This document presents 4 case studies to discuss barriers to correct diagnosis in neurology. Case 1 describes a woman misdiagnosed with back pain who later presented with spinal epidural abscesses. Case 2 involves a man diagnosed with labyrinthitis who later had a cerebellar infarct. Case 3 is about a woman discharged with headaches who returned with a cerebellar infarct. The document emphasizes considering alternative diagnoses and thorough neurological exams to avoid missed diagnoses.

1. Double Jeopardy:
Risk in Neurology
Jared D. Novack, MD, FACEP
Daniel J. Sullivan, MD, JD,FACEP

2. 2
Goals
 Lay out some cases to spur thought and
discussion.
 Talk about barriers to correct diagnosis.
 Break down your
own biases.

3. 3
Case #1 – Triage (Day 1)
 Patient was a 54-year-old female who presented
to the ED with low back pain.
 Nurse evaluation:
 Vitals: T 98.8°F (37.1°C); P 102; R 16; 9/10 (no BP)
 Chief Complaint: Dull but severe pain from neck to
knees posteriorly. No known recent injury.
 Moderate distress. Temp with chills and sweats.

4. 4
Case #1 – Physician HPI
 C/O back pain. Hx of chronic back pain, sciatica
and R hip bursitis.
 Today pain is different than usual. Usually the
pain is lower back; today all the way from her
shoulder blades down to the back of her legs.
 Pain is excruciating. She sees a psychiatrist
and is on several psychiatric medications.
 Low-grade fever at home, between 99.5°F
(37.5°C) and 100.9°F (38.3°C). She has been
waking up sweaty at night for several days.

5. 5
Case #1 – PMH
 PMH – Negative other than the psychiatric
history as above
 Social History – Negative
 Review of Systems:
 Fever
 Sweaty episodes
 Weak and tired
 Remainder of the ROS is negative

6. 6
Case #1 – Physician PE
 Vitals: T 98.7°F (37.1°C); P 105; R 18; BP 117/77
 General: Alert and responsive. Not toxic
appearing. Does not appear to be in severe
pain. Rates pain 10/10.
 HEENT: Normal
 Neck: [no documented exam]
 Chest: Clear, no distress, nl breath sounds
 Abdomen: Soft, NT; no guarding or rebound

7. 7
Case #1 – PE Continued
 Back: Diffuse pain to palpation, mid back, low
back, sciatic grooves, posterior thighs. No
point tenderness. SLR negative.
 Gait: Ambulates without difficulty.
 Neurologic: [There was no documented
neurologic exam].

8. 8
Case #1 - ED Course
 Physician ordered 25mg of promethazine
(Phenergan) and 10 mg morphine.
 Patient required a second dose of 10 mg
morphine.
 After that, the nurse noted partial relief.
 Chem 20 all WNL. WBC 9.3. UA WNL.
 No imaging.

9. 9
Case #1 - Disposition
 Impression: “Exacerbation of chronic back
pain.”
 Discharge Plan: “Patient requested an MRI. I
gave her a Rx for an outpatient MRI of the
lumbar spine. No urgency for this. No evidence
by history, examination or an acute neurologic
problem.”
 No follow-up documented. No signature on the
discharge form.

10. 10
Case #1 – Day 3
 Patient returned to the same ED after her
lumbar MRI.
 Triage: Patient moved from MRI to the ED.
Needs pain relief. Sharp pain in mid and lower
back.
 Vitals: T 97°F (36.1°C); P 78; R 18; BP 117/68

11. 11
Case #1 – Physician Evaluation
 CC: Low back pain.
 HPI: In for MRI today. Very uncomfortable.
Increasing pain in the back “very excruciating.”
Long Hx of back pain with multiple physician
referrals. Apparently was a surgical candidate,
but she declined lumbar disc surgery, opting
for conservative treatment. No loss of bowel or
bladder function. No extremity weakness. No
fever or chills. Ambulatory.

12. 12
Case #1 – Physician Evaluation
 ROS: Otherwise negative
 Physical Exam:
 General: Alert but appears sedated
 Extremities: Clear
 Back: Tender over lumbar area of her back
 Neurologic: DTSRs are grossly intact. There
are no sensory or motor deficits.

13. 13
Case #1 – ED Course
 Patient received 2 mg IV hydromorphone
(Dilaudid) and 25 mg Promethazine
(Phenergan).
 MRI Report: “Moderate sized central disc
protrusion at L5-S1. Mild annular bulging at
L4-L5. Neurolaminal encroachment at L5-S1.
Foramina and central canal are patent.”
 Impression: Exacerbation of chronic back pain.
 Discharge Plan: See PMD. Prednisone 60 mg
PO for 5 days. Return for increased pain.

14. 14
Case #1 – Day 8
 Patient presented to the same ED for a third
time.
 Chief Complaint: Low back pain.
 HPI: In ED twice; seen by PMD, who ordered
pain meds. Ongoing pain, L4-L5 herniation on
MRI. Has appointment with neurology, but in to
much pain. Requesting admission.
 Disposition: Admitted.

