- TIA (Transient ischemic attack)
- Stroke (hemorrhagic vs. ischemic, see the next 4)
- Ischemic Stroke
- Subdural hemorrhage /hematoma
- Intracerebral hemorrhage – can occur rapidly and cause focal neurologic symptoms.
- Subarachnoid hemorrhage.
- Seizures and postictal deficits e.g. Focal Seizures; Generalized seizures
- Postictal paresis/paralysis (Todd’s palsy) after a seizure. This is a focal weakness in a part of the body after a seizure.
- Migraines with auras) / Complicated migraine headaches
- Syncope / Presyncope
- Vertigo or dizziness
- Multiple sclerosis
- Cervicogenic headache / Cervicalgia headache
- Benign headache
- Head trauma
- Labyrinthitis
- Vestibular neuritis
- Other peripheral vestibulopathy
- Systemic infection
- CNS infection
- Benign Positional Vertigo.
- Hypotension
- Brain tumor* / Cancer
- Conversion disorder; Somatization disorder
- Panic attack
- Malingering
- Hypoglycemia
- Hyperglycemia
- Hyponatremia
- Drug or alcohol intoxication
- Hyperosmolar Hyperglycemic State (HHS)*
- Delirium (also called Acute confusional state) –
- Hypertensive encephalopathy
- Transient episodic dizziness caused by peripheral vestibulopathy
- Nerve or nerve root compression*
- Peripheral neuropathy
- Guilain Barre’
- Hepatic encephalopathy,
- Renal encephalopathy; Acute renal failure
- Pulmonary encephalopathies
- Other toxic or metabolic encephalopathy
- Wernicke encephalopathy
- Transient global amnesia
- Cerebral amyloid angiopathy
- Systemic Infection (Viral, bacterial, etc)
- Acute disseminated encephalomyelitis (ADEM)
- Encephalitis
- Brain abscesses
- Dementia
- Headache and neurologic deficits with cerebrospinal fluid lymphocytosis (HaNDL) syndrome
- Spinal epidural hematoma
- Aortic dissection
- Compressive myelopathy
- Spinal dural arteriovenous fistulas
The differential above can easily be derived by working through the VINDICATED MEN mnemonic
Explanations of differential diagnosis
- Brain tumor * – Hemorrhage into a tumor can cause abrupt focal symptoms that appear like a stroke. Also, some tumors which are outside the brain (eg, meningiomas) reach a critical mass and can cause abrupt displacement of brain tissue with the sudden onset of symptoms.
- Hyperosmolar Hyperglycemic State (HHS)* – Nonketotic hyperglycemic stupor is often associated with focal neurologic signs; there may be a focal region of brain edema on brain imaging tests.
- Nerve or nerve root compression* – Transient paresthesia and numbness caused by pressure-or position-related peripheral nerve or nerve root compression.
Further Reading
Eur J Radiol. 2017 Nov;96:133-144. Acute stroke differential diagnosis: Stroke mimics. https://www.ncbi.nlm.nih.gov/pubmed/28551302
Am Fam Physician. 2015 Apr 15;91(8):528-536. https://www.aafp.org/afp/2015/0415/p528.html
https://www.uptodate.com/contents/differential-diagnosis-of-transient-ischemic-attack-and-stroke
https://emedicine.medscape.com/article/1916852-differential