Missed Diagnosis of Subarachnoid Hemorrhage in the Emergency Department

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
Stroke (Impact Factor: 5.72). 05/2007; 38(4):1216-21. DOI: 10.1161/01.STR.0000259661.05525.9a
Source: PubMed


Subarachnoid hemorrhage (SAH) can be devastating, yet its initial presentation may be limited to common symptoms and subtle signs, potentially leading to misdiagnosis. Little is known about population rates of misdiagnosis of SAH, or hospital factors that may contribute to it. We estimated the population-based rate of missed SAH among emergency department (ED) patients and examined its relationship with hospital characteristics.
We studied persons admitted with a nontraumatic SAH to all Ontario hospitals over 3 years (April 2002 to March 2005). SAH was defined as missed if the patient had an ED visit related to the SAH (based on a prespecified definition) in the 14 days before admission. We examined the association between hospital teaching status and missed SAH and explored whether annual ED volume of SAH or CT availability explained this association.
Of 1507 patients diagnosed with SAH, 5.4% (95% CI, 4.3 to 6.6) had a missed diagnosis. The risk was significantly higher among patients triaged as low acuity (odds ratio 2.65; 95% CI, 1.46 to 4.80), as well as in nonteaching hospitals (adjusted odds ratio 2.12; 95% CI, 1.02, 4.44). Neither ED SAH volume nor on-site CT availability explained the effect of teaching status.
About 1 in 20 SAH patients are missed during an ED visit. Lower acuity patients are at higher risk of misdiagnosis, suggesting the need for heightened suspicion among patients with minimal clinical findings. The risk is also greater in nonteaching hospitals, but this is not explained by the annual volume of SAHs seen in the ED or access to CT.

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    • "SH most commonly occurs within two weeks of spontaneous SAH. SH may be due to minor bleeding, distension or dissection of the aneurysm wall.[2315] "
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    ABSTRACT: Background: Sentinel headache (SH) is a kind of secondary headache and is characterized as sudden, intense, and persistent, preceding spontaneous subarachnoid hemorrhage (SAH) by days or weeks. Methods: Eighty-nine consecutive patients with a diagnosis of spontaneous SAH were evaluated following admission to the Neurosurgical Service at Santa Casa Hospital, Belo Horizonte, between December 2009 and December 2010. Results: Out of the 89 patients, 64 (71.9%) were women. Mean age was 48.9 years (SD ± 13.4, ranging from 18 to 85 years). Twenty-four patients (27.0%) presented SH, which occurred, in average, 10.6 days (SD ± 13.5) before a SAH. No statistically significant differences were observed between the presence of SH and gender, arterial hypertension and migraine (P > 0.05), Glasgow Comma Scale (GCS) and World Federation of Neurological Surgeons (WFNS) scale at admission. Conclusion: The prevalence of SH was 27% in this study but no related factors were identified. Therefore, further clarification of this important entity is required so as to facilitate its recognition in emergency services and improve the prognosis of patients with cerebral aneurysms.
    Surgical Neurology International 12/2012; 3:162. DOI:10.4103/2152-7806.105101 · 1.18 Impact Factor
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    • "Much of the literature about misdiagnosis of headache focuses on subarachnoid hemorrhage (SAH) [11] [12] [13]. While older literature showed a misdiagnosis rate from 12–25%, the latest data based on misdiagnosis restricted to the ED puts that figure at 5% [13]. "
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    ABSTRACT: Approximately 5% of patients presenting to emergency departments have neurological symptoms. The most common symptoms or diagnoses include headache, dizziness, back pain, weakness, and seizure disorder. Little is known about the actual misdiagnosis of these patients, which can have disastrous consequences for both the patients and the physicians. This paper reviews the existing literature about the misdiagnosis of neurological emergencies and analyzes the reason behind the misdiagnosis by specific presenting complaint. Our goal is to help emergency physicians and other providers reduce diagnostic error, understand how these errors are made, and improve patient care.
    07/2012; 2012(7):949275. DOI:10.1155/2012/949275
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