Hemorrhagic stroke differential diagnosis

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

Differential diagnosis

It is clinically difficult to distinguish an ICH 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.

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	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	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	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	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	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	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	Absent of focal neurologic symptoms and signs	Absent of focal neurologic signs
	Pituitary apoplexy	Acute headache Change in mental status	Decreased visual acuity Ophthalmoplegia		Brain CT and MRI are the preferred imaging techniques
	Cerebral venous thrombosis			-	Brain MRI with venography should be considered
	Colloid cyst of the third ventricle			-	Head CT or MRI of the brain are usually diagnostic
	Cervical artery dissection			-	Brain MRI with MRA and cranial CT with CTA)
	Reversible cerebral vasoconstriction syndrome			-
	Spontaneous intracranial hypotension				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	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		✔	Cancer cells	MRI	✔	✔	✔	✔	✔	✔					Cachexia
Hemorrhagic stroke		✔	Xanthochromia	CT scan without contrast	✔	✔	✔	✔	✔	✔	✔	✔		Hypertension	Neck stiffness
Subdural hemorrhage		✔		CT scan without contrast	✔	✔	✔	✔	✔	✔	✔	✔		Trauma/fall	Confusion, dizziness, nausea, vomiting
Neurosyphilis		✔	↑ Leukocytes and protein	CSF VDRL-specifc CSF FTA-Ab -sensitive	✔	✔	✔	✔		✔		✔	✔	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					✔	✔					Fever, neck rigidity
Multiple sclerosis exacerbation		✔	↑ CSF IgG levels (monoclonal bands)	Clinical assesment and MRI	✔	✔	✔	✔	✔			✔	✔	History of relapses and remissions	Blurry vision, urinary incontinence, fatigue
Seizure	↓ or ↑			Clinical assesment and EEG	✔					✔	✔		✔	Previous history of seizures	Confusion, apathy, irritability,
Hypoglycemia or hyperglycemia	↓ or ↑			Serum blood glucose HbA1c			✔	✔		✔	✔		✔	History of diabetes	Palpitations, sweating, dizziness

Hemorrhagic stroke must be differentiated from other causes 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
Meningitis	+	-	-	-	-	+	+	-	-	History of fever and malaise	-	↑ Leukocytes, ↑ Protein ↓ Glucose	CSF analysis	Fever, neck rigidity
Encephalitis	+	+	+/-	+/-	-	-	+	+/-	+	History of fever and malaise	+	↑ Leukocytes, ↓ Glucose	CSF PCR	Fever, seizures, focal neurologic abnormalities
Brain tumor	+	-	-	-	+	+	+	-	+	Weight loss, fatigue	+	Cancer cells	MRI	Cachexia, gradual progression of symptoms
Hemorrhagic stroke	+	+	+	+	+	+	+	+	-	Hypertension	+	-	CT scan without contrast	Neck stiffness
Subdural hemorrhage	+	+	+	+	+	-	-	-	+	Trauma, fall	+	Xanthochromia	CT scan without contrast	Confusion, dizziness, nausea, vomiting
Neurosyphilis	+	-	+	+	+	+	-	+	-	STIs	+	↑ Leukocytes and protein	CSF VDRL-specifc CSF FTA-Ab -sensitive	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	Blurry vision, urinary incontinence, fatigue
Seizure	+	+	-	-	+	+	-	-	+	Previous history of seizures	-	Mass lesion	Clinical assesment and EEG	Confusion, apathy, irritability,

References

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