15. 15
Case #1 - Inpatient
 Orthopedic consultation on day 10; same focus
as prior evaluations. Focus on prior low back
problem.
 On day 11 she spiked a temp.
 Day 12 ID Consult: Two-week history of shaking
chills and burning sensation down her legs.
Fever yesterday. Culture growing MRSA.
 Profound weakness in all four extremities.
 Back pain gone, as she has no feeling in her
back or lower extremities.

16. 16
Case #1 – Impression / Outcome
 Impression: Bacteremia and spinal epidural
abscess.
 Surgical Report: Epidural abscess C6-7
and L5-S1. Purulent material
found at both places.
 Patient Outcome: Complete
permanent paralysis in her
lower extremities.

17. 17
Epidural Abscess
 Symptoms can involve multiple levels.
 Symptoms can move from one level to another.
 Fever may be subtle and come and go.
 Early there is absence of other neurologic
findings.
 No longer only IVDA patients.

18. 18
Epidural Abscess
 Plain imaging shows nothing.
 Early labs may show nothing.
 MRI needs contrast.
 MRI may simply miss
the level.

19. 19
Epidural Abscess
 Consider epidural abscess in the diff dx:
 Change in character of the pain
 History of fever or shaking chills
 New symptoms with no mechanism!!
 Avoid cognitive biases.
 Document a complete exam of the relevant
organ system.

20. 20
Rule Out Pathway ?
Adapted from J Neurosurg: Spine. Vol. 14. June 2011.

21. 21
Case #2 - Triage
 A 33-year-old male presented to the ED with
a sudden onset of dizziness.
 Triage: Sudden onset of dizziness. Spinning
feeling, vertigo. Started 3 hours PTA. No prior
similar problems.
 Hx: HTN
 Vitals: T 99.6°F (37.5°C); P 72; R 16; BP 140/90

22. 22
Case #2 – Physician Evaluation
 HPI: Sudden onset of dizziness, spinning
feeling. Patient feels like he is off balance and
like he is going to pass out. Has had severe
nausea. No ear pain. No upper resp symptoms.
No headache or weakness.
 PMH: HTN
 PSH: Neg
 Social Hx: Neg

23. 23
Case #2
 HEENT: Normal ear exam.
 Neck: Supple, no meningeal signs
 Chest: Clear, nl BS, no respiratory distress
 Heart: S1, S2 Nl, no murmurs
 Abdomen: Benign
 Extremities: Normal
 Neurologic: Cranial nerves 2-12 intact. No
motor or sensory deficits. Reflexes normal.

24. 24
Case #2
 Impression: Acute labyrinthitis
 Disposition: Home, follow up as needed.
 Outcome: He returned to the same ED the following
day with a headache, dizziness, vomiting, and
inability to gaze to the right. CT revealed a right
cerebellar infarct.
 Admitted. Later that evening he developed
decorticate posturing. He continued to deteriorate
and died.
 The family sued for failure to diagnose during the
first visit. Settled for an undisclosed amount.

25. 25
Case #3
 Patient was a 42-year-old female who
presented to the ED with a headache.
 Triage:
 Headache for one week
 Fiorinal Rx for headaches
 Vitals: T 98.4°F (36.9°C); P 80; R 12; BP 150/90

26. 26
Case #3 – Physician Evaluation
 HPI – Severe headache for 2 weeks. In bed
most of that time. Problem with walking; states
she loses her balance. Headache is severe; not
the worst headache of her life. Denies
associated symptoms.
 PMH – Negative
 PSH – Negative
 Social - Negative

27. 27
Case #3
 Constitutional: Awake, alert, O X 3. Appears
uncomfortable
 HEENT: Nl TMs, oropharynx. No sinus pain or
pressure.
 Neck: Supple, no meningeal signs
 Chest: Clear, no rales or rhonchi. No resp
distress
 Heart: S1, S2 normal, no murmurs

28. 28
Case #3
 Abdomen: Normal exam, including BS, no
tenderness, no distention.
 Extremities: All normal.
 Neurologic: No focal deficits. CN NL. Motor
and sensory normal.

29. 29
Case #3 – ED Course
 Toradol 60 IM
 Only lab abnormality was a WBC of 17K,
no shift
 CT read as negative by the radiologist
 EP performed an LP. All WNL.
 Repeat BP was 150/90. The nurse said patient
was C/O neck pain.
 Nursing notes indicate pain relieved post-
Toradol.

30. 30
Case #3 - Disposition
 Impression: Headache
 Discharged to home.
 Meds: Lortab and Pen V-K.
 Told to follow up with neurologist and return
to the ED if condition worsened.

