Misdiagnosis and Delay of Diagnosis in Hemorrhagic Meningioma: A Case Series and Review of the Literature.

OBJECTIVE: To evaluate the clinicoradiologic characteristics of hemorrhagic meningiomas (HMs) that are missed or misdiagnosed on radiologic imaging studies. METHODS: Clinical and radiologic data from 6 patients with HM who were initially misdiagnosed were collected and recorded respectively. In addition, we performed a literature review for misdiagnosed HM and summarized the results. RESULTS: Five of the 6 patients with misdiagnosed HM were female, and 1 was male. Both computed tomography (CT) and magnetic resonance imaging were performed in 4 patients, and CT alone was performed in 2. On CT, the HM was heterogeneously hyperdense in 5 patients and isodense in 1 patient. In all 4 patients who underwent magnetic resonance imaging, the HM was mixed iso- and hypointense on T1-weighted imaging and heterogeneously hyperintense on T2-weighted imaging. Marked heterogeneous contrast enhancement was observed in 2 patients, strong rim enhancement in 1, and peripheral enhancement in 1. The dural tail sign was seen in only 1 patient. The initial radiologic misdiagnoses were subdural hematoma (n = 1), malignant glioma (n = 1), ruptured arterial aneurysm (n = 1), metastasis (n = 2), and uncertain (n = 1). In the literature review, 22 cases of HM diagnostic error were collected. The main misdiagnoses were subdural hematoma (27.3%), traumatic hematoma (13.6%), vascular anomaly (13.6%), malignant glioma (4.5%), and metastasis (4.5%). CONCLUSIONS: Our study showed that in patients with HM with inadequate imaging evaluation, a small tumor associated with massive hematoma and atypical imaging features was more likely to be misdiagnosed.

Covert cases of Severe Acute Respiratory Syndrome Coronavirus 2: An obscure but present danger in regions endemic for Dengue and Chikungunya viruses.

BACKGROUND: The impact of SARS-CoV-2 in regions endemic for both Dengue and Chikungunya is still not fully understood. Considering that symptoms/clinical features displayed during Dengue, Chikungunya and SARS-CoV-2 acute infections are similar, undiagnosed cases of SARS-CoV-2 in co-endemic areas may be more prevalent than expected. This study was conducted to assess the prevalence of covert cases of SARS-CoV-2 among samples from patients with clinical symptoms compatible with either Dengue or Chikungunya viral infection in the state of Espírito Santo, Brazil. METHODS: Presence of immunoglobulin G (IgG) antibody specific to SARS-CoV-2 nucleoprotein was detected using a chemiluminescent microparticle immunoassay in samples from 7,370 patients, without previous history of COVID-19 diagnosis, suspected of having either Dengue (n = 1,700) or Chikungunya (n = 7,349) from December 1st, 2019 to June 30th, 2020. FINDINGS: Covert cases of SARS-CoV-2 were detected in 210 (2.85%) out of the 7,370 serum samples tested. The earliest undiagnosed missed case of COVID-19 dated back to a sample collected on December 18, 2019, also positive for Dengue Virus. Cross-reactivity with either Dengue virus or other common coronaviruses were not observed. INTERPRETATION: Our findings demonstrate that concomitant Dengue or Chikungunya outbreaks may difficult the diagnosis of SARS-CoV-2 infections. To our knowledge, this is the first study to demonstrate, with a robust sample size (n = 7,370) and using highly specific and sensitive chemiluminescent microparticle immunoassay method, that covert SARS-CoV-2 infections are more frequent than previously expected in Dengue and Chikungunya hyperendemic regions. Moreover, our results suggest that SAR-CoV-2 cases were occurring prior to February, 2020, and that these undiagnosed missed cases may have contributed to the fast expansion of SARS-CoV-2 outbreak in Brazil. Data presented here demonstrate that in arboviral endemic regions, SARS-CoV-2 infection must be always considered, regardless of the existence of a previous positive diagnosis for Dengue or Chikungunya.

