Lessons from a discrepency meeting: Cases of missed brain pathology

Transcription

1 Lessons from a discrepency meeting: Cases of missed brain pathology Poster No.: C-1298 Congress: ECR 2014 Type: Authors: Keywords: DOI: Educational Exhibit B. Dhesi, S. P. Walker, O. Abulaban, S. Hussain; Birmingham/UK Neuroradiology brain, CT, MR, Health policy and practice, Education, Safety, Quality assurance, Education and training /ecr2014/C-1298 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 10

2 Learning objectives To identify commonly missed brain pathologies on radiological investigations performed at our institution, and devise learning points to reduce the future incidence of such errors. Background As part of risk reduction and management, ESR and UK RCR guidelines recommend that imaging departments hold regular, anonymised discrepancy conferences so that important missed pathological findings can be discussed and pitfalls brought to the attention of colleagues (Ref 1 and 2). We have analysed a series of cases presented at our local discrepancy conferences and present a pictorial review of missed brain pathology, along with key educational recommendations. Findings and procedure details 155 discrepancies that have been discussed over the past two years were reviewed. Of these, 13 (8%) were related to the imaging of the brain. Of these discrepancies, there were ten CT scans and three MRI scans. Commonly missed findings included missed brain tumours, hydrocephalus and small subdural haematomas. Case 1 and 2: Uncontrasted CT brain scans were performed for two patients. The first patient presented with acute left sided weakness and an emergency CT brain was performed (Fig 1). Patient had a left vertebral artery thrombus which was missed on intial review. The second patient collapsed in the shower (Fig 2). This patient had bilateral MCA thrombi. These cases reiterate the importance to check arterial supply and look for the dense artery sign. There is a narrow window where thrombolysis can be used and looking for this sign can change the initial management of the patient. Case 3 and 4: Patient underwent uncontrasted CT brain after first seizure (Fig 3). Subtle effacement was noted of the anterior horn of the left lateral ventricle when images were Page 2 of 10

3 retrospectively reviewed after an MRI scan. The MRI scan demonstrated a large left glioblastoma multiforme. For subtle changes IV contrast needs to be administered. A second patient underwent uncontrasted CT Brain after 3 episodes of visual disturbance (Fig 4). Patient had previous breast cancer. Once again subtle changes are seen in the cerebellum. Post contrast images show multiple metastases. A low threshold for contrast should be used to investigate subtle abnormlaities on CT. Case 5 and 6: A patient had an MRI of their cervical spine because of continued neck pains after a road traffic accident 1 year previously, with more recent headache and left sided numbness (Fig 5). A lesion is seen within the cerebellopontine angle at the very superior aspect of the scan. On MR brina imaging it was suspected that this represents a menigioma. A second patient underwent CT sinuses with symptoms of recurrent sinusitis and facial pains. Calcification can be seen in the cerebellum at the very edge of the film. A subsequent MRI picked up a cerebellar tumour. These cases both illustrate 'edge of film' errors. Case 7: An 11 year old patient had 2-3 weeks of headaches and vomiting (Fig 7). In this case hydrocephalus was missed. Patient was transferred to a tertiary centre however, where a obstructive cervical spine lesion was identified. Radiologists should always look for hydrocephalus and know what is normal for different ages. Images for this section: Page 3 of 10

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10 Conclusion Discussion of cases in discrepancy meetings allows for identification of learning points. Learning points when reviewing brain imaging include: 1) Refer to the clinical history which should direct to the site of injury 2) Remember to look for any masses in trauma CT scans as well as for acute bleeding 3) Always remember to change windows in trauma to look for subdural haematomas 4) Always correlate the size of ventricles to the age of the patient, especially looking at the temporal horns for hydrocephalus Personal information References 1. Royal College of Radiologists - Standards for Radiology Discrepancy Meetings (2007). 2. European Society of Radiology - Brochure IV - Risk Management in Radiology in Europe (2004) Page 10 of 10