Encephalopathy differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]

Overview

Encephalopathy can present in many ways mimicking many other brain conditions. Certain conditions like encephalitis, meningitis, brain tumors, epilepsy, and overdosing of certain medications may mimic encephalopathy.

Differentiating from other symptoms

The symptoms of encephalopathy may overlap with the symptoms of other diseases:

  • Intracranial lesions like tumors, masses, granulomas which are differentiated by the presence of focal neurologic signs and symptoms

Encephalopathy 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[1] Fever, neck

rigidity

Encephalitis + + +/- +/- - - + +/- + History of fever and malaise + Leukocytes, ↓ Glucose CSF PCR Fever, seizures, focal neurologic abnormalities
Brain tumor[2] + - - - + + + - + Weight loss, fatigue + Cancer cells[3] MRI Cachexia, gradual progression of symptoms
Hemorrhagic stroke + + + + + + + + - Hypertension + - CT scan without contrast[4][5] Neck stiffness
Subdural hemorrhage + + + + + - - - + Trauma, fall + Xanthochromia[6] CT scan without contrast[4][5] Confusion, dizziness, nausea, vomiting
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,

Other differentials

Toxic encephalopathy must also be differentiated from other diseases that cause personality changes, altered level of consciousness and hand tremors (asterixis). The differentials include the following:[12][13][14][15][16][17][18][19][20][21][22]

Diseases History and Symptoms Physical Examination Laboratory Findings
Personality changes Altered level of consciousness Hand tremors (asterixis) Slurred speech Writing disturbances Voice monotonous Impaired memory Elevated blood ammonia Hyponatremia hypokalemia
Hepatic encephalopathy ++ ++ ++ ++ ++ ++ ++ ++ ++ ++
Alcohol intoxication + + -/+ ++ + - + - -/+ -/+
Alcohol withdrawal + + - ++ + - + - -/+ -/+
Uremia ++ ++ + -/+ -/+ -/+ - ++ Hyperkalemia
Wernicke encephalopathy + + -/+ + + + ++ - - -
Toxic encephalopathy from drugs + + -/+ -/+ + -/+ + + -/+ -/+
Altered intracranial pressure + -/+ - -/+ -/+ - -/+ - - -
Intoxication by chemical agents -/+ -/+ -/+ -/+ -/+ - - - -/+ -/+
Malnutrition -/+ - - - -/+ - -/+ - -/+ -/+
Hypoxic brain injury - -/+ - -/+ -/+ -/+ -/+ - - -
Meningitis and encephalitis -/+ -/+ - -/+ + - - - -/+ -
Hypoglycemia -/+ -/+ - -/+ -/+ - - - -/+ -/+

References

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  2. Morgenstern LB, Frankowski RF (1999). "Brain tumor masquerading as stroke". J Neurooncol. 44 (1): 47–52. PMID 10582668.
  3. 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.
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  8. Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
  9. 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.
  10. 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.
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  14. Roldán J, Frauca C, Dueñas A (2003). "[Alcohol intoxication]". An Sist Sanit Navar. 26 Suppl 1: 129–39. PMID 12813481.
  15. Seifter JL, Samuels MA (2011). "Uremic encephalopathy and other brain disorders associated with renal failure". Semin Neurol. 31 (2): 139–43. doi:10.1055/s-0031-1277984. PMID 21590619.
  16. Handler CE, Perkin GD (1983). "Wernicke's encephalopathy". J R Soc Med. 76 (5): 339–42. PMC 1439130. PMID 6864698.
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