Mis-diagnosed giant ovarian cyst and ventriculoperitoneal shunt malfunction.

Abdominal pseudocysts are common complications of ventriculoperitoneal shunt (VPS). We report the case of a 37-year-old woman treated by VPS for congenital obstructive hydrocephalus, who presented shunt dysfunction related to a voluminous abdominal cyst initially diagnosed as cerebrospinal fluid pseudocyst. The cyst was drained and the VPS was removed after endoscopic third ventriculocisternostomy (ETV). A few months later, a large new abdominal cyst appeared and was operated on. Diagnosis was rectified as massive ovarian mucinous cystadenoma. In any intra-abdominal cyst, differential diagnoses need considering to avoid mis-diagnosis in shunted patients, especially if the cyst is very large. The etiology of the hydrocephalus should also be investigated in case of shunt dysfunction. Even in case of longstanding shunt, ETV can be an alternative to shunt revision surgery in obstructive hydrocephalus, enabling VPS withdrawal and treatment of the hydrocephalus.

Characteristics and Burden of Diagnostic Error-Related Malpractice Claims in Neurosurgery.

BACKGROUND: Neurosurgery is a specialty associated with high risk of malpractice claims, which can be influenced by quality and safety of care. Diagnostic errors have gained increasing attention as a potentially preventable problem. Despite the burden of diagnostic errors, few studies have analyzed diagnostic errors in neurosurgery. We aimed to delineate the effect of diagnostic errors on malpractice claims involving a neurosurgeon. METHODS: This retrospective study used the national Japanese malpractice claims database and included cases closed between 1961 and 2017. To examine the effect of diagnostic errors in neurosurgery, we compared diagnostic error-related claims (DERCs) with non-DERCs in indemnity, clinical outcomes, and factors relating to neurosurgeons. RESULTS: There were 95 closed malpractice claims involving neurosurgeons during the study period. Of these claims, 36 (37.9%, 95% confidence interval [CI] 28.7%-47.9%) were DERCs. Patient death was the most common outcome associated with DERCs. Wrong, delayed, and missed diagnosis occurred in 25 (69.4%, 95% CI 53.1%-82.0%), 4 (11.1%, 95% CI 4.4%-25.3%), and 7 (19.4%, 95% CI 9.8%-35.0%) cases, respectively. The most common presenting medical condition in DERCs was stroke. Subarachnoid hemorrhage, accounting for 85.7% of stroke cases, led to 27.8% of the total indemnity paid in DERCs. CONCLUSIONS: DERCs are associated with higher numbers of accepted claims and worse outcomes. Identifying diagnostic errors is important in neurosurgery, and countermeasures are required to reduce the burden on neurosurgeons and improve quality. This is the first study to focus on diagnostic errors in malpractice claims arising from neurosurgery.

A Century in Review: Medicolegal Implications of Facial Nerve Paralysis.

Importance: It is important to recognize factors that may mitigate the risk of a potential lawsuit and increase knowledge and awareness of physicians. Objective: To evaluate and characterize facial nerve paralysis litigation claims and related potential causes. Design, Setting, and Participants: These data were extracted from the two main computerized legal databases: WestLaw and LexisNexis. The data were queried on April 2, 2020. The records from 1919 to 2020 were obtained from a population-based setting. A total of 186 cases were included. Data were gathered for all alleged cases of facial nerve paralysis. Main Outcomes and Measures: There was a continuous rise in the amount of malpractice payments with the highest mean amount being in the past decade. Results: From 1919 to 2020, a total of 186 malpractice cases for facial nerve damage were identified. A total amount of $89,178,857.99 was rewarded to plaintiffs in 66 cases. The mean amount of paid malpractice claim was $1,351,194.80. Improper performance/treatment was the most common reason for alleged litigation (n = 97). This was followed by misdiagnosis/delayed diagnosis (n = 47), and failure of informed consent (n = 34). The highest number of malpractice claims with a total of 53 cases was from 1991 to 2000. The highest mean amount per payment was in the past decade (2011-2020) with a mean of $3,841,052.68. Conclusions and Relevance: Over the past century, improper performance/procedure, delayed/misdiagnosis, and failure of informed consent were the most common reasons for litigations related to facial nerve paralysis.

