A Clinical Risk Case Study - Misdiagnosis of Brain Haemorrhage

A Clinical Risk Case Study - Misdiagnosis of Brain Haemorrhage

Setting the Scene

The patient, in this case, presented to A&E with a constant severe headache and vomiting without history of a head injury. A diagnosis of suspected urinary tract infection was made, despite test results not corroborating this. They were prescribed antibiotics and analgesia and sent to an out-of-hours GP.

The patient was found unconscious the next morning and was taken to A&E. A CT scan showed a large area of intracerebral haemorrhage. Unfortunately, no surgical treatment was possible and the patient sadly died.

The main learning points from this review stem from the following events:

• Lack of appreciation of the severity of the focal headache

• Not considering the possibility of a brain haemorrhage

• No brain scan was undertaken

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:

• Undertake further investigations into headaches that do not improve with analgesia and present alongside symptoms such as fever and vomiting without other obvious cause NICE Guidance CG150. Given the potential severity of conditions causing these symptoms, it is crucial to investigate further, using brain scans to determine whether patients are suffering from life-threatening conditions such as meningitis or brain haemorrhage.

• Other symptoms should also be highlighted as warranting further investigation if present with severe headaches, such as neurological changes, personality changes and impaired levels of consciousness.

• Consider brain haemorrhage as a differential diagnosis in cases of sudden onset of a severe headache that presents with vomiting and no other obvious cause, where infection can be ruled out on the basis of blood results and clinical symptoms. Whilst infection is a common cause of vomiting and headaches, it is unusual for a headache to be so severe as a result of dehydration caused by something such as gastroenteritis. This should prompt clinicians to look into less obvious causes of the patient’s symptoms. This is especially important when test results do not corroborate a diagnosis of infection.

• Perform CT brain scans when the cause of severe headache is uncertain and patients do not respond to analgesia. Undertaking brain imaging in such cases is paramount to diagnosing brain haemorrhage (2) and facilitating relevant treatment in a timely manner to reduce the chance of death in a condition with an already-high mortality rate of around 40% at 1 month (3).

• Ensure any diagnoses of infection or virus are backed up by clinical symptoms and test results where available. When diagnoses of infection are made in cases of severe headaches, ensure that other symptoms are in accordance with what would be expected for such infection, since misdiagnosing brain haemorrhage as infection can lead to failure to provide treatment for haemorrhage, ultimately resulting in severe, if not fatal, consequences for the patient.

To Summarise

This is a case of a patient who had a brain haemorrhage and was misdiagnosed with an infection, despite their clinical symptoms and test results not corroborating this diagnosis and their presentation of a severe headache.

TMLEP would like to highlight the importance of being aware of the possibility of brain haemorrhage as a differential diagnosis in patients who present with severe headaches and vomiting without clear cause and stress the necessity of investigating this in a timely manner to increase the chance of optimal outcome for the patient.

References

  • NICE Guidance CG150
  • Heit JJ, Iv M, Wintermark M. Imaging of Intracranial Hemorrhage. J Stroke. 2017;19(1):11–27. doi:10.5853/jos.2016.00563
  • An SJ, Kim TJ, Yoon BW. Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update. J Stroke. 2017;19(1):3–10. doi:10.5853/jos.2016.008
  • Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group and Professor Richard Lyon, Consultant in Emergency Medicine & Professor of Pre-Hospital Emergency Care. (2019). A Clinical Risk Case Study - Misdiagnosis of Brain Haemorrhage . TMLEP Clinical Risk Case Studies. 3 (4), 1.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0) 203 355 9796.