Medical Malpractice Insights: Do not mistake this for simple vertigo

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Conference Alert: I highly recommend the annual October “Diagnostic Error in Medicine” conference of the Society to Improve Diagnosis in Medicine. It’s virtual this year – and affordable. https://www.improvediagnosis.org/2020conference/

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Posterior Circulation Stroke 

Do not mistake this for simple vertigo

 Facts: A 54-year-old male experiences sudden onset of neck pain, nausea, and diaphoresis while driving to work. He pulls to the side of the freeway and calls 911. En route to Hospital A he becomes dizzy and on arrival to the ED is noted to be diaphoretic, clammy, bradycardic, and “appearing uncomfortable.” His neck pain worsens with motion and radiates to his head. A remote history of labyrinthitis is elicited by the emergency physician (who is at the tail end of a night shift). He is given metoclopramide and diphenhydramine and discharged with a diagnosis of cervical strain and positional vertigo. Two hours later he is worse and calls 911 again. This time he is taken to Hospital B where he is noted to be hemiparetic. A non-contrast head CT is non-diagnostic. A CTA is recommended but not done for 5 hours. It shows a vertebral artery dissection (VAD.) He is transferred to Hospital C for care of his stroke.

Plaintiff: Hospital A: I had a classic presentation of a VAD. You never asked me how my symptoms were different than my labyrinthitis years ago. You should have done an MRA and found it on my first visit, especially since your hospital is a stroke center. Hospital B: You should have gotten a CTA or MRA immediately for my classic symptoms; the non-contrast CT was unnecessary and delayed my care. With earlier care I would not be disabled now.

Defense: Your symptoms were consistent with labyrinthitis and a neck strain. Your CT at Hospital B was normal, as it would have been at Hospital A. There’s no clear treatment for a VAD, so it doesn’t make any difference.

Result: Confidential settlement against Hospital A, the emergency physician, and Hospital B for undisclosed amount after 3 years of litigation and an estimated $100,000 in legal costs.

Takeaways:

• Sudden onset of “cervical strain” and “positional vertigo” while driving to work? To the point of calling 911 and leaving your car on the side of the road? What were you thinking?
• Sudden onset of neck pain, dizziness, sweating, head pain, and nausea equals a classic presentation of a vertebral artery dissection (VAD) or cervical/carotid artery dissection (CAD).
• Not all VADs or CADs are classic;
• 42% of patients with VAD do not have vertigo.
• 49% do not have headache.
• 54% do not have neck pain.
• Sweating is always a bad sign.
• Perform a thorough neurologic exam and evaluate for signs of central vertigo/cerebellar pathology.
  • Evaluate cranial nerves, gait, truncal ataxia, finger to nose/heel to shin, rapid alternating movements, test of skew, motor, and sensation.

References/Further Resources:

1. Clinical Characteristics of Symptomatic Vertebral Artery Dissection: A Systematic Review. Gottesman RF et al. Neurologist. 2012;18(5):245-254.  Great review and summary in Medscape -> medscape.com/viewarticle/771223_1
2. http://www.emdocs.net/cervical-artery-dissection-the-elusive-diagnosis/
3. http://www.emdocs.net/posterior-circulation-strokes-why-do-we-miss-them-and-how-do-we-improve/
4. http://www.emdocs.net/posterior-circulation-strokes-dizziness-pearls-pitfalls/