The role of the epilepsy monitoring unit in the investigation of patients with epilepsy and intellectual disabilities.

BACKGROUND: A significant proportion of the people with intellectual disabilities (ID) has epilepsy and lives in institutions. These patients tend to have atypical presentations of epileptic seizures with an increased risk of misdiagnoses. They often have drug-resistant epilepsy (DRE) requiring polypharmacy with increased risk of morbidity. The aim of this study was to determine the usefulness of Epilepsy Monitoring Unit (EMU) in the diagnosis and management of these patients. METHODS: This is a retrospective observational study of people with epilepsy and ID living in institutions that were admitted to the EMU at London Health Sciences Center (LHSC), from January 2014 to December 2016. RESULTS: Out of 1121 patients admitted to the EMU at the LHSC, 1.96% (N = 22) fulfilled the inclusion criteria for this study. The mean age was 34.5 years (interquartile range [IQR]: 28.8-53); 50%(N = 11) were female. Fourteen (63.6%) had generalized epilepsy. Six (27.3%) had a history of status epilepticus. The mean number of antiseizure medications (ASMs) in those patients was three (IQR: 2-4). Eight (36.4%) patients had severely impaired or no language skills and seven (31.8%) required wheelchair. Eleven (50%) had a mood disorder and seven (31.8%) of them were taking antipsychotic medications. The mean duration of admission duration was 6.6 days (IQR: 3.5-8.5). There was a clinical-electrographic correlation between the behavioral events and epileptic seizures in nineteen (86.4%) of the patients. CONCLUSIONS: Admission to the EMU provided an accurate characterization of transient events in people with ID and epilepsy with improvement in their medical management.

Missed hand and forearm injuries in multiple trauma patients: An analysis from the TraumaRegister DGU®.

PURPOSE: Multiple trauma patients have a high risk of missed injuries. The main point of our study was to provide new epidemiological data on hand and forearm injuries in multiple trauma with a focus on those that were missed. Therefore, we used the database of the TraumaRegister DGU®. METHODS: In this study, we evaluated anonymous data from 139931 patients aged 1-100 years with multiple trauma in the TraumaRegister DGU® of the German Society for Trauma Surgery from 2007 to 2017. Patients with hand and forearm injuries documented during hospital stay were identified and analyzed. We included fractures, dislocations, tendon injuries, nerve injuries and vessel injuries. Patients with missed hand and forearm injuries were compared with patients with primary diagnosed injuries in view of gender, age, ISS, Abbreviated Injury Score (AIS), Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), trauma mechanism type of injury, hospital stay, RISC II and mortality rate. Missed injuries were defined as injuries that were recently diagnosed and documented in the intensive care unit (ICU). RESULTS: A total of 50459 multiple trauma patients (36.1%) had hand or forearm injuries, and 89472 patients (63.9%) had neither. Patients with hand injuries were younger and were more often involved in car and motorcycle accidents. Severe head trauma was evaluated less frequently, and severe thorax trauma was evaluated more often in patients with hand injuries. The times of diagnosis of hand injuries were documented in 10971 cases. A total of 727 patients (6.6%) with missed hand injuries were registered. The most commonly missed injuries in multiple trauma were 104 carpal fractures/dislocations (11.2%), 195 nerve injuries (25.4%) and 54 tendon injuries (11.4%). Predisposing factors for missing injuries were multiple diagnoses, primary care in the first hospital and direct from emergency room transfer to the ICU. CONCLUSION: In contrast to previous findings, severely injured patients, especially those with head injuries and GCS of ≤8, were not predisposed to have missed hand injuries compared to patients without severe head trauma. Special attention should be paid to younger patients after traffic accidents with multiple diagnoses and direct transfer to the ICU.

