Pitfalls in The Diagnosis of Neurological Disorders
Pitfalls in The Diagnosis of Neurological Disorders
Editor
Ambar Chakravarty
Honorary Professor and Emeritus Consultant Department of Neurology Vivekananda Institute of Medical Science Kolkata, West Bengal, India Past President Indian Academy of Neurology (2005–2006)
Foreword
Robert C Griggs
Jaypee Brothers Medical Publishers (P) Ltd
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Pitfalls in the Diagnosis of Neurological Disorders/ Ambar Chakravarty
First Edition: 2022
9789354656668
The Surviving members and Departed souls of the
Batch of 1965
MEDICAL COLLEGE BENGAL
Estd. 1835
Tribute to My Revered Teacher on his Birth Centenary
Professor Shyamal Kumar Sen MD FRCP
(1922–2011)
EDITOR
- Ambar Chakravarty MD FRCPC FRCP FRCPE FICP FIAN
- Honorary Professor and Emeritus Consultant
- Department of Neurology
- Vivekananda Institute of Medical Science
- Kolkata, West Bengal, India
- Past President Indian Academy of Neurology (2005–2006)
CO-EDITOR
- Angshuman Mukherjee MD DM
- Professor and Head
- Department of Neurology
- Vivekananda Institute of Medical Science
- Kolkata, West Bengal, India
SECTION EDITORS: CRITICAL CARE NEUROLOGY
- Venkatesh Aiyagari DM FAHA
- Professor
- Division Chief, Neurocritical Care
- Departments of Neurological Surgery and Neurology
- University of Texas Southwestern Medical Center Dallas, Texas, USA
- Bappaditya Ray MD
- Associate Professor
- Division of Neurocritical Care
- Departments of Neurology and Neurological Surgery
- University of Texas Southwestern Medical Center Dallas, Texas, USA
CONTRIBUTING AUTHORS
- Rahil Ansari MD (Med) DM (Neuro)
- Assistant Professor
- Department of Neurology
- Seth Gordhandas Sunderdas Medical
- College (GSMC) and the King Edward
- Memorial (KEM) Hospital
- Mumbai, Maharashtra, India
- Anshita Arora DCH DNB (Ped) Fellowship in Pediatric Neurology
- Assistant Professor and Consultant Pediatric Neurologist
- American International Institute of Medical Sciences and GBH American Hospital
- Udaipur, Rajasthan, India
- Ramesh Bhattacharyya MD DM
- Professor and Head
- Department of Neurology
- Calcutta National Medical College and Hospital
- Kolkata, West Bengal, India
- Atanu Biswas MD DM
- Professor
- Department of Neurology
- Institute of Post Graduate Medical Education and Research (IPGME&R)
- and
- Bangur Institute of Neuroscience
- Kolkata, West Bengal, India
- Debsadhan Biswas MD DM
- Assistant Professor
- Department of Neurology Medical College Kolkata
- Kolkata, West Bengal, India
- Niloy Biswas MS MCh
- Consultant Neurosurgeon
- Park Neurosciences Centre
- Kolkata, West Bengal, India
- Rupam Borgohain DM
- Professor and Head of Department
- Department of Neurology
- Nizam's Institute of Medical Sciences
- Hyderabad, Telangana, India
- Mitesh Chandarana MD DM
- Consultant Neurologist and Movement Disorder Specialist
- MediSquare Superspeciality Hospital and Research Institute
- Ahmedabad, Gujarat, India
- Swathy Chandrashekhar MD
- Assistant Professor
- Department of Neurology
- Kansas University Medical Center
- Kansas City, Kansas, USA
- Aparajita Chatterjee MD DM
- Postdoctoral Fellowship in Epilepsy
- Consultant Neurologist
- Fortis Hospital
- Kolkata, West Bengal, India
- Sandip Chatterjee DNB FRCS DNB (Neurosurg) FRCS (SN)
- Professor of Neurosurgery
- Vivekananda Institute of Medical Science
- and
- Senior Consultant Neurosurgeon
- Park Neuroscience Centre
- Kolkata, West Bengal, India
- Jasodhara Chaudhuri MD DM MRCPCH
- Clinical Tutor
- Department of Neurology
- Bangur Institute of Neurosciences
- Kolkata, West Bengal, India
