Double Jeopardy: Risk in Neurology

Jared D. Novack, MD, FACEP

Daniel J. Sullivan, MD, JD,FACEP

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Goals

Lay out some cases to spur thought and discussion.

Talk about barriers to correct diagnosis. Break down your

own biases.

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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.

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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.

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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

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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

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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].

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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.

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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.

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Epidural Abscess

Plain imaging shows nothing. Early labs may show nothing. MRI needs contrast. MRI may simply miss

the level.

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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.

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Rule Out Pathway ?

Adapted from J Neurosurg: Spine. Vol. 14. June 2011.

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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

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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

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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.

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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.

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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

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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

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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

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Case #3

Abdomen: Normal exam, including BS, no tenderness, no distention.

Extremities: All normal. Neurologic: No focal deficits. CN NL. Motor

and sensory normal.

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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.

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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.

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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.

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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.

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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.

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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?

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High-Risk StrokeVertebrobasilar 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

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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

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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

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Case #4 - Head CT

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Labs

139 107 8

4.2 24 0.9126

15.212.2 160

44.7

Urine BHCG (-)

U/A: normal

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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

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Case #4 - Repeat Head CT

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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

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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

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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.

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Potential ED Pitfalls

Anchoring on migrainewithout 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.

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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.

THANK YOU