Amyloidosis: diagnosis and new therapies for a misunderstood and misdiagnosed disease.

Amyloidosis is a group of diseases characterized by extracellular deposition of amyloid fibril complexes. Fibril deposition results in organ dysfunction and possible failure. Amyloidosis is regarded as a rare disease, but in general is underdiagnosed. The two main types of systemic amyloidosis are immunoglobulin light chain and transthyretin amyloidosis. The increased availability of noninvasive cardiac imaging, genetic testing and improved laboratory assays and protein identification methods have led to increased diagnosis. However, in many cases, the diagnosis is not made until the patient develops organ impairment. Earlier diagnosis is required to prevent irreversible organ failure. Novel treatments for immunoglobulin light chain and transthyretin amyloidosis that halt disease progression, prolong and increase quality of life have recently become available.

La clasificación de las vasculitis sistémicas: es momento de su renovación / Classification of systemic vasculitis: Time for an update

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Invalidation of Parkinson's disease diagnosis after years of follow-up based on clinical, radiological and neurophysiological examination.

INTRODUCTION: Diagnosis of Parkinson's disease (PD) is mainly based on clinical features. Accurate neurological examination is required but dopamine transporter (DaT) single photon emission computed tomography (SPECT) could be perfomed to support the diagnosis in ambiguous cases. The aim of this work is to describe the characteristics of patients with a prolonged PD misdiagnosis. METHODS: We collected data from 24 patients initially diagnosed with PD who had an atypical long-term evolution. We analyzed demographic and clinical characteristics and antiparkinsonian drugs medication. Brain MRI, DaT-SPECT and/or accelerometry/electromyography (EMG) recording were performed in a subgroup of patients. We analyzed the causes of erroneous PD diagnosis as well as the final diagnoses. RESULTS: Mean age at PD diagnosis was 60.4 ±â€¯14.8 years. Symptoms at onset were rest tremor (n = 19), gait instability (n = 7) and micrographia (n = 4). Mean duration before diagnosis correction was 8.4 ±â€¯5.3 years. All patients were treated by antiparkinsonian drugs with a mean daily levodopa equivalent dose (LED) of 508.1 ±â€¯528.4 mg. All 18 patients who underwent DaT-SPECT had a normal result. The most frequent final diagnoses were essential tremor (n = 11) and functional movement disorders (n = 9). CONCLUSION: Cases that have been initially diagnosed as PD and then progress in an atypical long-duration fashion may have been misdiagnosed. Absence of genuine bradykinesia, non-sustained response to antiparkinsonian drugs, or absence of levodopa-related side effects should prompt the clinician to reappraise the diagnosis and to consider performing a DaT-SPECT.

Misdiagnosis of high anion gap acidosis owing to instrument error of a device.

The anion gap (AG) is a tool to diagnose metabolic acid-base disorders in the physiological approach to acid-base assessment. It is used to detect high AG acidosis, a type of metabolic acidosis caused by serum concentration increase in usually unmeasured anions; AG larger than the reference for it indicates the presence of high AG acidosis. This report presents a case of hyperlactatemia which was not detected as high AG acidosis possibly because of instrument error of a device in measurement of serum sodium and chloride concentrations. The case indicates that the error will make AG unable to detect high AG acidosis of any cause. Hence, upon suspicion of high AG acidosis caused by measurable anions such as lactate and ketones, it is recommended to measure their serum concentration.

Misdiagnosis and pitfalls in Panayiotopoulos syndrome.

