Differentials
Ischemic stroke
SIGNS / SYMPTOMS
Symptoms of ischemic stroke may be maximal at onset, particularly in embolic infarction.
In ischemic stroke, patients do not typically exhibit gastrointestinal symptoms (nausea/vomiting) or headache.[3]
Symptoms that spontaneously improve or resolve suggest ischemia rather than hemorrhage.
INVESTIGATIONS
Acute hemorrhage appears bright due to hyperattenuation of the x-ray beams in CT scan.
Ischemic infarct appears as hypoattenuation (darkness), although may not appear for many hours after stroke onset.
Hypertensive encephalopathy
SIGNS / SYMPTOMS
Hypertension significantly above patient's baseline blood pressure associated with headache, decreased consciousness or cognitive abnormalities, visual changes or loss, and signs of increased intracranial pressure.
Less frequently these patients present with focal abnormalities in the neurologic examination.
INVESTIGATIONS
Cerebral edema on CT or MRI. Certain patients present characteristic changes in the posterior aspect of the brain.
Hypoglycemia
SIGNS / SYMPTOMS
Sweating, tremor, hunger, confusion, and ultimately a decreased level of consciousness.
May have known history of diabetes mellitus and insulin use or medical conditions associated with hypoglycemia.
INVESTIGATIONS
Low serum glucose on blood chemistry.
Complicated migraine
SIGNS / SYMPTOMS
Repetitive history of similar events; preceding aura; headache in a marching pattern.
INVESTIGATIONS
MRI shows no evidence of infarction.
Seizure disorder
SIGNS / SYMPTOMS
A history of seizures and/or a witnessed seizure followed by postictal deficits.
INVESTIGATIONS
EEG results may identify seizure activity.
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, functional neurologic disorder displays multiple signs that are neurologically inconsistent. Some patients will have had adverse life events, but, importantly, these are neither necessary nor sufficient for the diagnosis.[93] Psychological comorbidities - especially anxiety, panic, and depression - are common, affecting over 50% of patients.[94]
INVESTIGATIONS
CT and MRI show no evidence of infarction or hemorrhage in functional neurologic and somatic symptom disorders.
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