Hemorrhagic stroke differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Differential diagnosis

[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


Differential Disease Symptoms Signs Laboratory findings Diagnostic modality Management
Thunderclap headache Sentinel headache[3] Absent of focal neurologic symptoms and signs Absent of focal neurologic signs
Pituitary apoplexy[4] Acute headache

Change in mental status

Decreased visual acuity

Ophthalmoplegia

Brain CT and MRI are the preferred imaging techniques
Cerebral venous thrombosis[5][6] - Brain MRI with venography should be considered
Colloid cyst of the third ventricle[7] - Head CT or MRI of the brain are usually diagnostic
Cervical artery dissection[8][9] - Brain MRI with MRA and cranial CT with CTA)
Reversible cerebral vasoconstriction syndrome -
Spontaneous intracranial hypotension[10][11] Brain MRI is the preferred imaging techniques
Stroke Ischemic stroke
transient ischemic attack (TIA)
Infection Sinusitis
Others Hypoglycemia Headache,

Loc

Abnormal sensation

Palpitations, sweating, dizziness

Speech difficulty

Gait abnormality

Low blood glucose

Electrolyte imbalance

Acute hypertensive crisis/Malignant hypertension Urgent evaluation of serum creatinine, urinalysis, metabolic and cardiac evaluation (EKG, chest x ray, and cardiac enzymes) Urgent evaluation with MRI and CT of the brain
Brain tumor[12] Headache Cachexia Sensory and motor deficit, Gait abnormality and speech difficulty


Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
Na+, K+, Ca2+ CT /MRI CSF Findings Gold standard test Motor Deficit Sensory deficit Speech difficulty Gait abnormality Cranial nerves Headache LOC Motor weakness Abnormal sensations
Brain tumour[12] ✔ Cancer cells[13] MRI ✔ ✔ ✔ ✔ ✔ ✔ Cachexia
Hemorrhagic stroke ✔ Xanthochromia[14] CT scan without contrast[15][16] ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Hypertension Neck stiffness
Subdural hemorrhage ✔ CT scan without contrast[15][16] ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Trauma/fall Confusion, dizziness, nausea, vomiting
Neurosyphilis[17][18] ✔ ↑ Leukocytes and protein CSF VDRL-specifc

CSF FTA-Ab -sensitive[19]

✔ ✔ ✔ ✔ ✔ ✔ ✔ STIs Blindness, confusion, depression,

Abnormal gait

Complex or atypical migraine Clinical assesment ✔ ✔ ✔ Family history of migraine Presence of aura, nausea, vomiting
Conversion disorder Diagnosis of exclusion ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Tremors, blindness, difficulty swallowing
Electrolyte disturbance ↓ or ↑ Depends on the cause Confusion, seizures
Meningitis or encephalitis ↑ Leukocytes,

↑ Protein

↓ Glucose

CSF analysis[20] ✔ ✔ Fever, neck

rigidity

Multiple sclerosis exacerbation ✔ ↑ CSF IgG levels

(monoclonal bands)

Clinical assesment and MRI [21] ✔ ✔ ✔ ✔ ✔ ✔ ✔ History of relapses and remissions Blurry vision, urinary incontinence, fatigue
Seizure ↓ or ↑ Clinical assesment and EEG [22] ✔ ✔ ✔ ✔ Previous history of seizures Confusion, apathy, irritability,
Hypoglycemia or hyperglycemia ↓ or ↑ Serum blood glucose

HbA1c

✔ ✔ ✔ ✔ ✔ History of diabetes Palpitations, sweating, dizziness

References

  1. ↑ Linn FH, Rinkel GJ, Algra A, van Gijn J (1998). "Headache characteristics in subarachnoid haemorrhage and benign thunderclap headache". J Neurol Neurosurg Psychiatry. 65 (5): 791–3. PMC 2170334. PMID 9810961.
  2. ↑ Markus HS (1991). "A prospective follow up of thunderclap headache mimicking subarachnoid haemorrhage". J Neurol Neurosurg Psychiatry. 54 (12): 1117–8. PMC 1014694. PMID 1783930.
  3. ↑ 3.0 3.1 Polmear A (2003). "Sentinel headaches in aneurysmal subarachnoid haemorrhage: what is the true incidence? A systematic review". Cephalalgia. 23 (10): 935–41. PMID 14984225.
  4. ↑ 4.0 4.1 Dodick DW, Wijdicks EF (1998). "Pituitary apoplexy presenting as a thunderclap headache". Neurology. 50 (5): 1510–1. PMID 9596029.
  5. ↑ 5.0 5.1 de Bruijn SF, Stam J, Kappelle LJ (1996). "Thunderclap headache as first symptom of cerebral venous sinus thrombosis. CVST Study Group". Lancet. 348 (9042): 1623–5. PMID 8961993.
  6. ↑ 6.0 6.1 Bousser MG, Chiras J, Bories J, Castaigne P (1985). "Cerebral venous thrombosis--a review of 38 cases". Stroke. 16 (2): 199–213. PMID 3975957.
  7. ↑ 7.0 7.1 KELLY R (1951). "Colloid cysts of the third ventricle; analysis of twenty-nine cases". Brain. 74 (1): 23–65. PMID 14830663.
  8. ↑ 8.0 8.1 Mitsias P, Ramadan NM (1992). "Headache in ischemic cerebrovascular disease. Part I: Clinical features". Cephalalgia. 12 (5): 269–74. PMID 1423556.
  9. ↑ 9.0 9.1 Touzé E, Gauvrit JY, Moulin T, Meder JF, Bracard S, Mas JL; et al. (2003). "Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study". Neurology. 61 (10): 1347–51. PMID 14638953.
  10. ↑ 10.0 10.1 Rando TA, Fishman RA (1992). "Spontaneous intracranial hypotension: report of two cases and review of the literature". Neurology. 42 (3 Pt 1): 481–7. PMID 1549206.
  11. ↑ 11.0 11.1 Schievink WI, Wijdicks EF, Meyer FB, Sonntag VK (2001). "Spontaneous intracranial hypotension mimicking aneurysmal subarachnoid hemorrhage". Neurosurgery. 48 (3): 513–6, discussion 516-7. PMID 11270540.
  12. ↑ 12.0 12.1 Morgenstern LB, Frankowski RF (1999). "Brain tumor masquerading as stroke". J Neurooncol. 44 (1): 47–52. PMID 10582668.
  13. ↑ 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.
  14. ↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
  15. ↑ 15.0 15.1 Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
  16. ↑ 16.0 16.1 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.
  17. ↑ 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.
  18. ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
  19. ↑ 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.
  20. ↑ 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.
  21. ↑ 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.
  22. ↑ Manford M (2001). "Assessment and investigation of possible epileptic seizures". J Neurol Neurosurg Psychiatry. 70 Suppl 2: II3–8. PMC 1765557. PMID 11385043.


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