Terminology for our times: Excluding every diagnosis is not necessary
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7407.166-a (Published 17 July 2003) Cite this as: BMJ 2003;327:166All rapid responses
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It may well be 'not done' to respond to one's own letter,
particularly when the response is unlikely to be read. However I wish to
record the following to illustrate the practice of gross over-
investigation which is consuming much of the extra investment in the NHS.
Our MR is presently performed off site, with the patients unseen by
the radiologists, and cards sometimes sneaked through to MR unseen by
radiologists. I received the films of a comprehensive brain MR for the
clinical details "Left sided inattention. CT scan normal. ?Any evidence of
stroke". So far, so not-all-that-bad. However, the request went on:"MR
angiography in case there has been carotid or vertebral dissection". This
had been carried out- clearly, I would have rejected this ridiculous idea
had I been present.
Physicians are the main proponents of the idea that any tortuous
'reasoning', which leads to a preferably glamorous sounding diagnosis, is
legitimate and is, indeed, a sign of cleverness. Whatever the specialty of
the doctor, he or she generally feels justified in demanding that the
imaging department disproves the diagnosis, no matter how ludicrous.
In this case there was no stroke, but an essentially absent vertebral
artery. I have done my best to ensure that the matters stops now, but I am
not sanguine. Goodness knows what will happen if these people ever gain
access to functional MRI.
Competing interests:
None declared
Competing interests: No competing interests
Really ludicrous?
I entirely agree that a request for a complex radiological
investigation without discussion with the Consultant Radiologist who is
being asked to give their opinion is both discourteous and can lead to
inappropriate investigation when their may be better options (one wouldn't
make an in-hospital referral to a Consultant Cardiologist with the sole
information being: Chest pain ? MI ?any evidence of coronary dissection)
However I would dispute that the investigation for a dissection is
necessarily ludicrous. A clinical syndrome of inattention suggests a
cortical deficit due to large-vessel occlusion. In approximate order of
likelihood for the aetiology for the syndrome are:
Cardioembolism (unlikely if ecg, CXR & clinical exam are normal
and able to be investigated with echo (transthoracic and/or
transoesophageal)if doubt)
Extracranial carotid atheroembolism (stenosis excludable by carotid
ultrasound)
Intracranial atheroembolism/in situ thrombosis (only excludable by MRA,
cerebral angiogram (with attendant risks) or transcranial doppler
(unlikely to be available in UK))
Carotid dissection (extra or intracranial)-which can be spontaneous and
non-painful
The aetiology of the stroke is the key for effective secondary
prevention of a disease with high mortality, morbidity and risk of
recurrence. There is a reasonable consensus (admittedly not based on
randomised-controlled trials) that patients with dissection should be
anticoagulated to prevent recurrence. The diagnosis of dissection is not
just about being glamorous or clever- it potentially changes management.
The difficulty with commenting on the case is shared with the
radiologist. What he would need to know would be:-
Were the symptoms transient (explaining the lack of lesion on MR)?
Were the signs "hard" or just probable?
Is there any suspicion this could be a post-ictal phenomenon?
What is the overall risk factor profile of the patient (high vascular risk
would decrease the proportional likelihood of dissection)?
Have they had other appropriate investigations (eg carotid duplex &
echo)?
Would the clinician institute anticoagulation if a dissection was found?
These could all be facilitated by discussion of the case with the
Radiologist concerned
Stroke has a history of being under-investigated (from the
neuroimaging, vascular and cardiac imaging fronts), with potential denial
of the optimal secondary prevention strategy. If there was a reliable non-
invasive method of imaging the coronary arteries, I am sure this would be
standard practice in Cardiology. A difference in the British mindset
between an acute cerebral infarction and an acute myocardial infarction
Competing interests:
None declared
Competing interests: No competing interests