Panayiotopoulos syndrome (PS) is a frequent (6% among children of 1-15 years) and benign epileptic syndrome, characterized by predominantly autonomic symptoms (emesis, pallor, flushing, cyanosis, mydriasis/miosis, cardiorespiratory and thermoregulatory alterations, incontinence of urine and/or feces, hypersalivation, and modifications of intestinal motility) associated with simple motor focal seizures, which can be followed by secondary generalization. Panayiotopoulos syndrome can be extremely insidious, because it can mimic several condition, such as gastroenteritis, gastroesophageal reflux disease, encephalitis, syncope, migraine, sleep disorders, or even metabolic diseases. This peculiar pleiotropism should be kept in mind by child neurologists and pediatricians and general practitioners, because a wrong diagnosis may lead to inappropriate interventions. The consequences are high morbidity, costly mismanagement, and stress for children and their parents. The availability of electroencephalography (EEG) recording in pediatric Emergency Departments might be useful for a prompt and not-cost-consuming diagnosis. On the other hand, it is important to be aware of the possible, multifaceted, clinical presentations of PS and its clinical, radiological, and neurophysiological features in order to improve both recognition and management.

Possible Missed Acute Coronary Syndrome Rate in North Texas: Is There Room to Improve?

BACKGROUND: Acute coronary syndrome (ACS) is a common diagnosis in the emergency department (ED). Missing this diagnosis may lead to increased morbidity or mortality. With improved cardiac biomarkers tests, it is unknown if that has decreased the prevalence of ACS diagnoses in ED patients who were recently evaluated in the ED. METHODS: This is a retrospective review of ED patients who were diagnosed with ACS and seen in the ED 7 and 30 days before that visit in North Texas between 2009 and 2015. The demographics and temporal trends of missed ACS rates are described. Logistic regression was used to evaluate if any factors (ie, age, ethnicity, sex, insurance status) were significant. RESULTS: Between December 26, 2008 and June 29, 2015, there were 24,914 diagnoses of ACS in the ED. The overall prevalence of patients diagnosed with ACS 7 days after their ED visit was 3.2% and 8.8% at 30 days. For patients diagnosed with ACS 7 days and 30 days after an ED visit, the most common initial ED diagnoses were nonspecific chest pain (57.7%), atherosclerotic disease (19.5%), and heart failure (12.8%). Between 2009 and 2015, there was no overall change in the rate of ACS diagnoses in patients seen 7 or 30 days before an ED visit. CONCLUSIONS: The prevalence of missed ACS in the North Texas region at 7 and 30 days after the initial ED visit is low and has not changed over the past several years.

Quantification of inaccurate diagnosis of COPD in primary care medicine: an analysis of the COACH clinical audit.

Background: Inaccurate diagnosis in COPD is a current problem with relevant consequences in terms of inefficient health care, which has not been thoroughly studied in primary care medicine. The aim of the present study was to evaluate the degree of inaccurate diagnosis in Primary Care in Spain and study the determinants associated with it. Methods: The Community Assessment of COPD Health Care (COACH) study is a national, observational, randomized, non-interventional, national clinical audit aimed at evaluating clinical practice for patients with COPD in primary care medicine in Spain. For the present analysis, a correct diagnosis was evaluated based on previous exposure and airway obstruction with and without the presence of symptoms. The association of patient-level and center-level variables with inaccurate diagnosis was studied using multivariate multilevel binomial logistic regression models. Results: During the study 4,307 cases from 63 centers were audited. The rate of inaccurate diagnosis was 82.4% (inter-regional range from 76.8% to 90.2%). Patient-related interventions associated with inaccurate diagnosis were related to active smoking, lung function evaluation, and specific therapeutic interventions. Center-level variables related to the availability of certain complementary tests and different aspects of the resources available were also associated with an inaccurate diagnosis. Conclusions: The prevalence data for the inaccurate diagnosis of COPD in primary care medicine in Spain establishes a point of reference in the clinical management of COPD. The descriptors of the variables associated with this inaccurate diagnosis can be used to identify cases and centers in which inaccurate diagnosis is occurring considerably, thus allowing for improvement.

