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Misdiagnosis of cerebellar hemorrhage – features of ‘pseudo-gastroenteritis’ clinical presentations to the ED and primary care

  • Seung-Han Lee , Victoria Stanton , Richard E. Rothman , Barbara Crain , Robert Wityk , Zheyu Wang and David E. Newman-Toker EMAIL logo
Published/Copyright: February 21, 2017
Diagnosis
From the journal Diagnosis Volume 4 Issue 1

Abstract

Background:

Early-stage cerebellar hemorrhage can present with nausea or vomiting absent other neurological symptoms or signs, potentially leading to an incorrect diagnosis of gastroenteritis. We sought to determine the frequency of gastroenteritis-like presentations and delayed or missed diagnoses among patients with spontaneous cerebellar hemorrhage.

Methods:

This is a retrospective, case-control analysis of atraumatic, primary cerebellar hemorrhages derived from a systematic search of surgical pathology and autopsy databases at two large urban, academic medical centers from 1984 to 2006. Hospital visit and clinical symptom data were abstracted from electronic and paper medical records for included patients. Delayed or missed diagnoses were defined as those at least one previous visit for relevant clinical symptoms in the 7 days prior to the correct diagnosis being confirmed.

Results:

Among 254 records captured by our search filter, we identified 35 cases of pathologically proven primary cerebellar hemorrhage. Four patients (11%) were misdiagnosed initially – three with “gastroenteritis” and one with “hypertension”. In this small sample, misdiagnosed patients presented more often with normal mental state (100% vs. 35%, p=0.07) and nausea/vomiting (100% vs. 58%, p=0.22). Although patients deteriorated clinically after the initial misdiagnosis, and potentially dangerous diagnostic tests and treatment strategies were instituted as a result of misdiagnosis, none of the misdiagnosed patients died or suffered major permanent harms due to diagnostic delay.

Conclusions:

Our study is limited by the small number of identified cases. Nevertheless, it appears that patients with cerebellar hemorrhages can present with relatively unimpressive clinical findings without obvious neurological manifestations. Such individuals are sometimes misdiagnosed with gastroenteritis or other benign disorders initially, possibly when neurologic examination, particularly gait testing, is omitted or abridged. A careful search for subtle cerebellar signs, including dysarthria, limb ataxia, nystagmus or tandem gait instability, absent in true gastroenteritis cases, could potentially reduce misdiagnosis.

Keywords: diagnosis; diagnostic errors; hemorrhage, posterior fossa; neurologic examination; signs and symptoms, digestive
Corresponding author: David E. Newman-Toker, MD, PhD, Professor of Neurology and Otolaryngology, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, CRB-II, Room 2M-03 North, 1550 Orleans Street, Baltimore, MD 21231, USA, Phone: + 410-502-6270

Acknowledgments

Dr. Newman-Toker’s effort was partly supported by grants from the National Institutes of Health (1K23RR17324), Agency for Healthcare Research and Quality (1R13HS019252) and the Armstrong Institute Center for Diagnostic Excellence. Dr. Stanton’s effort was supported by the University of California, San Francisco Dean’s Summer Fellowship Program.

  1. Author contributions: Seung-Han Lee conducted the data abstraction and primary analysis, and drafted the first version of the manuscript. Victoria Stanton helped develop and conduct the database search and reviewed and critically edited the manuscript. Richard Rothman assisted in developing the study design/concept and reviewed and critically edited the manuscript. Barbara Crain helped develop the database search and reviewed and critically edited the manuscript. Robert Wityk assisted in developing the study design/concept and reviewed and critically edited the manuscript. Zheyu Wang conducted the statistical analyses and reviewed and critically edited the manuscript. David E. Newman-Toker conceived manuscript concept, helped design the search and analytic plan and reviewed and critically edited the manuscript. All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

  2. Research funding: None declared.

  3. Employment or leadership: None declared.

  4. Honorarium: None declared.

  5. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

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Supplemental Material:

The online version of this article (DOI: 10.1515/dx-2016-0038) offers supplementary material, available to authorized users.

Received: 2016-10-11
Accepted: 2017-1-23
Published Online: 2017-2-21
Published in Print: 2017-3-1

©2017 Walter de Gruyter GmbH, Berlin/Boston

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  2. Editorial
  3. Exploring the iceberg of inappropriateness in hemostasis testing
  4. Review
  5. Diagnoses in and out of time: historical and medical perspectives on the diagnoses of distress
  6. Mini Review
  7. Five things to know about diagnostic error
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  12. Misdiagnosis of cerebellar hemorrhage – features of ‘pseudo-gastroenteritis’ clinical presentations to the ED and primary care
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https://doi.org/10.1515/dx-2016-0038
Keywords for this article
diagnosis; diagnostic errors; hemorrhage, posterior fossa; neurologic examination; signs and symptoms, digestive

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. Exploring the iceberg of inappropriateness in hemostasis testing
  4. Review
  5. Diagnoses in and out of time: historical and medical perspectives on the diagnoses of distress
  6. Mini Review
  7. Five things to know about diagnostic error
  8. Opinion Paper
  9. The scientific nature of diagnosis
  10. Original Articles
  11. An assessment of overutilization and underutilization of laboratory tests by expert physicians in the evaluation of patients for bleeding and thrombotic disorders in clinical context and in real time
  12. Misdiagnosis of cerebellar hemorrhage – features of ‘pseudo-gastroenteritis’ clinical presentations to the ED and primary care
  13. The kinetics of haemoglobin and ferritin in longitudinal community patients with iron deficiency or hypoxia
  14. Which of low-density lipoprotein cholesterol estimates can be used in children with type 1 diabetes?
  15. Case Report
  16. Aseptic myonecrosis following intramuscular benzathine penicllin G injection: a novel syndrome
  17. Congress Abstracts
  18. Diagnostic Error in Medicine
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