ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis

Abstract

Objective: With the emergency department (ED) being a high-risk site for diagnostic errors, we sought to estimate ED diagnostic accuracy for identifying acute cerebrovascular events.

Methods: MEDLINE and Embase were searched for studies (1995-2016) reporting ED diagnostic accuracy for ischemic stroke, TIA, or subarachnoid hemorrhage (SAH). Two independent reviewers determined inclusion. We identified 1,693 unique citations, examined 214 full articles, and analyzed 23 studies. Studies were rated on risk of bias (QUADAS-2). Diagnostic data were extracted. We prospectively defined clinical presentation subgroups to compare odds of misdiagnosis.

Results: Included studies reported on 15,721 patients. Studies were at low risk of bias. Overall sensitivity (91.3% [95% confidence interval (CI) 90.7-92.0]) and specificity (92.7% [91.7-93.7]) for a cerebrovascular etiology was high, but there was significant variation based on clinical presentation. Misdiagnosis was more frequent among subgroups with milder (SAH with normal vs abnormal mental state; false-negative rate 23.8% vs 4.2%, odds ratio [OR] 7.03 [4.80-10.31]), nonspecific (dizziness vs motor findings; false-negative rate 39.4% vs 4.4%, OR 14.22 [9.76-20.74]), or transient (TIA vs ischemic stroke; false discovery rate 59.7% vs 11.7%, OR 11.21 [6.66-18.89]) symptoms.

Conclusions: Roughly 9% of cerebrovascular events are missed at initial ED presentation. Risk of misdiagnosis is much greater when presenting neurologic complaints are mild, nonspecific, or transient (range 24%-60%). This difference suggests that many misdiagnoses relate to symptom-specific factors. Future research should emphasize studying causes and designing error-reduction strategies in symptom-specific subgroups at greatest risk of misdiagnosis.

Figure 1. Citation search and selection flow diagram

^aMEDLINE was accessed via PubMed; Embase was accessed via embase.com. ^bHand search of citation lists from selected studies and investigator files identified 19 additional manuscripts for review. ^cAbstracts coded as yes or maybe by at least one reviewer were included in full-text review. ^dAfter full-text evaluation by 2 reviewers, any differences were resolved by discussion and adjudication by a third, independent reviewer. ^eDiagnostic reference standard was low in 4 studies (see appendix e-1). ^fOne study was removed because of duplicate data (see appendix e-1). ED = emergency department.

Figure 2. Emergency department (ED) diagnostic accuracy for acute cerebrovascular events by study: Sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV)

Forest plots show sensitivity, specificity, PPV, and NPV (mean [95% confidence interval]) in ED diagnosis of cerebrovascular events. Results are shown by study and pooled. Note significant heterogeneity across studies, discussed in the text.