Tarnutzer Alexander Andrea, Lee Seung-Han, Robinson Karen A, Wang Zheyu, Edlow Jonathan A, Newman-Toker David E
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.
Neurology. 2017 Apr 11;88(15):1468-1477. doi: 10.1212/WNL.0000000000003814. Epub 2017 Mar 29.
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.
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.
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.
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.
鉴于急诊科（ED）是诊断错误的高风险场所，我们试图评估急诊科对急性脑血管事件的诊断准确性。
检索MEDLINE和Embase数据库中关于急诊科对缺血性卒中、短暂性脑缺血发作（TIA）或蛛网膜下腔出血（SAH）诊断准确性的研究（1995 - 2016年）。两名独立评审员确定纳入标准。我们识别出1693条独特的文献引用，审查了214篇全文，并分析了23项研究。对研究进行偏倚风险评估（QUADAS - 2）。提取诊断数据。我们前瞻性地定义了临床表现亚组以比较误诊几率。
纳入研究共涉及15721例患者。研究的偏倚风险较低。脑血管病因的总体敏感性（91.3% [95%置信区间（CI）90.7 - 92.0]）和特异性（92.7% [91.7 - 93.7]）较高，但根据临床表现存在显著差异。在症状较轻（精神状态正常与异常的SAH；假阴性率23.8%对4.2%，比值比[OR] 7.03 [4.80 - 10.31]）、非特异性（头晕与运动体征；假阴性率39.4%对4.4%，OR 14.22 [9.76 - 20.