31. 31
Case #3 – Bounceback
 Returned 12 hours later C/O a headache and
dizziness.
 Seen by the same ED physician, who noted the
patient had the same complaint but now also
had a sore throat.
 Nurse noted BP of 170/104, headache,
dizziness, nausea and pain in the neck.

32. 32
Case #3 – ED Course
 Repeat CT with contrast revealed a left
cerebellar non-hemorrhagic infarct that was
new and C/W the CT from the day before.
 MRI/MRA revealed left vertebral artery
occlusion with severe stenosis.
 After admission, patient became unresponsive.
Intubated and resuscitated.
 Massive cerebellar infarct.
 Severe permanent disability.

33. 33
Challenges to Correct Diagnosis
 Posterior Circulation Stroke
 Notoriously challenging to diagnose.
 They mimic other conditions.
 Neurologic exam can be nuanced in these cases.
 Basilar occlusion syndromes present with
hypertonicity that can be spastic and mimic seizure.
 Time course is critical.
 History often does not direct you to the diagnosis.
 High index of suspicion in “bizarre” neurologic
presentations with any focal motor or ocular findings.

34. 34
Questions to Address
in a Case Like This
 What was the last known normal time?
 This is the time when the clock starts for the
therapeutic window.
 Why the consideration of acute
decompensation from meningitis?
 If one considers that likely, is LP still reasonable
with the risk of acute intracranial hypertension?
 Is there another neurologic diagnosis more
likely than stroke in this case?

35. 35
High-Risk Stroke
Vertebrobasilar Stroke:
 Untreated mortality 70%-80%
 Survivors moderately to
severely disabled.,
 70% recanalized
  mortality to 25%-45%
 2/3 with favorable outcome
 Treatment window probably
up to 12 hours
 ENDOSTROKE Study (2015)
 tPA is standard of care
 Thrombectomy may be helpful

36. 36
Case #4: “My Head Hurts”
 26 y/o honorably discharged Marine
 She presents to ED with worsening cephalgia
3 months after leaving the service; pain 9/10.
 Seen in ED 2 days prior for headache:
 Non-focal exam, improved with Toradol
 No imaging done, clinical exam only
 Discharged home with “migraine” as diagnosis
 ROS:
 Unremarkable; family notes heavy exercising
 Meds:
 None reported

37. 37
Case #4
 T 99.4°F (37.4°C); P 94; R 22; BP 150/84; 98%
room air; glucose 160
 In ED has “non-focal neurologic” examination:
 No photophobia / phonophobia
 Fundoscopy challenging
 Headache seems worse when supine
 Symptomatic treatment in ED:
 Toradol, Compazine, IVF
 Non-con head CT and screening labs

38. 38
Case #4 - Head CT

39. 39
Labs
139 107 8
4.2 24 0.9
126
15.2
12.2 160
44.7
Urine BHCG (-)
U/A: normal

40. 40
Case #4 - ED Course
 ED Course:
 Some improvement with
medications; pain 4/10
 Suddenly complains of
worsening pain
 Brief seizure, 60 seconds, tonic-clonic
 Post-ictal with left arm weakness
 Emergent repeat non-contrast head CT

41. 41
Case #4 - Repeat Head CT

42. 42
Case #4 - Diagnosis & Treatment
 Acute hemorrhagic stroke (ICH)
 BP control in ED (SBP < 160)
 Coagulation parameters checked and normal
 Admitted to Neuro-ICU
 Consultation in ED with neurology and
neurosurgery

43. 43
Case #4 - Diagnosis & Treatment
 Diagnosis made in ICU
 Cerebral venous sinus thrombosis
 (Right transverse sinus)
 Confirmed on CT – venography and MRI
 ICU treatment
 Heparin infusion, close monitoring
 Good recovery, outstanding outcome

44. 44
Cerebral Venous Vein Thrombosis
 Points to consider in this high-risk case:
 26 y/o female with no history of migraine
and 2 visits to ED for headache.
 Heavy exercise predisposes to dehydration.
 NuvaRing / IUD not often reported as a medication.
 CVST is notoriously challenging to diagnosis.
 Supine positioning that worsens headache is
worrisome for increased intracranial pressure.
 Initial non-con head CT on second visit was NOT
normal.
 High index of suspicion is necessary.
Journal of Emergency Medicine, Vol. 42, No. 4, pp. 413-416, 2012.

45. 45
Potential ED Pitfalls
 Anchoring on migraine
without a prior history.
 Failure to recognize CVST in
differential diagnosis.
 Average number of visits to an ED to diagnosis
CVST is ≥ 3.
 Unusual diagnosis in ED, but potentially lethal.
 Failure to recognize CVST may lead to
anchoring
bias by admitting services as well.
Journal of Emergency Medicine, Vol. 28, No. 2, pp. 140-147, 2010.

46. 46
Summary
 Stay curious and pay attention to detail.
 COMPLETE Neuro exam.
 Look for what doesn’t fit.
 Its okay to get an MRI.
 Walk the patient around before you send
them home.

47. THANK YOU