Diagnostic Error in Stroke—Reasons and Proposed Solutions
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Purpose of Review
We discuss the frequency of stroke misdiagnosis and identify subgroups of stroke at high risk for specific diagnostic errors. In addition, we review common reasons for misdiagnosis and propose solutions to decrease error.
According to a recent report by the National Academy of Medicine, most people in the USA are likely to experience a diagnostic error during their lifetimes. Nearly half of such errors result in serious disability and death. Stroke misdiagnosis is a major health care concern, with initial misdiagnosis estimated to occur in 9% of all stroke patients in the emergency setting. Under- or missed diagnosis (false negative) of stroke can result in adverse patient outcomes due to the preclusion of acute treatments and failure to initiate secondary prevention strategies. On the other hand, the overdiagnosis of stroke can result in inappropriate treatment, delayed identification of actual underlying disease, and increased health care costs. Young patients, women, minorities, and patients presenting with non-specific, transient, or posterior circulation stroke symptoms are at increased risk of misdiagnosis. Strategies to decrease diagnostic error in stroke have largely focused on early stroke detection via bedside examination strategies and a clinical decision rules. Targeted interventions to improve the diagnostic accuracy of stroke diagnosis among high-risk groups as well as symptom-specific clinical decision supports are needed.
There are a number of open questions in the study of stroke misdiagnosis. To improve patient outcomes, existing strategies to improve stroke diagnostic accuracy should be more broadly adopted and novel interventions devised and tested to reduce diagnostic errors.
KeywordsDiagnostic error Stroke misdiagnosis Stroke mimics Stroke chameleons Patient safety
Compliance with Ethical Standards
Conflict of Interest
Ekaterina Bakradze and Ava L. Liberman declare no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 2.•• Medicine I.o., E. National Academies of Sciences, and Medicine, Improving diagnosis in health care, ed. E.P. Balogh, B.T. Miller, and J.R. Ball. 2015, Washington, DC: The National Academies Press. 472. Detailed report regarding what is known about diagnostic error in medicine, methods to improve diagnostic safety in healthcare and suggested new research directions. Google Scholar
- 4.Saber Tehrani AS, et al., 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank. BMJ Qual Saf, 2013. 22(8): p. 672 80.Google Scholar
- 5.Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870–947. https://doi.org/10.1161/STR.0b013e318284056a.PubMedCrossRefGoogle Scholar
- 6.Kuruvilla A, Bhattacharya P, Rajamani K, Chaturvedi S. Factors associated with misdiagnosis of acute stroke in young adults. J Stroke Cerebrovasc Dis. 2011;20(6):523–7. https://doi.org/10.1016/j.jstrokecerebrovasdis.2010.03.005.PubMedCrossRefGoogle Scholar
- 8.• Richoz B, et al. Acute stroke chameleons in a university hospital: Risk factors, circumstances, and outcomes. Neurology. 2015;85(6):505–11. Author reported 2.1% (47 out of 2200) missed ischemic stroke rate using prospective stroke registry. Stroke chameleons presented with milder stroke and fewer focal stroke signs compared to accurately diagnosed stroke patients. Cerebellar strokes had higher disability and mortality rates at 12 months. PubMedCrossRefGoogle Scholar
- 12.• Tsivgoulis G, et al. Safety of intravenous thrombolysis in stroke mimics: prospective 5-year study and comprehensive meta-analysis. Stroke. 2015;46(5):1281–7. Meta-analysis of nine studies showing rates of symptomatic intracerebral hemorrhage of 0.5% among 392 stroke mimics treated with intravenous thrombolytic, significantly lower risk than in patients with acute ischemic stroke (risk ratio = 0.33; 95% confidence interval 0.14–0.77; P = 0.010). PubMedCrossRefGoogle Scholar
- 15.•• Newman-Toker DE, et al. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis (Berl). 2014;1(2):155–66. Author reported 12.7% of potential missed stroke diagnoses and 1.2% of probable missed diagnoses using a multistate administrative data collection. Google Scholar
- 16.•• Madsen TE, et al. potentially missed diagnosis of ischemic stroke in the emergency department in the Greater Cincinnati/Northern Kentucky Stroke Study. Acad Emerg Med. 2016;23(10):1128–35. A large retrospective population-based study of stroke patients with reported 14% patients initially missed in the ED. PubMedPubMedCentralCrossRefGoogle Scholar
- 17.Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Arch Neurol. 1995;52(11):1119–22. https://doi.org/10.1001/archneur.1995.00540350113023.PubMedCrossRefGoogle Scholar
- 20.Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, et al. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47(2):581–641. https://doi.org/10.1161/STR.0000000000000086.PubMedCrossRefGoogle Scholar
- 21.Henriksen K, et al. Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review. Diagnosis, 2017. [Epub ahead of print].Google Scholar
- 22.Shojania, K.G., et al., The autopsy as an outcome and performance measure. Evid Rep Technol Assess (Summ), 2002(58): p. 1–5.Google Scholar
- 32.Lever NM, Nyström KV, Schindler JL, Halliday J, Wira C III, Funk M. Missed opportunities for recognition of ischemic stroke in the emergency department. J Emerg Nurs. 2013;39(5):434–9. https://doi.org/10.1016/j.jen.2012.02.011.
