missed cerebellar infarction

brainct

Pitfalls in the Diagnosis of Cerebellar Infarction. Acad Emerg Med 2007;14:63-68.

This retrospective review of 15 cases of misdiagnosed cerebellar infarction sheds light on a number of preventable errors.

  1. 28yo with headache, vertigo, nausea, fall to left, vision loss. Left sided weakness on exam but no documented gait. Normal CT/MRI. Diagnosed as migraine
  2. 38yo with neck pain, vertigo, scotomas. No documented neuro exam. No imaging. Diagnosed as polyneuropathy
  3. 30yo with headache, vertigo, dysarthria, left leg weak. No documented neuro exam. No imaging. No diagnosis
  4. 69yo with headache, nausea, vomiting, combative. Sleepy on exam but no documented gait/coordination/EOM. Normal CT. Diagnosed as meningitis
  5. 45yo with headache, dizzy, vomiting. Poorly documented neuro exam. No imaging. Diagnosed as migraine.
  6. 45yo with dizzy, vomiting, left facial numbness. No documented neuro exam. Normal CT. Diagnosed as gastritis
  7. 42yo with headache, dizzy, unsteady, left lip tingling, neck pain, vomit. No documented neuro exam. Normal CT. Diagnosed as toxic encephalopathy.
  8. 56yo with vertigo, headache, eyes darting back and forth. Left hand weak but no gait/coordination documented. Normal CT. Diagnosed toxic encephalopathy.
  9. 34yo with occipital headache, numb left face/arm, fall to left. Unclear neuro exam. Normal CT. Diagnosed as migraine.
  10. 74yo with nausea, vomting, headache, vertigo. No gait/coordination documented. No imaging. Diagnosed as gastro.
  11. 81yo with vertigo, light-headed, headache. No gait/coordination documented. No imaging. Diagnosed as presyncope.
  12. 64yo with nausea, vomiting, diaphoretic, unsteady, headache. No gait/coordination documented. CT cortical hyperdensity. Diagnosed as intraparenchymal bleed.
  13. 94yo with dizzy, nausea, vomiting, right-sided tinnitus, vision loss, headache. No gait/coordination documented. No imaging. Diagnosed as vasovagal.
  14. 14 53yo with dizzy, nausea, vomiting diaphoresis, headache. No gait/coordination documented. CT normal. Diagnosed as MI r/o gallbladder.
  15. 67yo with dizzy, vomiting. no gait/coordination documented. No imaging. Diagnosed as gastro.

All patients worsened over the next few days in hospital or bounced back after discharge, and had a diagnosis of cerebellar infarct or vertebral artery dissection on CTA or MRI.

The potential pitfalls the authors summarized included

  1. Related to the clinical examination
    1. Failure to recognize that young patients without traditional risk factors can have strokes
    2. Failure to understand the spectrum of presenting complaints of cerebellar stroke
    3. Failure to properly perform and correctly interpret the findings of neurological examination, particularly gait testing and nystagmus
    4. Overfixation of prior neurological or other medical conditions
  2. Related to diagnostic testing
    1. Failure to perform brain imaging
    2. Failure to recognize the limitations in brain imaging, particularly CT scanning in acute brain ischemia
    3. Failure to perform tests to determine the underlying vascular lesion
  3. Related to establishing a diagnosis and disposition
    1. Failure to arrive at a specific diagnosis that fully explains the clinical data
    2. Failure to consider in-hospital observation in ambiguous cases
    3. Failure to obtain neurological consultation in difficult cases

 

Take home points:

  1. Cerebellar infarct present with diverse symptoms: consider posterior circulation infarct in patients (regardless of age) with headache, dizziness, vomiting, and neuro symptoms, and before diagnosing and discharging patients with vertigo, migraine, or gastro.
  2. Use your neuro exam. Do a thorough exam, including cranial nerves (and HINTS test), coordination and gait
  3. Don’t rely on CT. Most posterior circulation strokes will have normal CT brains (like the image above), either because it’s not sensitive to detect ischemia inside the brain, or the problem is happening outside the brain (eg vertebral artery dissection). So don’t rely on CT head to rule out posterior circulation stroke: if you’re concerned about a patient or can’t explain their symptoms consider CTA neck or consult neurology for admission/MRI

 

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