title: 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.
authors.affiliation: From the Department of Neurology (A.A.T.), University Hospital Zurich, Switzerland; Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; Department of Oncology and Department of Biostatistics (Z.W.), Johns Hopkins University, Baltimore, MD; and Department of Emergency Medicine (J.A.E.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
authors.forename: Alexander Andrea
authors.initials: AA
authors.lastname: Tarnutzer
authors.affiliation: From the Department of Neurology (A.A.T.), University Hospital Zurich, Switzerland; Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; Department of Oncology and Department of Biostatistics (Z.W.), Johns Hopkins University, Baltimore, MD; and Department of Emergency Medicine (J.A.E.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
authors.forename: Seung-Han
authors.initials: SH
authors.lastname: Lee
authors.affiliation: From the Department of Neurology (A.A.T.), University Hospital Zurich, Switzerland; Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; Department of Oncology and Department of Biostatistics (Z.W.), Johns Hopkins University, Baltimore, MD; and Department of Emergency Medicine (J.A.E.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
authors.forename: Karen A
authors.initials: KA
authors.lastname: Robinson
authors.affiliation: From the Department of Neurology (A.A.T.), University Hospital Zurich, Switzerland; Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; Department of Oncology and Department of Biostatistics (Z.W.), Johns Hopkins University, Baltimore, MD; and Department of Emergency Medicine (J.A.E.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
authors.forename: Zheyu
authors.initials: Z
authors.lastname: Wang
authors.affiliation: From the Department of Neurology (A.A.T.), University Hospital Zurich, Switzerland; Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; Department of Oncology and Department of Biostatistics (Z.W.), Johns Hopkins University, Baltimore, MD; and Department of Emergency Medicine (J.A.E.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Edlow
authors.affiliation: From the Department of Neurology (A.A.T.), University Hospital Zurich, Switzerland; Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; Department of Oncology and Department of Biostatistics (Z.W.), Johns Hopkins University, Baltimore, MD; and Department of Emergency Medicine (J.A.E.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. toker@jhu.edu.
authors.forename: David E
authors.initials: DE
authors.lastname: Newman-Toker
mesh_terms: D002561:Cerebrovascular Disorders / Q000175:diagnosis*; D003951:Diagnostic Errors; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D016239:MEDLINE / Q000706:statistics & numerical data; D008297:Male; D059906:Neuroimaging