- 33.Arch AE, Weisman DC, Coca S, Nystrom KV, Wira CR III, Schindler JL. Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke. 2016;47(3):668–73. https://doi.org/10.1161/STROKEAHA.115.010613.
- 37.Kerber KA, Morgenstern LB, Meurer WJ, McLaughlin T, Hall PA, Forman J, et al. Nystagmus assessments documented by emergency physicians in acute dizziness presentations: a target for decision support? Acad Emerg Med. 2011;18(6):619–26. https://doi.org/10.1111/j.1553-2712.2011.01093.x.PubMedPubMedCentralCrossRefGoogle Scholar
- 38.Morgenstern LB, Lisabeth LD, Mecozzi AC, Smith MA, Longwell PJ, McFarling DA, et al. A population-based study of acute stroke and TIA diagnosis. Neurology. 2004;62(6):895–900. https://doi.org/10.1212/01.WNL.0000115103.49326.5E.PubMedCrossRefGoogle Scholar
- 39.Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke. 2006;37(10):2484–7. https://doi.org/10.1161/01.STR.0000240329.48263.0d.PubMedPubMedCentralCrossRefGoogle Scholar
- 42.Beam CA, Layde PM, Sullivan DC. Variability in the interpretation of screening mammograms by US radiologists. Findings from a national sample. Arch Intern Med. 1996;156(2):209–13. https://doi.org/10.1001/archinte.1996.00440020119016.PubMedCrossRefGoogle Scholar
- 44.Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504–10. https://doi.org/10.1161/STROKEAHA.109.551234.PubMedPubMedCentralCrossRefGoogle Scholar
- 45.Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006;145(7):488–96. https://doi.org/10.7326/0003-4819-145-7-200610030-00006.PubMedCrossRefGoogle Scholar
- 46.Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49(2):196–205. https://doi.org/10.1016/j.annemergmed.2006.06.035.PubMedCrossRefGoogle Scholar
- 47.Troxel DB, Doctor’s company Diagnostic error in medical practice by specialty 2014. accessed September, 1 2017 2017.Google Scholar
- 48.Vermeulen MJ, Schull MJ. Missed diagnosis of subarachnoid hemorrhage in the emergency department. Stroke. 2007;38(4):1216–21. https://doi.org/10.1161/01.STR.0000259661.05525.9a.PubMedCrossRefGoogle Scholar
- 52.Murphy DR, Wu L, Thomas EJ, Forjuoh SN, Meyer AND, Singh H. Electronic trigger-based intervention to reduce delays in diagnostic evaluation for cancer: a cluster randomized controlled trial. J Clin Oncol. 2015;33(31):3560–7. https://doi.org/10.1200/JCO.2015.61.1301.PubMedPubMedCentralCrossRefGoogle Scholar
- 59.•• Tarnutzer, A.A., et al., ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. Neurology, 2017. 88(15): p. 1468–1477. Recent meta-analysis of 23 studies including 15,721 patients eventually diagnosed with ischemic stroke, subarachnoid hemorrhage, and transient ischemic attack, with 8.7% of overall reported rate of stroke misdiagnosis. Google Scholar
- 60.Dupre CM, Libman R, Dupre SI, Katz JM, Rybinnik I, Kwiatkowski T. Stroke chameleons. J Stroke Cerebrovasc Dis. 2014;23(2):374–8. https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.07.015.PubMedCrossRefGoogle Scholar
- 61.Merino JG, Luby M, Benson RT, Davis LA, Hsia AW, Latour LL, et al. Predictors of acute stroke mimics in 8187 patients referred to a stroke service. J Stroke Cerebrovasc Dis. 2013;22(8):e397–403. https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.04.018.PubMedCrossRefGoogle Scholar
- 62.El Husseini N, Goldstein LB. “Code stroke”: hospitalized versus emergency department patients. J Stroke Cerebrovasc Dis. 2013;22(4):345–8. https://doi.org/10.1016/j.jstrokecerebrovasdis.2011.09.012.PubMedCrossRefGoogle Scholar
- 65.Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369(9558):293–8. https://doi.org/10.1016/S0140-6736(07)60151-2.PubMedPubMedCentralCrossRefGoogle Scholar
- 66.Hemphill, J.C., 3rd, M. Farrant, and T.A. Neill, Jr., Prospective validation of the ICH Score for 12-month functional outcome. Neurology, 2009. 73(14): p. 1088–1094, DOI: https://doi.org/10.1212/WNL.0b013e3181b8b332.