- Gautam Das MD DM
- Consultant Neurologist
- Department of Neurology
- Ramrikdas Haralalka Hospital and Bangur Institute of Neuroscience
- Kolkata, West Bengal, India
- Soumik Das MD DM
- Assistant Professor
- Department of Radiodiagnosis
- Raiganj Government Medical College and Hospital
- Raiganj, West Bengal, India
- Ashis Datta MD DM
- Consultant Neurologist and In-charge of Epilepsy Care
- and Electrophysiology Laboratory
- Institute of Neurosciences Kolkata
- Kolkata, West Bengal, India
- Joy D Desai MD DNB
- Director of Neurology
- Jaslok Hospital
- Mumbai, Maharashtra, India
- Neelu Desai MD DNB Fellowship Child Neurology (Lond)
- Consultant in Pediatric Neurology
- PD Hinduja Hospital and Medical Research Centre
- Mumbai, Maharashtra, India
- Emmaculate M Fields MSN AGACNP-BC
- Clinical Assistant Professor
- Neurocritical Care Nurse Practitioner
- Division of Critical Care Neurology
- Department of Neurology
- University of Oklahoma Health Sciences Center
- Oklahoma City, Oklahoma, USA
- Stephen Figueroa MD
- Associate Professor
- Division of Neurocritical Care
- Departments of Neurology and Neurological Surgery
- UT Southwestern Medical Center
- Oklahoma, USA
- Nitika Gautam DNB
- Resident
- Department of Pediatric Neurology
- PD Hinduja Hospital and Medical Research Centre
- Mumbai, Maharashtra, India
- Kimberly Glaser MSN AGACNP-BC
- Neurocritical Care Nurse Practitioner
- Division of Neurocritical Care
- Department of Neurology
- University of Texas Southwestern Medical Center
- Dallas, Texas, USA
- Goutam Guha MD DM
- Professor and Head
- Department of Neurology
- NRS Medical College
- Kolkata, West Bengal, India
- Omkar P Hajirnis DNB (Ped)
- MRCPCH (UK) Fellowship in Pediatric Neurology
- Consultant Pediatric Neurologist
- Jupiter Hospital
- Thane, Maharashtra, India
- Amit Halder MD DM
- Associate Professor
- Department of Neurology
- Vivekananda Institute of Medical Science and
- Consultant Neurologist
- Fortis Hospital
- Kolkata, West Bengal, India
- Robert Hamilton MD
- Assistant Professor
- Department of Neurology
- University of Oklahoma Health Sciences Center
- Oklahoma City, Oklahoma, USA
- Kimmo Hatanpaa MD PhD
- Professor
- Division of Neuropathology
- Department of Pathology
- University of Texas Southwestern Medical Center
- Dallas, Texas, USA
- Mausaminben Hathidara MD
- Assistant Professor
- Department of Neurology
- University of Pittsburgh
- Altoona Campus, Pennsylvania, USA
- Anaita Udwadia Hegde DCH MD (Ped) MRCPCH (Lond)
- Fellowship in Pediatric Neurosciences
- Consultant Pediatric Neurologist
- Narayana Health SRCC Children's Hospital, Jaslok Hospital and
- Research Center
- Wadia Children's Hospital
- Mumbai, Maharashtra, India
- Mahesh Jadav DM
- Senior Resident
- Department of Neurology
- Sanjay Gandhi Post Graduate Institute of Medical Sciences
- Lucknow, Uttar Pradesh, India
- Sunila Jaggi MD
- Professor of Radiology
- Bombay Hospital Institute of Medical Sciences
- Mumbai, Maharashtra, India
- Kshiteeja Jain MD DM
- Senior Resident
- Department of Neurology
- Seth Gordhandas Sunderdas Medical College (GSMC) and the King Edward Memorial (KEM) Hospital
- Mumbai, Maharashtra, India
- Neeraj Jain MD (Med) DM (Neuro)
- Additional Professor
- Department of Neurology
- Seth Gordhandas Sunderdas Medical College (GSMC) and the King Edward Memorial (KEM) Hospital
- Mumbai, Maharashtra, India
- Shikha Jain MD
- Assistant Professor
- Department of Pediatrics
- All India Institute of Medical Sciences
- Nagpur, Maharashtra, India
- Jayantee Kalita DM
- Professor, Department of Neurology
