The most prevalent neurology misadventure is diagnostic error, and the most frequent incorrectly diagnosed conditions are brain tumor, followed by abscess, SAH, and other causes of HA.² Neurosurgeons are most frequently sued for technical procedural errors and postoperative complications, although diagnostic and nonoperative treatment errors appear to underpin many successful claims. Technical surgical errors are usually straightforward, promptly recognized, and unpredictable. The mere occurrence of a technical error is not malpractice without additional evidence of substandard skill. Claims alleging such errors are generally not successful and, for the competent surgeon, there are few risk management protocols that would minimize these isolated events. Therefore, technical error claims will not be discussed. Postoperative complications include known risks stemming from each particular procedure, and claims frequently allege lack of informed consent. Informed consent guidelines are well documented in the literature, and they are discussed elsewhere in this Handbook.

The confluence of several unrelated trends portends an increase in neurosurgical claims alleging diagnostic or treatment error:

• First, neurosurgeons are often the initial point of contact for nonsurgical conditions traditionally referred to neurologists.

• Second, the unprecedented growth of sophisticated neurodiagnostic testing raises the standard of care and hence the likelihood of suit.

• Third, the surgical specialists, perhaps due to reimbursement issues, seem increasingly likely to assume nonoperative patient care such as conservative spine management, pharmacologic treatment of postoperative or post-traumatic epilepsy, and evaluation of HA and facial pain.

• Fourth, medical and surgical treatments are often inextricably intertwined, leaving each specialist vulnerable to any claim against the other.

Thus, the management strategies discussed in this chapter are equally applicable to the medical and surgical neurologist, focusing on the common ground of diagnostic and treatment error (hereinafter the term “neurologist” refers to both the medical and surgical specialist unless otherwise specified).

STRATEGIES FOR HEADACHE

General Considerations

HAs are ubiquitous, arguably the most common disorder encountered by the practicing physician, and the most common presenting symptom in malpractice claims against medical neurologists.³ HA may be of little clinical significance or, paradoxically, herald a catastrophic illness, such as brain tumor, SAH, or meningitis. A complete and accurate diagnosis of the HA patient requires a detailed history coupled with a full neurologic and general medical examination, as well as diagnostic testing and neuroimaging in selected cases.

The single most important step in the evaluation is to classify the type of HA and, pari passu, ascertain whether it is acute, longstanding, or with recent change. This practical approach will allow the neurologist to determine the need for any diagnostic testing and initiate a proper treatment plan, all with the appropriate degree of urgency. Too often, the inexperienced, poorly trained, or hurried neurologist distorts a patient’s history or fails to perform an adequate examination, resulting in the wrong diagnosis. Most malpractice suits stem from the failure to establish a rapport and elicit an accurate history. The art of history taking cannot be taught in this or any other book, and includes an innate ability to instill confidence and trust. The author suggests the following methodology for taking a history, and recommends that physicians formulate their own techniques, which will evolve with time, experience, and continuing education:

Allow ample time for the consultation. Introduce yourself and invite the patient to sit for the interview before changing into a gown. Advise the patient that you have read the referring doctor’s letter, but never accept either the patient’s or referring physician’s diagnosis.

Ask the patient, “Tell me about your HAs.” Allow the patient to speak uninterruptedly before asking questions. Then begin taking a history with open-ended questions to determine the quality, severity, location, duration, and time course of the pain, as well as precipitating, exacerbating, and relieving factors. It is often helpful to ask the patient to describe a typical attack. Be certain to determine whether the patient has more than one type of HA. It is essential to separately evaluate each type of HA, which may not be possible during the initial consultation due to time constraints.

Communication skills are critical. Knowing which clues to follow and when to interrupt the patient are fundamental to an accurate history. Failure to understand the patient’s terminology often leads to a misdiagnosis. For example, the word “throbbing” may be incorrectly translated into a migraine. It is not uncommon for a HA specialist to distort the history until it fits a preconceived diagnostic category.

The scope of the history must be sufficiently broad to address systemic diseases that may be relevant to the HA. Past, family, and social histories provide valuable information about the patient’s condition. Before concluding the history, always ask the patient’s opinion about the cause of the HA. This is often the most enlightening part of the interview.

Specific Approach

HAs are classified as primary or secondary disorders. A primary HA disorder means that there is no specific cause and the HA itself is the problem, while in a secondary disorder the HA is symptomatic of an underlying disease. Evaluating a patient with HA requires a systematic approach to distinguish the benign (primary) HA from more serious conditions causing secondary HAs. The following discussion is limited to nontraumatic HAs in the adult population, with particular attention to the more common causes of malpractice suits. Lack of space necessitates omitting many conditions, truncating differential diagnoses, and ignoring various diagnostic and therapeutic options. Therefore, this overview should not be considered a definitive or complete guide for HA management.

Exclude Secondary HAs

The first step is to exclude serious conditions causing secondary HAs. The neurologist performing a history and examination should direct particular attention to the following warning signs or “red flags” suggesting a secondary HA, and proceed with appropriate diagnostic and therapeutic intervention.

Sudden Onset (Thunderclap) HA.

The sudden onset of a severe HA mandates an immediate and thorough evaluation. Potential etiologies include SAH, intracerebral hemorrhage, venous or sinus thrombosis, aneurysmal expansion, intracranial or extracranial arterial dissection, pituitary apoplexy, and less common conditions such as intermittent hydrocephalus (e.g., due to colloid cyst of the third ventricle).

SAH warrants further discussion. More than half of patients presenting to the emergency room with a sentinel HA and SAH are misdiagnosed. The failure to diagnose this condition results in the highest average and highest total indemnity for all claims involving diagnostic error.⁴ The sine qua non of SAH is a sudden HA classically described as the “first” or “worst HA of my life,” and often associated with nausea or vomiting. The HA is usually followed by pain radiating into the cervical or occipital region, followed by meningismus as blood enters the spinal subarachnoid space. There may be focal neurologic deficits, cognitive impairment, or a history of premonitory symptoms suggestive of a sentinel bleed or expansion of an aneurysm. A thorough history of the HA is essential—even known migraineurs may suffer a SAH. The patient with a thunderclap HA must have immediate computerized tomography (CT) of the brain, and, if the CT is negative, a lumbar puncture (LP) to include measurement of opening pressure and testing for xanthrochromia. Some conditions such as venous or sinus thrombosis may not be evident on CT. It may be reasonable, based on the clinical history, sequence of events, and time of presentation, as well as CT and LP results, to proceed with MRA or angiography.