- 68.Easton, J.D., et al., Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke, 2009. 40(6): p. 2276-93.Google Scholar
- 73.Rose KM, Rosamond WD, Huston SL, Murphy CV, Tegeler CH. Predictors of time from hospital arrival to initial brain-imaging among suspected stroke patients: the North Carolina Collaborative Stroke Registry. Stroke. 2008;39(12):3262–7. https://doi.org/10.1161/STROKEAHA.108.524686.PubMedCrossRefGoogle Scholar
- 74.Centers for Disease, C. and Prevention, Prehospital and hospital delays after stroke onset—United States, 2005–2006. MMWR Morb Mortal Wkly Rep, 2007 56(19): p. 474–478.Google Scholar
- 78.Savitz SI, Caplan LR, Edlow JA. Pitfalls in the diagnosis of cerebellar infarction. Acad Emerg Med. 2007;14(1):63–8. https://doi.org/10.1111/j.1553-2712.2007.tb00373.x.PubMedCrossRefGoogle Scholar
- 79.Brown DL, Lisabeth LD, Garcia NM, Smith MA, Morgenstern LB. Emergency department evaluation of ischemic stroke and TIA: the BASIC Project. Neurology. 2004;63(12):2250–4. https://doi.org/10.1212/01.WNL.0000147292.64051.9B.PubMedCrossRefGoogle Scholar
- 80.Rostanski SK, Stillman J, Williams O, Marshall RS, Yaghi S, Willey JZ. The influence of language discordance between patient and physician on time-to-thrombolysis in acute ischemic stroke. Neurohospitalist. 2016;6(3):107–10. https://doi.org/10.1177/1941874416637405.PubMedPubMedCentralCrossRefGoogle Scholar
- 82.Cruz-Flores S, Rabinstein A, Biller J, Elkind MS, Griffith P, Gorelick PB, et al. Racial-ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(7):2091–116. https://doi.org/10.1161/STR.0b013e3182213e24.PubMedCrossRefGoogle Scholar
- 85.Newman-Toker DE, Hsieh YH, Camargo CA Jr, Pelletier AJ, Butchy GT, Edlow JA. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008;83(7):765–75. https://doi.org/10.4065/83.7.765.PubMedPubMedCentralCrossRefGoogle Scholar
- 88.• Brandler ES, et al. Prehospital stroke identification: factors associated with diagnostic accuracy. J Stroke Cerebrovasc Dis. 2015;24(9):2161–6. Retrospective pre-hospital analysis of stroke diagnosis by EMS showed that seizure was among common symptom associated with both stroke mimics and stroke chameleons. PubMedCrossRefGoogle Scholar
- 94.Khatri P, Kleindorfer DO, Yeatts SD, Saver JL, Levine SR, Lyden PD, et al. Strokes with minor symptoms: an exploratory analysis of the National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator trials. Stroke. 2010;41(11):2581–6. https://doi.org/10.1161/STROKEAHA.110.593632.PubMedPubMedCentralCrossRefGoogle Scholar
- 101.• Shamy MC, et al. How patient Demographics, imaging, and beliefs influence tissue-type plasminogen activator use: a survey of North American neurologists. Stroke. 2016;47(8):2051–7. Online survey of neurologists using a clinical vignette, demonstrated how physicians’ willingness to treat with thrombolytic increased with additional clinical data suggestive of acute stroke. PubMedCrossRefGoogle Scholar
- 104.Singh H, Graber ML, Hofer TP. Measures to improve diagnostic safety in clinical practice. J Patient Saf. 2016:1. https://doi.org/10.1097/PTS.0000000000000338.
- 106.• Goyal MS, et al. Streamlined hyperacute magnetic resonance imaging protocol identifies tissue-type plasminogen activator-eligible stroke patients when clinical impression is stroke mimic. Stroke. 2016;47(4):1012–7. Single-center report of the implementation of a hyperacute MRI protocol for patients within a treatment window, who were not initially thought to warrant thrombolytic treatment for neurological deficits. Seven patients, who would not have received acute thrombolytic treatments prior to the adoption of hyperacute MRI, did receive thrombolysis. PubMedPubMedCentralCrossRefGoogle Scholar
- 109.Newman-Toker DE, Camargo CA Jr, Hsieh YH, Pelletier AJ, Edlow JA. Disconnect between charted vestibular diagnoses and emergency department management decisions: a cross-sectional analysis from a nationally representative sample. Acad Emerg Med. 2009;16(10):970–7. https://doi.org/10.1111/j.1553-2712.2009.00523.x.
- 110.•• Goyal N, et al. FABS: an intuitive tool for screening of stroke mimics in the emergency department. Stroke. 2016;47(9):2216–20. A scoring system to help distinguish stroke mimic from true strokes. A FABS score of > 3 has shown to have 90% sensitivity and 91% specificity to identify stroke mimics with absence of facial droop being the most sensitive component. PubMedCrossRefGoogle Scholar
- 111.• Ali SF, et al. The TeleStroke mimic (TM)-score: a prediction rule for identifying stroke mimics evaluated in a Telestroke Network. J Am Heart Assoc. 2014;3(3):e000838. A predictor rule to prospectively identify stroke mimics during telestroke evaluation of possible ischemic stroke. A score of ≤ 5 strongly raises suspicion for a mimic and a score of ≥ 20 strongly supports the diagnosis of stroke. PubMedPubMedCentralCrossRefGoogle Scholar
- 122.AHRQ Research Summit on Improving Diagnosis in Health Care. Content last reviewed August 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety.html.