Misjudgment of pre-stroke functional status contradicts beneficial outcomes after endovascular therapy for large vessel occlusion.

Endovascular therapy (EVT) trials enrolled ischemic stroke patients with good pre-stroke functional status. However, this information needed for rapid decision-making is commonly lacking in clinical practice. We hypothesized that initial misjudgment of pre-stroke functional status attenuates clinical outcomes of EVT. Data were derived from our prospective registry of ischemic stroke patients undergoing EVT for anterior circulation large vessel occlusion (01/2016-12/2017). Considering all information accumulated during hospital course, pre-stroke modified Rankin scale (mRS) was independently re-assessed and compared with pre-EVT assessments. Misjudgment was defined as any difference in mRS categories between first- and second-look assessments. Multivariable model was built to adjust for confounding variables of unfavorable outcome (mRS 3-6) and death at 90 days. Overall, we studied 217 patients: median age 75 years (IQR 64-81), 54% women, median NIHSS 17 (12-20) points. Second-look assessment of pre-stroke mRS revealed 73 (34%) cases initially being misjudged by ≥ 1 category and 17 (8%) by ≥ 2 categories. None of the second-look mRS assessments resulted in a lower mRS category than initially rated. Patients whose pre-stroke mRS score was misjudged prior to EVT showed more frequently unfavorable outcome (62/73 [84.9%] vs. 94/144 [65.3%], p = 0.002) or were deceased (30/73 [41.1%] vs. 25/144 [17.4%], p < 0.001) at 90 days than patients with consistent mRS assessments. Moreover, unfavorable outcomes occurred in nearly all patients whose initial mRS was misjudged by ≥ 2 categories (mRS 3-6: 17/17 [100%]; death: 14/17 [82.4%]; p < 0.001). In conclusion, thorough pre-EVT assessment of pre-stroke functional status appears decisive for proper selection of EVT candidates.

The misdiagnosis of functional disorders as other neurological conditions.

BACKGROUND: Several studies have shown that when patients with functional neurological disorders are followed up, it is rare to find another neurological condition that better explains the initial symptoms in hindsight. No study has examined the reverse, studying patients with a range of neurological disease diagnoses with the aim of assessing how often a new diagnosis of functional disorder better explains the original symptoms. METHODS: A prospective multi-centre cohort study of 2637 new neurology outpatient referrals from primary care in Scotland. Neurologists provided initial diagnoses and a rating of the extent to which their symptoms were explained by an 'organic' neurological disease. Patients were followed up 19 months later with a questionnaire to their primary care physician asking about diagnostic change, and when indicated also by discussion with the original assessing neurologist and review of secondary care records. RESULTS: Valid responses were obtained for 2378 out of 2637 patients (90%) with symptoms 'largely' or 'completely' explained by organic disease at baseline. At follow-up, we found diagnostic errors in 48 patients. Of those, ten (0.4%) had a functional diagnosis and 38 patients (1.6%) had a different 'organic' diagnosis which better explained the original symptoms. CONCLUSIONS: Patients diagnosed with neurological disease sometimes have a functional diagnosis at follow-up which, with hindsight, better explains the original symptoms. This occurs at a frequency similar to the misdiagnosis of 'organic' neurological disease as functional disorder. Misdiagnosis can harm patients in either direction, especially as we enter an era of evidence-based treatment for functional neurological disorders.

Missed foot fractures in multiple trauma patients.

