Some reasons for misdiagnosis in patients with neurological emergencies.
|History||Patients 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 exam||Patients 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 testing||For 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 infarction||No MRI available|
MRI must target the correct segment(s) of the spine.
|False normal CT in early stroke||EEG often not available in the emergency department. Not performing LP in seizure patients who may have encephalitis or neurocysticercosis.|
|Preconceived notions||Headache improved with triptans so is not a serious secondary cause.||Posterior circulation strokes are obvious or devastating events||All patients with SEA have risk factors or fever, or neurological deficits||Young people do not get strokes||Seizures (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.|