Clinical Consequences of Misinterpretations of Neuroradiologic CT Scans by On-CallRadiology Residents
Nirish R. Lal
,a,
Uwada M. Murraya,
O. Petter Eldevika and
Jeffrey S. Desmonda
a From the Departments of Radiology (N.R.L., U.M.M., O.P.E.) and Emergency Medicine (J.S.D.), University of Michigan Medical Center, Ann Arbor.
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FIG 1. 51-year-old man with headache, neck pain, and loss of consciousness after a fall. An emergency noncontrast head CT was performed to determine the presence of hemorrhage or fracture. The initial interpretation by the on-call resident was no significant abnormality. The next morning, the staff neuroradiologist identified a 2 x 3-cm right cerebellopontine angle lesion (arrows) causing mass effect on the pons and fourth ventricle, most likely representing an epidermoid. This error in interpretation was given a grade 4 (should have been identified) by the panel. The patient was scheduled for a follow-up MR examination; however, the 10 -hour delay in diagnosis did not change his outcome.FIG 2. 43-year-old woman with loss of consciousness after a motor vehicle accident. An emergency noncontrast head CT was performed to evaluate for hemorrhage. The initial interpretation by the on-call resident identified a scalp hematoma. The next morning, the staff neuroradiologist also identified an 8-mm soft-tissue mass left of the midline in the suprasellar cistern (arrow). This error in interpretation was given a grade 3 (could usually be identified) by the panel. The patient was scheduled for a follow-up MR angiogram, which showed the mass to be an aneurysm of the left supraclinoid carotid artery, and she later underwent elective surgery. The 15-hour delay in diagnosis did not change this patient's outcome.
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FIG 3. 78-year-old woman with back pain 5 years after a mastectomy for breast cancer.
A and B, An emergency lumbosacral spine CT was performed to evaluate for L3 compression fracture. The initial interpretation by the on-call resident identified multilevel degenerative changes with a questionable lesion at L5 versus degenerative change. The next morning, the staff neuroradiologist noted destructive lesions on the right side of L4 (A, arrows) and the posterior aspect of L5 (B, arrows), consistent with metastases. This error in interpretation was given a grade 4 (should have been identified) by the panel. The patient had been sent home instead of being admitted for metastatic workup, so she was called back the next day; however, the 6-hour delay in diagnosis did not change her outcome.
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FIG 4. 15-year-old girl with left hemotympanum. An emergency temporal bone CT was performed to evaluate for temporal bone fracture. The initial interpretation by the on-call resident identified a left temporal bone fracture. The next morning, the staff neuroradiologist also noted a hemorrhagic contusion of the left frontal lobe (open arrow), with surrounding edema (closed arrows). This error in interpretation was given a grade 2 (would not ordinarily be expected to be identified) by the panel. The patient was called back for reevaluation and a follow-up head CT. The 11-hour delay in diagnosis did not change her outcome.FIG 5. 70-year-old man with metastatic prostate cancer, presented with right-sided weakness and mental status changes. An emergency head CT was performed to evaluate for metastasis or infarct. The initial interpretation by the on-call resident was intra-axial edema (arrows) from a metastasis or infarct. The next morning, the staff neuroradiologist interpreted this lesion to represent an extra-axial fluid collection. This error in interpretation was given a grade 2 (would not ordinarily be expected to be identified, difficult to distinguish) by the panel. The initial error in interpretation resulted in a 13-hour delay in treatment, as the patient was taken to the operating room for drainage of the subdural hematoma the next day; however, his outcome was not changed
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FIG 6. 66-year-old man with right hemiparesis and aphasia. An emergency noncontrast head CT was performed to determine whether the patient was a potential candidate for thrombolysis. The initial interpretation by the on-call resident identified a high-attenuation focus in the left basal ganglia (arrow), most likely representing hemorrhage. The next morning, the staff neuroradiologist interpreted this lesion as calcification, not hemorrhage. This error in interpretation was given a grade 3 (could usually be identified) by the panel. The initial misinterpretation resulted in thrombolytic therapy being withheld, denying the patient the potential benefit of that treatment and thereby representing a potentially serious change in his outcome.FIG 7. 61-year-old woman with end-stage renal disease presented with a change in mental status. An emergency noncontrast head CT was performed to evaluate for septic emboli or hemorrhage. The initial interpretation by the on-call resident was negative. The next morning, the staff neuroradiologist noted a right cerebellar infarct (arrows). This error in interpretation was given a grade 3 (could usually be identified) by the panel. The initial misinterpretation resulted in a change in management, as the patient received dialysis to exclude uremia as the possible cause of her symptoms, and a delay in the treatment of her stroke, resulting in a potentially serious change in the patient's outcome
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AJNR - American Journal of Neuroradiology