Evidence map›Paper›PMID 28356464›Full record

SynthesisNeurology2017

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

Alexander Andrea Tarnutzer, Seung-Han Lee, Karen A Robinson, Zheyu Wang, Jonathan A Edlow, David E Newman-Toker

3 registry-linked trialsOpen access · bronzeAbstract readMeta-AnalysisReview
PubMed Full text at PMC Publisher
In one paragraph

Synthesis in Neurology, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to 3 registered trials, which are not on this map. Cited by 124 papers, 7 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
124citing papers in PubMed, 7 pooled it
18.9field-weighted citation impact, top 1% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

NCT03672890 completednot on this mapstarted 2018, after this paper: background citation

Telestroke for Comprehensive Stroke Care in Acute Stroke Ready Hospitals

Typeobservational_patient_registrySponsorUniversity of MinnesotaRan2018 to 2020Enrolled551ConditionsStrokeArmsTelestroke
NCT03724110 completednot on this mapstarted 2018, after this paper: background citation

Telestroke for Comprehensive Transient Ischemic Attack Care in Acute Stroke Ready Hospitals

Typeobservational_patient_registrySponsorUniversity of MinnesotaRan2018 to 2022Enrolled300ConditionsTransient Ischemic AttackArmsTelestroke
NCT04761874 nacompletednot on this mapstarted 2019, after this paper: background citation

TELEstroke to CAre for STroke Patients at a Comprehensive Stroke Center During the COVID-19 Pandemic

TypeinterventionalSponsorUniversity of MinnesotaRan2019 to 2020Enrolled296ConditionsStroke, AcuteArmsTelestroke
3 · Its place in the literature

Who cites it

124 citing papers in PubMed, 7 syntheses or guidelines pooled it, 263 citations in OpenAlex.

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  12. [The SCD diagnostic strategy, procedure and pathway for episodic vestibular syndrome].Lin chuang er bi yan hou tou jing wai ke za zhi = Journal of clinical otorhinolaryngology head and neck surgery · 2026
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64 more citing papers are in PubMed but not listed here.

4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

6 authors at 3 institutions in 3 countries.

Alexander Andrea TarnutzerFrom 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.
Seung-Han LeeFrom 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.
Karen A RobinsonFrom 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.
Zheyu WangFrom 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.
Jonathan A EdlowFrom 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.
David E Newman-TokerFrom 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.
University Hospital of Zurich · CHJohns Hopkins University · USChonnam National University · KR

Funding

Research Supplement to Promote Diversity in Health-Related Research U01DC013778-01A1U01DC013778 · NIDCD · JOHNS HOPKINS UNIVERSITY · PI NEWMAN-TOKER, DAVID · 2014 to 2018
$5.4M
Building a New Model for Diagnosis of ED Dizzy PatientsK23RR017324 · NCRR · JOHNS HOPKINS UNIVERSITY · PI NEWMAN-TOKER, DAVID E · 2003 to 2007
$656k
NCRR NIH HHS K23 RR017324NIDCD NIH HHS U01 DC013778
6 · The paper itself

Abstract

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

methodsMEDLINE 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.

resultsIncluded 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.

conclusionsRoughly 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.

Indexed as

Diagnostic ErrorsNeuroimagingCerebrovascular DisordersEmergency Service, HospitalFemaleHumansMaleMEDLINE

Identifiers

PMID28356464
PMCPMC5386439
OpenAlexW2597539190

What OpenQuestion holds

Textmetadata
Read underepoch 390

Registered trials

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.