PTSD: Post-Traumatic Stroke Disorder

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PTSD Post-Traumatic Stroke Disorder
Joshua McKay MD and Ryan Kraemer MD University of
Alabama at Birmingham
Diagnostic Errors
Presentation Characteristics
Learning Objectives
Hospital Course

• Continued to experience her original symptoms
• Treated as previously diagnosed panic attacks
• During one of these episodes she developed a
  severe generalized headache
• Repeat head CT showed hemorrhagic conversion of
  the ischemic lesion
• BP was 234/140
• No history or prior documentation of hypertension

• Leading cause of medical malpractice claim
• Second leading cause of preventable adverse
  events
• Account for an estimated 40,000-80,000 deaths per
  year
• Cognitive errors are the most common cause of
  misdiagnosis

• Presentation characteristics commonly associated
  with cognitive errors
• Atypical presentation
• Non-specific complaints
• Low prevalence of disease
• Presence of co-morbidities

1. Recognize a medical condition that can mimic
   panic attacks
2. Recognize common cognitive errors that may lead
   to delay in diagnosis and increased morbidity
   and/or mortality

 

Patient Presentation
Evaluation and Diagnosis
Cognitive Errors

• 54 yo AAF with post traumatic stress disorder
  secondary to a MVA presented to her psychiatrist
  with new onset intermittent severe headaches
  associated with nervousness and tachypnea
• Diagnosed with panic attacks and treated
• Four Months Later
• Presents to her PCP with similar symptoms
• Treated for previously diagnosed panic attacks
• One Year After Onset of Symptoms
• Presents to emergency department complaining of
  acute onset of left-sided weakness
• Vital signs, including BP 115/48, within normal
  limits
• MRI confirms ischemic stroke
• Additional work-up unrevealing
• Treated appropriately for stroke

• Laboratory Data
• Diagnosis
• Pheochromocytoma
• Following surgical resection the patient had
  complete resolution of symptoms

• Common cognitive errors illustrated in this case
• Premature Closure
• Failure to consider reasonable alternatives after
  an initial diagnosis is reached
• Likely played a role in the initial diagnostic
  process
• Anchoring
• Locking onto a salient feature early in the
  diagnostic process and then failing to adjust
  this process when new information is obtained
• With a diagnosis of PTSD, it was easy to anchor
  to the complaint of nervousness while ignoring
  features not consistent with panic attacks
• Diagnostic Momentum
• Failure to consider other diagnoses after a
  diagnosis has been attached to a patient
• Led to continued treatment for panic attacks and
  further delayed the proper diagnosis

Take Home Points
Serum (nmol/L) 24 hour Urine (mcg/24 hrs)
Metanephrines 7.7 (nl lt0.5) 7310 (nl 90-315)
Normetanephrines 146 (nl lt0.9) 115,291 (nl 122-676)

• Symptoms of a pheochromocytoma can mimic those of
  a panic attack
• Cognitive errors can lead to substantial
  morbidity and/or mortality
• An increased awareness of cognitive errors can
  help physicians avoid these pitfalls in diagnosis.

References
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1991324377-84. 3. Leape LL, Berwick DM, Bates
DW. Counting deaths due to medical errors. JAMA
2002288(19)2405. 4. Graber M, Franklin N,
Gordon R. Diagnostic error in internal medicine.
Arch Intern Med 20051651493-1499. 5.
Kostopoulou O, Delaney BC, Munro CW. Diagnostic
difficulty and error in primary care - a
systematic review. Fam Pract 200825(6)400-13. 6.
Redman JC, Peloso OA, Milne RL, Kaminsky NI,
Ellis SC, Wolfel DA, Martinez PU. Asymptomatic
pheochromocytoma. Diagnosis after hemorrhagic
stroke in a middle-aged patient. Postgrad Med
198373(4)279,282-5.
CT-Abd/Pelvis revealed a 10 cm complex right
adrenal mass