Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia.
Department of Neurology, Emory University School of Medicine, Atlanta, Georgia.
JAMA Neurol. 2019 Mar 1;76(3):326-332. doi: 10.1001/jamaneurol.2018.3989.
Diagnostic errors can lead to the initial misdiagnosis of optic nerve sheath meningiomas (ONSM), which can lead to vision loss.
To identify factors contributing to the initial misdiagnosis of ONSM.
DESIGN, SETTING, AND PARTICIPANTS: We retrospectively reviewed 35 of 39 patients with unilateral ONSM (89.7%) who were seen in the tertiary neuro-ophthalmology practice at Emory University School of Medicine between January 2002 and March 2017. The Diagnosis Error Evaluation and Research taxonomy tool was applied to cases with missed/delayed diagnoses.
Evaluation in a neuro-ophthalmology clinic.
Identifying the cause of diagnostic errors for patients who initially received a misdiagnosis who were found to have ONSM.
Of 35 patients with unilateral ONSM (30 women [85.7%]; mean [SD] age, 45.26 [15.73] years), 25 (71%) had a diagnosis delayed for a mean (SD) of 62.60 (89.26) months. The most common diagnostic error (19 of 25 [76%]) was clinician assessment failure (errors in hypothesis generation and weighing), followed by errors in diagnostic testing (15 of 25 [60%]). The most common initial misdiagnosis was optic neuritis (12 of 25 [48%]), followed by the failure to recognize optic neuropathy in patients with ocular disorders. Five patients who received a misdiagnosis (20%) underwent unnecessary lumbar puncture, 12 patients (48%) unnecessary laboratory tests, and 6 patients (24%) unnecessary steroid treatment. Among the 16 patients who initially received a misdiagnosis that was later correctly diagnosed at our institution, 11 (68.8%) had prior magnetic resonance imaging (MRI) results that were read as healthy; 5 (45.5%) showed ONSM but were misread by a non-neuroradiologist and 6 (54.5%) were performed incorrectly (no orbital sequence or contrast). Sixteen of the 25 patients (64%) had a poor visual outcome.
Biased preestablished diagnoses, inaccurate funduscopic examinations, a failure to order the correct test (MRI brain/orbits with contrast), and a failure to correctly interpret MRI results were the most common sources of diagnostic errors and delayed diagnosis with worse visual outcomes and increased cost (more visits and tests). Easier access to neuro-ophthalmologists, improved diagnostic strategies, and education regarding neuroimaging should help prevent diagnostic errors.
诊断错误可能导致视神经鞘脑膜瘤（ONSM）的初步误诊，从而导致视力丧失。
确定导致 ONSM 初步误诊的因素。
设计、设置和参与者：我们回顾性分析了 2002 年 1 月至 2017 年 3 月在埃默里大学医学院三级神经眼科诊所就诊的 39 例单侧 ONSM 患者中的 35 例（89.7%）。应用诊断错误评估和研究分类工具对漏诊/延迟诊断的病例进行分析。
在神经眼科诊所进行评估。
确定最初接受误诊的单侧 ONSM 患者（30 名女性[85.7%]；平均[标准差]年龄为 45.26[15.73]岁）出现诊断错误的原因。
35 例单侧 ONSM 患者（25 例[71%]诊断延迟）平均（标准差）为 62.60（89.26）个月。最常见的诊断错误（25 例中的 19 例[76%]）是临床医生评估失败（假设生成和权衡错误），其次是诊断测试错误（25 例中的 15 例[60%]）。最常见的初始误诊是视神经炎（25 例中的 12 例[48%]），其次是未能识别眼部疾病患者的视神经病变。5 名误诊患者（20%）接受了不必要的腰椎穿刺，12 名患者（48%）接受了不必要的实验室检查，6 名患者（24%）接受了不必要的类固醇治疗。在我们机构最初被误诊但后来正确诊断的 16 例患者中，11 例（68.8%）有先前的磁共振成像（MRI）结果显示正常；5 例（45.5%）显示 ONSM，但被非神经放射科医生误读，6 例（54.5%）MRI 检查不正确（无眼眶序列或对比）。25 例患者中有 16 例（64%）视力预后较差。
预先确定的诊断偏见、不准确的眼底检查、未能进行正确的检查（脑/眶对比增强 MRI）以及未能正确解读 MRI 结果是导致诊断错误和诊断延迟的最常见原因，且与较差的视力预后和增加的费用（更多的就诊和检查）有关。更容易获得神经眼科医生的帮助、改进诊断策略以及对神经影像学的教育应有助于预防诊断错误。
