Emergency Medicine International / 2012 / Article / Tab 1

Review Article

Avoiding Misdiagnosis in Patients with Neurological Emergencies

Table 1

Some reasons for misdiagnosis in patients with neurological emergencies.

HeadacheDizzinessBack PainWeaknessSeizure

HistoryPatients use words like “migraine” and “sinus infection” that may mislead the physician.
Beware previous diagnoses; they might be wrong.
The use of the word “vertigo” versus other dizziness descriptors is not etiologically useful.Patients use word “sciatica” which may lead physicians to diagnose sciatica.Stroke patients may complain of “clumsiness” or “my arm felt like lead” rather than “weakness”.Patient (or witness) says “seizure” after a faint
Seizure patients often present after the seizure with only an altered mental status or with a postictal “Todd’s” paralysis

Physical examPatients with SAH may be well appearing and neurologically intact.Patients with small posterior circulation strokes can mimic a peripheral vestibular presentation.Patients with serious causes of back pain can present without neurological deficits.Patients with stroke can present with just about any focal deficit depending upon the occluded vessel. Myasthenia patients’ symptoms wax and wane.
GBS patients’ first symptoms may be purely sensory.
Patients may be lethargic, but neurologically intact.

Diagnostic testingFor SAH, CT sensitivity is good but decays with time.
CT has poor sensitivity for CVST and dissection.
CT is a poor test for cerebellar and brainstem infarctionNo MRI available
MRI must target the correct segment(s) of the spine.
False normal CT in early strokeEEG often not available in the emergency department. Not performing LP in seizure patients who may have encephalitis or neurocysticercosis.

Preconceived notionsHeadache improved with triptans so is not a serious secondary cause.Posterior circulation strokes are obvious or devastating eventsAll patients with SEA have risk factors or fever, or neurological deficitsYoung people do not get strokesSeizures (or seizure-like movements) are sometimes seen with strokes.
Convulsive movements are common in syncope.

CVST: cerebral venous sinus thrombosis, SAH: subarachnoid hemorrhage, CT: CAT scan, MRI: magnetic resonance imaging, SEA: spinal epidural abscess.

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