Table 1.

Some reasons for misdiagnosis in patients with neurological emergencies.

	Headache	Dizziness	Back Pain	Weakness	Seizure
History	Patients use words like “migraine” and “sinus infection” that may mislead the physician. Beware previous diagnoses; they might be wrong.	The use of the word “vertigo” versus other dizziness descriptors is not etiologically useful.	Patients use word “sciatica” which may lead physicians to diagnose sciatica.	Stroke patients may complain of “clumsiness” or “my arm felt like lead” rather than “weakness”.	Patient (or witness) says “seizure” after a faint Seizure patients often present after the seizure with only an altered mental status or with a postictal “Todd's” paralysis
Physical exam	Patients with SAH may be well appearing and neurologically intact.	Patients with small posterior circulation strokes can mimic a peripheral vestibular presentation.	Patients with serious causes of back pain can present without neurological deficits.	Patients with stroke can present with just about any focal deficit depending upon the occluded vessel. Myasthenia patients' symptoms wax and wane. GBS patients' first symptoms may be purely sensory.	Patients may be lethargic, but neurologically intact.
Diagnostic testing	For SAH, CT sensitivity is good but decays with time. CT has poor sensitivity for CVST and dissection.	CT is a poor test for cerebellar and brainstem infarction	No MRI available MRI must target the correct segment(s) of the spine.	False normal CT in early stroke	EEG often not available in the emergency department. Not performing LP in seizure patients who may have encephalitis or neurocysticercosis.
Preconceived notions	Headache improved with triptans so is not a serious secondary cause.	Posterior circulation strokes are obvious or devastating events	All patients with SEA have risk factors or fever, or neurological deficits	Young people do not get strokes	Seizures (or seizure-like movements) are sometimes seen with strokes. Convulsive movements are common in syncope.

CVST: cerebral venous sinus thrombosis, SAH: subarachnoid hemorrhage, CT: CAT scan, MRI: magnetic resonance imaging, SEA: spinal epidural abscess.