- Sanjay Gandhi Postgraduate Institute of Medical Sciences
- Lucknow, Uttar Pradesh, India
- Sarosh M Katrak MD DM FRCP FIAN
- Emeritus Professor
- Department of Neurology
- Grant Medical College
- Mumbai, Maharashtra, India
- Subhash Kaul MD DM FIAN
- Senior Neurologist
- Krishna Institute of Medical Sciences
- Secunderabad, Telangana, India
- Satish V Khadilkar MD DM DNBE FIAN FICP FAMS FRCP
- Dean and Professor and Head
- Department of Neurology
- Bombay Hospital Institute of Medical Sciences
- Mumbai, Maharashtra, India
- Ashley King MSN AGACNP-BC
- Neurocritical Care Nurse Practitioner
- Division of Neurocritical Care
- Department of Neurology
- University of Texas Southwestern Medical Center
- Dallas, Texas, USA
- Asha Kishore MD DM
- Senior Consultant Neurologist and Movement Disorder Specialist
- Centre of Excellence in Neurosciences
- Aster Medcity, Kochi, Kerala, India
- Rahul Kulkarni MD DM DNB FAAN
- Consultant Neurologist
- Deenanath Mangeshkar Hospital
- Pune, Maharashtra, India
- Mritunjai Kumar DM
- Assistant Professor
- Department of Neurology
- Sanjay Gandhi Postgraduate Institute of Medical Sciences
- Lucknow, Uttar Pradesh, India
- LG Viswanathan DM
- Assistant Professor
- Department of Neurology
- National Institute of Mental Health and Neurosciences
- Bengaluru, Karnataka, India
- Mukul Malhotra MD DM
- Consultant Pediatric Neurology
- Indus International Hospital
- Derabassi, Punjab, India
- Jayasree Manikinda DM
- Consultant Neurologist
- Krishna Institute of Medical Sciences
- Secunderabad, Telangana, India
- Essie Mathews MSN AGACNP-BC DNP
- Neurocritical Care Nurse Practitioner
- Division of Neurocritical Care
- Department of Neurology
- University of Texas Southwestern Medical Center
- Dallas, Texas, USA
- Rukmini Mridula DM
- Associate Professor
- Department of Neurology
- Nizam's Institute of Medical Sciences
- Hyderabad, Telangana, India
- Adreesh Mukherjee MD DM
- Assistant Professor
- Department of Neurology
- Bangur Institute of Neurosciences
- Kolkata, West Bengal, India
- Mausumi Mukherjee MD
- Associate Professor
- Department of Pediatric Medicine
- Institute of Child Health
- Kolkata, West Bengal, India
- Karthik Muthusamy MD DM
- Senior Associate Consultant
- Department of Clinical Genomics
- Mayo Clinic
- Jacksonville, Florida, USA
- M Nagappa MD DM
- Additional Professor
- Department of Neurology
- National Institute of Mental Health
- and Neurosciences
- Bengaluru, Karnataka, India
- Faith Newton MSN AGACNP-BC
- Neurocritical Care Nurse Practitioner
- Division of Neurocritical Care
- Department of Neurology
- University of Texas Southwestern Medical Center
- Dallas, Texas, USA
- Brian Nguyen DO
- Neurocritical Care Fellow
- Department of Neurology
- University of Texas Southwestern Medical Center
- Dallas, Texas, USA
- Huy Nguyen MD
- Neurocritical Care Fellow
- Department of Neurology
- University of Texas Southwestern Medical Center
- Dallas, Texas, USA
- Sandip Pal MD DM
- Professor and Head
- Department of Neurology
- Medical College Kolkata
- Kolkata, West Bengal, India
- Kausik Pan MD DM
- Assistant Professor
- Department of Neurology
- Vivekananda Institute of Medical Science
- Kolkata, West Bengal, India
- Riddhi Patel MD DM
- Associate Consultant in Neurology
- Bombay Hospital Institute of Medical Sciences
- Mumbai, Maharashtra, India
- Chandrakanta Patra MD
- Postdoctoral Trainee
- Calcutta National Medical College and Hospital
- Kolkata, West Bengal, India
- Sanjay Prakash MD DM
- Professor and Head
- Department of Neurology
- Smt BK Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth
- Vadodara, Gujarat, India