BACKGROUND: Missed or underestimated injuries are one of the central problems in trauma care. Foot injuries can easily be missed because they lay beyond the regularly screened field of a trauma computer tomography scan (CT scan). During primary and secondary survey a careful examination of the extremities often becomes of secondary interest in the severely injured patient. METHODS: Thirty-four thousand ninety-one multiple trauma patients of the TraumaRegister DGU® were evaluated from 2002 to 2014. We differentiated between patients with foot injuries, patients with missed foot injuries and patients without foot injuries. Included were ankle fractures, calcaneus fractures, talus fractures, metatarsal fractures, toe fractures, amputation, soft tissue injuries and/or ligamentous injuries. RESULTS: Summarized evaluation of 34,091 trauma patients showed a share of 2532 patients with foot injuries. Time of diagnosis was documented in 2199 cases. 2055 patients had early diagnosed foot injuries and 144 patients had initially missed foot injuries. Missed foot injuries were especially found in patients with car accidents or fall from ≥3 m. Patients with higher Abbreviated Injury Scale (AIS) or lower Glasgow Coma Scale (GCS) were not significantly more affected by missed foot injuries. Missing foot injuries was also not caused by injury severity or higher age. CONCLUSIONS: Our data highlights the need of careful evaluation of the feet during primary and secondary survey particularly when a tibia or femur fracture is diagnosed. Special attention should be turned to patients after car accidents or fall from great height. Suicide victims also need major attention. Patients with early operations also need careful examination and tertiary survey is highly recommended.

The Value of Autopsy in Neonates in the 21st Century.

BACKGROUND: Autopsy rates in neonatal intensive care unit (NICU) patients who died are declining worldwide. Postmortem magnetic resonance imaging (MRI) is suggested as adjunct to or substitute for autopsy. OBJECTIVE: The aim of this paper was to determine the additional diagnostic value of autopsy in NICU patients and whether autopsy findings were potentially detectable using postmortem MRI. METHODS: From 2008 to 2015, 298 infants died during admission to our NICU. Permission for unrestricted, nonforensic autopsy was obtained in 100 (33.6%) of these 298 infants. Retrospectively, autopsy reports and medical records of NICU patients were compared. Additional autopsy findings were graded according to the Goldman system, grading the clinical relevance of additional findings. In addition, the potential detectability of these additional findings on postmortem MRI was assessed. RESULTS: Additional findings obtained by autopsy were found in 48% of the cases, divided into major (Goldman I/II, 24%) and minor (Goldman III/IV, 24%) additional findings. Major additional findings were significantly more often found in patients with a lower gestational age, and minor additional findings in patients with a higher postnatal age at death. Of all patients with additional findings determined by autopsy, 56.3% would most likely not have been detected using postmortem MRI. CONCLUSIONS: Our results emphasize the still very important role of autopsy in the NICU setting and show that conventional autopsy could probably not be completely substituted by postmortem MRI.

Systematic literature review on the delays in the diagnosis and misdiagnosis of cluster headache.

INTRODUCTION: Patients with cluster headache (CH), the most common trigeminal autonomic cephalalgia, often face delayed diagnosis, misdiagnosis and mismanagement. OBJECTIVES: To identify, appraise and synthesise clinical studies on the delays in diagnosis and misdiagnosis of CH in order to determine its causes and help the management of this condition. METHODS: The systematic review was prepared, conducted and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis. It was registered with International Prospective Register of Systematic Reviews. A systematic search of different electronic databases (Medline, EMBASE, PsycINFO, PubMed, CINAHL, BNI, HMIC, AMED, HBE and Cochrane Library) was carried out in May 2017. Reference lists of relevant articles were hand searched. RESULTS: The search identified 201 unique studies. Fifteen studies met the inclusion criteria of which 13 case series studies and two survey studies. Nine studies assessed the delays in diagnosis and misdiagnosis of CH, five studies the delays in diagnosis and one study the misdiagnosis of CH. The studies included 4661 patients. Delays in diagnosis, misdiagnosis and mismanagement have been reported in many European countries, Japan and in the USA with well-developed health services. The patients with CH often visited many different clinicians, surgeons and dentists and received multiple diagnosis prior to being correctly diagnosed. CONCLUSION: This systematic review shows that the delays in the diagnosis of CH are a widespread problem, the time to diagnosis still vary from country to country and both patients and physicians are responsible for the delays in diagnosis.