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Published on: September 25, 2019
Pitfalls in the diagnosis of cerebellar infarction
Sean I Savitz1, Louis R Caplan, Jonathan A Edlow
1Departments of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. ssavitz@bidmc.harvard.edu
Insights
Delayed diagnosis of cerebellar infarction in emergency departments leads to poor outcomes. Incomplete exams and normal CT scans often result in misdiagnosis, increasing mortality and disability.
Area of Science:
- Neurology
- Emergency Medicine
- Diagnostic Imaging
Background:
- Cerebellar infarctions are a significant cause of neurological disease.
- Missed or delayed diagnosis can lead to severe complications like hydrocephalus and brainstem infarction.
Purpose of the Study:
- Identify preventable medical errors in misdiagnosed cerebellar ischemic strokes.
- Analyze initial misdiagnoses in emergency department settings.
Main Methods:
- Retrospective review of 15 misdiagnosed cerebellar infarction cases over five years.
- Detailed analysis of presenting symptoms, neurological examinations, diagnostic tests, and patient outcomes.
- Categorization of errors contributing to misdiagnosis.
Main Results:
- 40% mortality rate; 50% of survivors experienced disabling deficits.
- Younger patients (<50) often presented with headache and dizziness.
- Incomplete neurological exams and normal initial CT scans were common, with MRI revealing infarction.
- Common misdiagnoses included migraine, toxic encephalopathy, and meningitis.
Conclusions:
- Diagnosis of cerebellar infarction is frequently missed or delayed in emergency departments.
- Diagnostic pitfalls exist in clinical evaluation, testing, and disposition.
- Improved diagnostic strategies are needed to reduce morbidity and mortality.
Background:
Cerebellar infarctions are an important cause of neurologic disease. Failure to recognize and rapidly diagnose cerebellar infarction may lead to serious morbidity and mortality due to hydrocephalus and brain stem infarction.
Objectives:
To identify sources of preventable medical errors, the authors obtained pilot data on cerebellar ischemic strokes that were initially misdiagnosed in the emergency department.
Methods:
Fifteen cases of misdiagnosed cerebellar infarctions were collected, all seen, or reviewed by the authors during a five-year period. For each patient, they report the presenting symptoms, the findings on neurologic examination performed in the emergency department, specific areas of the examination not performed or documented, diagnostic testing, the follow-up course after misdiagnosis, and outcome. The different types of errors leading to misdiagnosis are categorized.
Results:
Half of the patients were younger than 50 years and presented with headache and dizziness. All patients had either incomplete or poorly documented neurologic examinations. Almost all patients had a computed tomographic scan of the head interpreted as normal, and most of these patients underwent subsequent magnetic resonance imaging showing cerebellar infarction. The initial incorrect diagnoses included migraine, toxic encephalopathy, gastritis, meningitis, myocardial infarction, and polyneuropathy. The overall mortality in this patient cohort was 40%. Among the survivors, about 50% had disabling deficits. Pitfalls leading to misdiagnosis involved the clinical evaluation, diagnostic testing, and establishing a diagnosis and disposition.
Conclusions:
This study demonstrates how the diagnosis of cerebellar infarction can be missed or delayed in patients presenting to the emergency department.