- Shripad Pujari MD DM DNB FRCP
- Consultant Neurologist
- Deenanath Mangeshkar Hospital
- Pune, Maharashtra, India
- Sukalyan Purkayastha MD DM
- Head, Neurointervention and Endovascular Surgery
- Consultant Neuroradiologist
- Institute of Neurosciences Kolkata
- Kolkata, West Bengal, India
- Sarbani Raha MD
- Pediatric Neurologist
- Child Neurology and Epilepsy Clinic
- Vadodara, Gujarat, India
- Gudipati Ananta Ram MD
- Senior Neuroradiologist
- Krishna Institute of Medical Sciences
- Secunderabad, Telangana, India
- Neetu Ramrakhiani MD DM
- Consultant Neurologist
- Fortis Escorts Hospital
- Jaipur, Rajasthan, India
- Kaushik Rana MD DM
- Assistant Professor
- Department of Neurology
- Smt BK Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth
- Vadodara, Gujarat, India
- Chaturbhuj Rathore MD DM
- Professor, Department of Neurology
- Smt BK Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth
- Vadodara, Gujarat, India
- Parthvi Ravat MD (Med) DNB (Neuro)
- Senior Clinical Associate
- PD Hinduja Hospital
- Mumbai, Maharashtra, India
- Sangeeta Ravat MD (Med) DM (Neuro)
- Professor and Head
- Department of Neurology
- Seth Gordhandas Sunderdas Medical College (GSMC) and the
- King Edward Memorial (KEM) Hospital
- Mumbai, Maharashtra, India
- Debarti Ray MD
- Vascular Neurologist and Neurohospitalist
- Baylor University Medical Center
- Baylor Scott and White Health Systems
- Dallas, Texas, USA
- Jia W Romito MD
- Assistant Professor
- Divisions of Neuroanesthesia and Neurocritical Care
- Departments of Anesthesiology and Pain Management,
- Neurology and Neurological Surgery
- University of Texas Southwestern Medical Center
- Dallas, Texas, USA
- Debasish Roy MD DNB DM
- Professor, Department of Neurology
- Vivekananda Institute of Medical Science
- Kolkata, West Bengal, India
- Danny Samkutty MD
- Assistant Professor
- Department of Neurology
- University of Oklahoma Health Sciences Center
- Oklahoma City, Oklahoma, USA
- Udit Saraf MD DM
- Assistant Professor and Movement Disorder Specialist
- Department of Neurology
- Amrita Institute of Medical Sciences
- Kochi, Kerala, India
- Spencer Septien DO
- Neurocritical Care Fellow
- Department of Neurology
- University of Texas Southwestern Medical Center
- Dallas, Texas, USA
- Samir Shah MD
- Vascular Neurologist and Neurohospitalist
- Neurology Consultants of Dallas
- Texas Health Presbyterian Hospital
- Dallas, Texas, USA
- Kartavya Sharma MD
- Assistant Professor
- Division of Neurocritical Care
- Departments of Neurology and Neurological Surgery
- University of Texas Southwestern Medical Center
- Dallas, Texas, USA
- Maria Shoaib MD
- Neurology Resident
- Department of Neurology
- University of Oklahoma Health Sciences Center
- Oklahoma City, Oklahoma, USA
- Sanjib Sinha MD DM
- Professor and Head
- Department of Neurology
- National Institute of Mental Health and Neurosciences
- Bengaluru, Karnataka, India
- Mayur Thakkar MD DM
- Assistant Professor
- Department of Neurology
- Seth Gordhandas Sunderdas Medical College (GSMC) and the
- King Edward Memorial (KEM) Hospital
- Mumbai, Maharashtra, India
- Sweety Trivedi MD DM
- Post Doctoral Fellow
- Department of Neurology
- Sanjay Gandhi Postgraduate Institute
- Lucknow, Uttar Pradesh, India
- Bidkar Sayli Umakant MD DM
- Assistant Professor of Pediatric Neurology,
- Department of Neurological Sciences, Christian Medical College
- Vellore, Tamil Nadu, India
- Hardeep Uppal MD
- Neurology Resident
- Department of Neurology
- University of Texas Southwestern Medical Center
- Dallas, Texas, USA
- Meera Viswanathan MPAS PA-C
