Reasons behind missed or misjudged TBI diagnosis
by: Drs. Olli Tenovuo and Anu Makinen; Department of Neurolgy University of Turku, Finland
Objectives: Earlier studies and clinical experience indicate that a significant portion of acute TBIs remain undiagnosed. The purpose of this study was to clarify factors that have led to a missed or misjudged (in regard to severity) diagnosis of acute TBI.
Method: From a database of 1041 TBI patients, treated at a neurological outpatient university clinic during the years 1993-2005, we selected those in whom a diagnosis of TBI was either totally missed or where the TBI severity was gravely underestimated during the first contact with a treating physician. We excluded patients < 15 or > 80 years of age, with a chronic subdural haematoma, with an injury before 1990, with a minimal TBI or with unavailable documents concerning the first attendance. All possible injury-, patient-, physician- or system- related factors leading to a misjudgement were recorded.
Results: After exclusion, the database included 777 TBI patients. In 171 of these (22%) the diagnosis of TBI was either missed (74%) or severely misjudged (26%). Of these, 121 patients were selected at random and their documents analysed in detail. A factor confounding the TBI diagnosis was present in 74% of patients. The most common causes were a multi-trauma (in 42% of victims), painfulness (40%), centrally acting drugs given in emergency ward (40%) and surgical procedures (24%). Several confounding factors were found in 46% of patients. An indication for acute head CT (according to a national guideline) was fulfilled in 96% of patients, yet it was done in only 43% of patients. Of these CT scans, 27% were interpreted erroneously, with the trauma signs remaining unnoticed. In 27% of patients, there were no notes of external head injuries and in 17% no notes of the neurological state. The presence of amnesia had been recorded in only seven of these 121 patients. The delay to TBI diagnosis was more than 1 year in nearly half of these patients.
Conclusions: There are multiple reasons for missed or misjudged diagnosis of an acute TBI, the most common being the presence of confounding factors, making the diagnosis difficult and the inadequate recording of TBI signs. The guidelines for TBI diagnostics do not realize in practice. The assessment of acute TBI may face several caveats and should be concentrated to specialized units.
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