Diff Diagnosis List

Diff Diagnosis List Part I

I - Differential Diagnosis of Stupor
II - Cerebral Vasculitis
III - Horner's Syndrome Review
IV - Subacute etiologies of Headache
V - Review of Nystagmus

Differential Diagnosis of Stupor

Vascular	CVA (brainstem, thalamic, large hemispheric) ICH SAH Epidural/subdural hematoma
Metabolic	Thyroid disturbance Adrenal insufficiency DKA, hyper, hypoglycemia Hepatic Renal Medication induced Toxin induced Wernicke’s encephalopathy
Infectious	Meningitis Encephalitis Brain abscess Sepsis
Neoplastic	1 brain tumor, metastasis Limbic encephalitis
Inflammatory	ADEM CNS vasculitis
Hypertensive encephalopathy
Seizures	Non convulsive status epilepticus Post icital
Hydrocephalus
Psychogenic coma

Workup

Labs – CBC, BMP, LFT, TSH, urine tox, ammonia, ABG, EKG, if infection suspected – CXR, U/A, blood, urine cultures
Tx – 100 mg IV thiamine then glucose
Imaging – CT or MRI brain, if no mass lesion or focal neuro deficit, LP, EEG











Causes of cerebral vasculitis

Primary angiitis of the CNS
Infectious – HIV, VZV
Meningitis – fungal, viral, treponemal, parasitic
Drug induced – amphetamines, cocaine
Lymphoma
GCA – high ESR, older age, EXTRADURAL

Systemic Vasculitis
Behcet’s – genital/oral ulcers, ocular signs
PAN – fever, arthralgias, myalgias, mononeuropathies
Churg Strauss – asthma, eosinophilia, neuropathy
Wegner’s - +ANCA, neuropathy
SLE – fever, rash, pleuritis, encephalopathy

Vasculitis workup:
Labs: ESR, CRP, ANA, CBC c diff, BMP
Imaging: CXR, MRI brain, MRA, CTA or angiogram of head and neck

Review of Horner’s syndrome

Horner’s syndrome – ptosis, anhidrosis, miosis

1 order sympathetic fibers: hypothalamus → brainstem → descend to interomediolateral cell column of spinal cord at C8-T2
2 order sympathetic fibers: exit spinal cord at T1 → ascend cervical sympathetic chain → synapse at superior cervical ganglion at carotid artery bifurication
3 order/postganglionic sympathetic fibers: travel along ICA → 1) sudomotor fibers travel along EXTERNAL carotid artery 2) pupillomotor fibers enter cavernous sinus → superior orbital fissure via long cillary nerve → iris dilator and Muller muscle

Agents to localize Horner syndrome
4% cocaine – inhibits NE reuptake, will lead to POOR papillary dilatation in sympathetic lesion at any order
1% hydroxyamphetamine – stimulates release of NE from presynaptic postganglionic nerve terminals, 1st, 2nd order fibers will result in papillary dilation, 3rd order will NOT dilate









Basic diff dx for subacute onset of severe HA

Vascular – ICH, SAH, CVT
Infectious – meningitis, encephalitis, brain abscess
Neoplastic – 1 neoplasm or metastatic
Idiopathic intracranial hypertension
Vasculitis – CNS or systemic
Metabolic – thyroid, electrolyte, toxin
Hydrocephalus

Labs – CBC, BMP, LFT, TSH, coags, ESR
Imaging – CT/MRI, CTV/MRV
Lumbar puncture







Characterization of Nystagmus

	Peripheral	Central
Vertigo	Intense	Mild
N/V	Intense	Less common
Duration	Short	Persitent
Fatigability	Yes	None with multiple trials
Direction	Fixed, horizontal or diagonal, rotatory or torsional	Multidirectional, can include vertical
Latency	Several seconds	None

Horizontal nystagmus if caused by labyrinth or vestibular nerve – the fast phase of nystagmus is opposite the affected side ie fast phase to L signals R vestibular dysfunction