- Neurocritical Care Physician Assistant
- Division of Neurocritical Care
- Department of Neurology
- University of Texas Southwestern Medical Center
- Dallas, Texas, USA
- Praveen Kumar Yada MD DM
- Senior Consultant Neurologist
- Krishna Institute of Medical Sciences
- Secunderabad, Telangana, India
All physicians make mistakes. During their early training, mistakes are, thankfully, prevented by more senior trainees or by an experienced supervisor. But when one has become senior oneself, who will let her/him know that she/he is making an error? Thankfully, most of my errors were either unimportant or soon became obvious to me. But not all. The skilled clinician should learn humility from the errors she/he makes. And errors should become “the teachable moment” that enables you to let others learn how to avoid not just the same error but other similar errors. Many experienced clinical neurologists develop their own “rules for avoiding an incorrect diagnosis.” Some of these neurologists share these rules with their students, but only a few remarkable teachers share their experience with a wider audience. Professor Chakravarty is one of the few. I first met Professor Chakravarty in Calcutta, India, in 1997 when I participated in a Teaching Program organized by him and Bangalore, India, in 2006, when I was his guest during his Presidency of the Indian Academy of Neurology. We were able to spend sufficient time together for me to learn that he was a charismatic leader and a highly experienced clinician. I was recently privileged to read his 2021 Neurology & Internal Medicine—A Case Based Study . That volume as well as this new text on “Pitfalls in Diagnosis” reflects his stellar ability to present and discuss interesting cases that illustrate crucial diagnostic insights.
This compendium of challenging diseases and errors to be wary of will help the careful reader to identify diagnostic “traps” where either physical findings or a coincidental (and incidental, irrelevant) condition can mislead the less experienced clinician. Read and pay attention to this book carefully! The errors you will learn about may help you save your peace of mind and your reputation. More importantly, it may keep you from harming one of your patients.
The topics covered by this book include challenging problems in the diagnosis of common diseases such as headache, multiple sclerosis, stroke, and equally challenging problems in recognizing rare disorders. One of the most illuminating discussions is that of the other diagnosis to consider when one has the results of cervical spine imaging suggesting that there could be spinal cord compression and that there is most certainly evidence that the neural foramina are comprised I have had over 50+ years’ experience seeing patients who had cervical spine operations for spinal cord and spinal root compression, but who then did not improve or stabilize with surgery. They subsequently proved to have ALS, MS, or another disease. This experience trained me to be suspicious of allowing imaging findings to dictate treatment. One rule I developed that served me well was “Never order a neuro-diagnostic test until you have decided what you are looking for…and if you find something unexpected consider the possibility that it's an incidental finding”—“an incidentaloma.” The discussion of the many disorders that can misled the unwary is a valuable resource for the clinician who should be hoping to avoid an unnecessary operation. This topic is just one of many “pitfalls” this useful resource will help avoid. Give it your serious attention!
