Unfortunately in my experience, many of my patients that come to me with cerebellar strokes tell me the same story that goes something like this: “I was having X symptom. I went to the ER and they couldn’t figure out what was wrong with me. So they sent me home. But I didn’t get any better. Actually, I got worse. So I went back to the hospital X hours/days later. That’s when they found my stroke.”
This is obviously a severe disservice to our communities that desperately need us. So I was curious why this diagnosis is missed so frequently in the ER. Research to the rescue!
Pitfalls in the Diagnosis of Cerebellar Infarction as originally seen in Academic Emergency Medicine
In this article, the researchers looked back on 15 cases of cerebellar stroke that had been missed at first glance and analyzed what was missing in their evaluation in the ER. Of the 15, 8 were discharged home and 7 were admitted into the hospital for further observation. 2 in the hospital went into a coma (due to brain stem compression) before they could figure it out and later died. Of the other 5 that eventually were correctly diagnosed, 3 were left with some kind of “gait disorder” while 2 fully recovered. Of the 8 discharged home from the ER, all eventually returned to the hospital. Half of them died. Two had “disabling neurologic deficits” and 2 fully recovered.
I realized that N=15 is very small, but yikes! 40% of them DIED, 30% had significant residual neurologic problems and 30% fully recovered. That’s a 70% failure rate. How sad! We can do better than that.
Next the researchers looked into what went wrong with these patients initial stent in the ER. The problems fell into 3 categories: clinical examination, diagnostic testing, and establishing a diagnosis and disposition. Here’s a nice chart from the article that explains in further detail.
So the antidote to that to me is 1) don’t rush the exam, 2) pick the right tests and 3) ask for help if you can’t figure it out and lastly 4) don’t give up!
One other article I found enlightening on the topic….
This was a survey study done in the Mayo Clinic system. They asked 415 emergency room physicians and residents about their habits in diagnosing “dizziness” in the ER. What they found was again disturbing. Let’s back up and talk about the backgrounds of these physicians. These people staff the Mayo Clinic. It is a world renowned academic teaching hospital, meaning that the attending physicians should be up on their game, so they can teach the resident understudies how to be awesome emergency physicians. Knowing that, I’m scared of what this study found.
They found two-thirds incorrectly defined dizziness into symptom categories based on a research article that is almost FIFTY years old. Almost all said that symptom quality– vertigo/spinning, lightheadedness, imbalance and the ambiguous “other”– was the most important factor in achieving a diagnosis into one of those categories. Most failed to recognize the difference diagnostically between one continuous episode of dizziness (central origin) vs. brief repeated episodes of dizziness (peripheral origin) which can be a deadly mistake. They also tended to not assign much importance to head or neck pain associated with the dizziness, “despite the well-recognized association between dizziness and vertebral artery dissection.” Similarly to the previous article, the emergency physicians surveyed tended to believe that a negative CT scan excluded infarcts, “despite the known low sensitivity of CT scans for identifying posterior fossa infarcts.” This trend was seen more in residents, indicating that experience may change this mistake.
This article did mention that it is well documented that there are regional differences in practice in all areas of medical. But they don’t believe this to the case in this study as Mayo Clinic is a large, multi-site facility over several regions.
This article is 11 years old, so I HOPE that there has been some education on this dire topic in emergency medicine circles since then. Having such renown physicians making and teaching erroneous methods hurts my heart. It may be prudent to check your own referral sources’ knowledge of such things.
I’m currently in the midst of doing a literature review in preparation to write a case report. If you would like more background information on the case or information about the project, please click here. If you would like to see other article reviews related to this project, please click here.