Traumatic Brain Injury: Or something else? Differential Diagnosis

If there is no definite evidence of an accidental event, the following differential diagnoses may be considered for a person who is impaired in consciousness. Diseases that may cause impaired consciousness:

Respiratory system (J00-J99)

  • Coma hypercapnium – coma caused by a marked increase in the level of carbon dioxide in the blood.

Endocrine, nutritional and metabolic diseases (E00-E90).

  • Addison’s crisis – decompensated Addison’s disease; this describes primary adrenocortical insufficiency resulting in, among other things, failure of cortisol production.
  • Coma basedowicum – coma in metabolic derailment in the context of Graves’ disease (thyroid disease).
  • Coma diabeticum (coma in metabolic derailment in the context of diabetes mellitus/sugar disease):
    • Diabetic ketoacidosis (DKA; synonym: ketoacidotic coma; severe metabolic derailment (ketoacidosis) in insulin deficiency) – predominantly in type 1 diabetes mellitus.
    • Hyperosmolar nonketotic coma or syndrome (HNKS; synonyms: hyperosmolar diabetic coma; hyperglycemic coma) – typical in diabetes mellitus type 2.
  • Coma hypochloraemicum – coma in metabolic derailment in the context of a severe salt deficiency syndrome.
  • Coma hypoglycaemicum – coma due to severe hypoglycemia (hypoglycemia).
  • Coma posthypoglycaemicum – coma after a prolonged hypoglycemia (hypoglycemia).
  • Coma pyloricum – coma in metabolic derailment in the context of decompensated pyloric stenosis (gastric orifice stenosis).
  • Hypercalcemic crisis – life-threatening form of hyperparathyroidism (parathyroid hyperfunction).
  • Hyperproteinemic coma (hyperviscosity syndrome, HVS) – coma due to a change in the viscosity of the blood, resulting in a restriction of flow.
  • Hypokalemic tetany – neuromuscular hyperexcitability due to a deficiency of potassium.
  • Hypocalcemic tetany – neuromuscular hyperexcitability due to a deficiency of calcium.
  • Hypopituitarism (hypopituitarism) – inability of the pituitary gland (pituitary gland) to produce enough hormones.
  • Myxedema coma (hypothyroid coma) – life-threatening course of hypothyroidism (hypothyroidism), which is accompanied by a severe disturbance of consciousness.

Cardiovascular system (I00-I99).

  • Apoplexy (stroke)
  • Basilar artery thrombosis – occlusion of a basilar artery of the brainstem associated with severe neurologic damage.
  • Cerebral sinus thrombosis – occlusion of a venous cerebral blood vessel.
  • Brainstem hemorrhage
  • Brainstem infarction
  • Intracranial hemorrhage (bleeding within the skull; parenchymal, subarachnoid, sub- and epidural, and supra- and infratentorial hemorrhage)/intracerebral hemorrhage (ICB; cerebral hemorrhage).
  • Subarachnoid hemorrhage (SAB; hemorrhage between the spider tissue membrane and the soft meninges); frequency: 1-3%); symptomatology: proceed according to “Ottawa rule for subarachnoid hemorrhage”:
    • Age ≥ 40 years
    • Meningismus (symptom of painful neck stiffness in irritation and disease of the meninges).
    • Syncope (brief loss of consciousness) or impaired consciousness (somnolence, sopor and coma).
    • Onset of cephalgia (headache) during physical activity.
    • Thunderclap headache/destructive headache (about 50% of cases).
    • Restricted mobility of the cervical spine (Cervical spine).

    Aneurysm (outpouching of an artery) is the cause of subarachnoid hemorrhage in 75-80% of cases.High serum lactate levels in the emergency department are associated with increased mortality (death rate); it has long been known that cerebral lactate levels and the cerebral lactate-to-pyruvate ratio are increased

  • Subdural hematoma (SDH) – hematoma (bruise) under the hard meninges between the dura mater (hard meninges) and the arachnoid (spider tissue membrane); risk group: patients on anticoagulation (anticoagulants)
    • Acute subdural hematomaSymptoms: Disturbances of consciousness up to unconsciousness
    • Chronic subdural hematomaSymptoms: uncharacteristic complaints such as a feeling of pressure in the head, cephalgia (headache), vertigo (dizziness), restriction or loss of orientation and ability to concentrate

    Antithrombotic drugs have increased the number of subdural hematomas:

    • Low-dose acetylsalicylic acid: odds ratio of 1.24 (95 percent confidence interval: 1.15-1.33)
    • Clopidogrel: odds ratio of 1.87 (1.57-2.24). Vitamin K antagonists (VKA): odds ratio of 3.69 (3.38-4.03).
    • Direct oral anticoagulants (DOAK): odds ratio of 1.73 (1.31-2.28).
    • Vitamin K antagonists + antiplatelet agents (TAH): odds ratio of 4.00 (3.40-4.70).
    • Vitamin K antagonists with clopidogrel: odds ratio of 7.93 (4.49-14.02).

Liver, gallbladder, and biliary tract-pancreas (pancreas) (K70-K77; K80-K87).

  • Hepatic failure coma – coma that may develop during the course of liver cirrhosis.
  • Hepatic decay coma (endogenous hepatic coma) – coma, which is due to acute death of liver cells.

Neoplasms – tumor diseases (C00-D48).

  • Brain tumors, unspecified

Psyche – nervous system (F00-F99; G00-G99).

Genitourinary system (kidneys, urinary tract – sex organs) (N00-N99).

  • Coma uremicum – coma caused by uremia (occurrence of urinary substances in the blood above normal values).

Causes (external) of morbidity and mortality (V01-Y84).

  • Coma dyspepticum (infantum) – coma caused by desiccosis (dehydration) in an infant in the context of intoxication (poisoning), usually after an intestinal infection.
  • Shaking trauma – children before 3 years of age with an unclear history and a disproportionate neurologic status; 10-30% of children die as a result of shaking traumaNote: More than 90% of all severe intracranial injuries in infancy and early childhood are the result of maltreatment.

Injuries, poisonings, and other sequelae of external causes (S00-T98).

  • Brain contusion (brain contusion)
  • Brain mass hemorrhage

Further

  • Headbanging (movement of the head in time with the music: quickly back and forth, sideways, in circles or figure eights).
  • Child abuse

Medication

Environmental pollution – intoxications (poisoning).

  • Poisonings as caused by:
    • Alkaloids
    • Alcohol
    • Hypnotics (sleeping pills)
    • Carbon monoxide
    • Hydrocarbons (aliphatic, aromatic)
    • Opiates (painkillers such as morphine)
    • Sedatives (tranquilizers)
    • Hydrogen cyanide/potassium cyanide