Robert C Griggs MD FAAN (Honorary)
Professor of Neurology, Medicine, Pathology and Laboratory
Medicine, and Pediatrics and the Center for Health + Technology
Chair of Neurology (1986–2008) Emeritus
University of Rochester Medical Center, New York, USA
PREFACE
Like all human beings, doctors too are not immune from making mistakes—mistakes not only in making a diagnosis or missing a diagnosis but also in providing appropriate therapeutic care to his/her patients. Although making the correct diagnosis is the most fundamental step in providing appropriate medical care, the overall rate of diagnostic errors in medical practice all over the world may be as high as 15–20% or may be higher in countries with limited recourses. Advances in medical technology have not solved the problem of diagnostic error in medicine, as seen by autopsy studies. Diagnostic error continues to be a widespread problem and may affect hundreds of people across the globe. Diagnostic error is more difficult to define than other types of medical errors. The majority of diagnostic errors is due to cognitive errors by physicians, particularly in synthesizing the available information to identify the correct diagnosis. And this is particularly evident in neurological practice even in the current days of sophisticated technological support. It is indeed true that all these facilities are not universally available and even if available, would prove to be very expensive to common people. The problem arises when such modern supportive measures are not appropriately used to solve a clinical problem or the results provided are misinterpreted. A recent US National Academy of Medicine report defines a diagnostic error as the failure to establish an accurate and timely explanation of the patient's health problem(s) or communicate that explanation to the patients. It emphasizes that improving diagnosis is not only possible but also represents a moral, professional, and public health imperative. Therefore, it is crucial to identify causes of diagnostic error and define strategies to improve diagnostic accuracy to achieve a better clinical outcome. And this is exactly what had been attempted in this volume. An all-round attempt had been made to discuss the diagnostic strategies to a host of common and uncommon problems encountered in neurological practice, both in a clinic setting and in the setting of an intensive care unit. Such diagnostic processes would be critically evaluated to find lacunae or areas where an average clinician would be apt to make a mistake and means to avoid making such mistakes would be highlighted, on many occasions with the help of illustrative case studies. A total of over 50 such clinical problems have been identified which would be discussed in the light of the issues raised above, by several renowned clinicians both from India and abroad. In the process, over 100 authentic clinical cases have been discussed highlighting issues pertaining to arriving at the correct diagnosis and avoiding pitfalls. Many chapters would be followed by Editorial notes and Appendices on some key issues relating to diagnostic pathways, again at times with the help of illustrative case studies. This volume, most certainly, is much different from the standard neurological differential diagnosis texts available in the market.
Since 2018, with the help from some of my colleagues and friends both in India and abroad, I have been able to write, edit, and publish as many as five books, three of which happened to be entirely case-based studies (headache disorders, vertigo and dizziness, and the most recent one dealing with problems lying in the interface of neurology and internal medicine) and the other two (clinical neuro-ophthalmology and mimics of epileptic seizures) also contained several illustrative cases. Having received some educational grants, it was possible to distribute all these five books free of any cost to every member of the Indian Academy of Neurology and to all trainees in neurology in every teaching institute of the country. The feedbacks received had really been very encouraging.
My deepest gratitude goes to Professor Robert C Griggs of University of Rochester, New York, USA, for kindly writing the Foreword of the book and reviewing a few sections. I am privileged to have a fairly long association with him spanning several years.
I also would like to thank profusely the contributing authors, some of whom are world-renowned authorities, for kindly writing for this volume in the midst of their numerous commitments. Special mention needs to be made of Drs Sarosh M Katrak, Satish V Khadilkar, Sanjib Sinha, Subhash Kaul, Sangeeta Ravat, Joy D Desai, Sulalyan Purkayastha, and Sandip Chatterjee for their contributions. Drs Venkatesh Aiyagari and Bappaditya Ray of the University of Texas South Western Medical Center, Dallas, Texas, USA, deserve very special thanks for their hard work in compiling the section on Critical Care Neurology comprising 15 very interesting cases, all being discussed in an interactive manner. My longtime younger colleagues Drs Angshuman Mukherjee, Debasish Roy, and Amit Halder had always remained by my side, helping me whenever needed.
I am indebted to the publishers for their cooperation in bringing out the book in time even in the midst of the pandemic. I would like to especially thank Mr Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director) and Mr MS Mani (Group President) from Jaypee Brothers Medical Publishers (P) Ltd . I would also like to extend my thanks to Dr Richa Saxena (Associate Director-Professional Publishing), Ms Pooja Bhandari (Production Head), Mr Sabyasachi Hazra (Senior Business Manager, Publishing), and Ms Ritu Kumari (Development Editor).
Last, I wish and pray that the book becomes really useful to all those for whom it had been written !
Ambar Chakravarty
May 2022