + | + | + | + | History of alcohal abuse | - | - | Clinical assesment and lab findings | Ophthalmoplegia, confusion |
| CNS abscess | + | + | - | - | + | + | + | - | - | History of drug abuse, endocarditis, immunosupression | + | ↑ leukocytes, ↓ glucose and ↑ protien | MRI is more sensitive and specific | High grade fever, fatigue,nausea, vomiting |
| Drug toxicity | - | + | - | + | + | + | - | + | - | - | - | - | Drug screen test | Lithium, Sedatives, phenytoin, carbamazepine |
| Conversion disorder | + | + | + | + | + | + | + | + | History of emotional stress | - | - | Diagnosis of exclusion | Tremors, blindness, difficulty swallowing | |
| Metabolic disturbances (electrolyte imbalance, hypoglycemia) | - | + | + | + | + | + | - | - | + | - | - | Hypoglycemia, hypo and hypernatremia, hypo and hyperkalemia | Depends on the cause | Confusion, seizure, palpitations, sweating, dizziness, hypoglycemia |
| Multiple sclerosis exacerbation | - | - | + | + | - | + | + | + | + | History of relapses and remissions | + | ↑ CSF IgG levels
(monoclonal bands) |
Clinical assesment and MRI [10] | Blurry vision, urinary incontinence, fatigue |
| Seizure | + | + | - | - | + | + | - | - | + | Previous history of seizures | - | Mass lesion | Clinical assesment and EEG [11] | Confusion, apathy, irritability, |
References
- ↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
- ↑ 2.0 2.1 Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
- ↑ 3.0 3.1 DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
- ↑ Carbonnelle E (2009). "[Laboratory diagnosis of bacterial meningitis: usefulness of various tests for the determination of the etiological agent]". Med Mal Infect. 39 (7–8): 581–605. doi:10.1016/j.medmal.2009.02.017. PMID 19398286.
- ↑ Morgenstern LB, Frankowski RF (1999). "Brain tumor masquerading as stroke". J Neurooncol. 44 (1): 47–52. PMID 10582668.
- ↑ Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
- ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
- ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
- ↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
- ↑ Giang DW, Grow VM, Mooney C, Mushlin AI, Goodman AD, Mattson DH; et al. (1994). "Clinical diagnosis of multiple sclerosis. The impact of magnetic resonance imaging and ancillary testing. Rochester-Toronto Magnetic Resonance Study Group". Arch Neurol. 51 (1): 61–6. PMID 8274111.
- ↑ Manford M (2001). "Assessment and investigation of possible epileptic seizures". J Neurol Neurosurg Psychiatry. 70 Suppl 2: II3–8. PMC 1765557. PMID 11385043.