Differential Diagnosis for Acute Neurological Presentation

The following differential diagnosis is organized into categories to help guide the thought process for a patient presenting with symptoms that could be indicative of acute ischemic stroke, seizures, or complicated migraine.

• Single Most Likely Diagnosis
  • Acute ischemic stroke: This is often the first consideration in a patient presenting with sudden onset of focal neurological deficits, given its high prevalence and significant morbidity and mortality if not promptly treated.
• Other Likely Diagnoses
  • Seizures: Especially if the patient has a history of seizure disorder or if the presentation includes loss of consciousness, convulsions, or post-ictal confusion.
  • Complicated migraine: Should be considered, especially in patients with a history of migraines, if the presentation includes headache, aura, or other migraine-like symptoms, even though migraines are typically less immediately dangerous than stroke.
• Do Not Miss Diagnoses
  • Subarachnoid hemorrhage: Although less common, it is critical to rule out due to its high mortality rate and need for urgent intervention.
  • Cerebral venous sinus thrombosis: A rare but potentially fatal condition that requires prompt diagnosis and treatment.
  • Status epilepticus: Continuous or recurrent seizures without recovery in between, which is a medical emergency.
  • Meningitis or encephalitis: Infections that can present with sudden onset of neurological symptoms and require immediate treatment.
• Rare Diagnoses
  • Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS): A rare genetic disorder that can mimic acute ischemic stroke.
  • Posterior reversible encephalopathy syndrome (PRES): Associated with hypertension, eclampsia, and certain medications, presenting with headache, seizures, and visual disturbances.
  • Reversible cerebral vasoconstriction syndrome (RCVS): Characterized by sudden, severe headache and sometimes seizures or stroke-like symptoms, often related to vasoconstriction of cerebral arteries.

Each of these diagnoses has distinct features and requires a tailored approach to diagnosis and management. A thorough history, physical examination, and appropriate diagnostic tests (such as imaging studies and laboratory tests) are crucial for making an accurate diagnosis.