Differential Diagnosis for Hypertensive Crisis and Hemorrhagic Stroke Prehospital

Single Most Likely Diagnosis

• Hypertensive crisis: This is the most likely diagnosis given the context of the question, as hypertensive crisis can present with severely elevated blood pressure and symptoms that overlap with those of a hemorrhagic stroke, such as headache and altered mental status. The key differentiator would be the presence of focal neurological deficits in a stroke.

Other Likely Diagnoses

• Hemorrhagic stroke: This is another likely diagnosis, as it can present with sudden onset of severe headache, vomiting, and decreased level of consciousness, similar to a hypertensive crisis. The presence of focal neurological deficits would support this diagnosis.
• Ischemic stroke: Although the question specifically mentions hemorrhagic stroke, ischemic stroke should also be considered, as it can present with similar symptoms, including sudden onset of focal neurological deficits.

Do Not Miss Diagnoses

• Aortic dissection: This is a critical diagnosis not to miss, as it can present with severe hypertension and symptoms similar to those of a stroke, including chest or back pain. Missing this diagnosis could be fatal.
• Subarachnoid hemorrhage: This condition can present with sudden onset of severe headache and decreased level of consciousness, similar to a hypertensive crisis or hemorrhagic stroke. It requires immediate medical attention.
• Status epilepticus: Although less likely, status epilepticus can present with altered mental status and seizures, which could be mistaken for a stroke or hypertensive crisis. It is critical to consider this diagnosis, especially if the patient has a history of epilepsy.

Rare Diagnoses

• Pheochromocytoma: This rare tumor can cause episodic hypertension and symptoms that might mimic a hypertensive crisis or stroke. Although unlikely, it should be considered in patients with unexplained severe hypertension.
• Reversible cerebral vasoconstriction syndrome (RCVS): This rare condition can present with sudden onset of severe headache and can be associated with stroke-like symptoms. It is often associated with vasoactive substance use or other specific factors.
• Cerebral venous sinus thrombosis: This condition can present with headache, seizures, and altered mental status, which could be mistaken for a stroke or hypertensive crisis. It is more common in patients with specific risk factors, such as hypercoagulable states.