LAUSR

In Response: We thank Dr Chen for his interest in our recent study, "Misdiagnosis Worsens Prognosis in Subarachnoid Hemorrhage With Good Hunt and Hess Score." We agree that the relationship between SAH misdiagnosis and outcome found in our cohort and previous studies points out the importance of improving the diagnostic strategy for this severe vascular disease. We admit that the incidence of misdiagnosis could be underestimated since some misdiagnosed patients might have died before receiving any medical assistance and, therefore, would not have been included in our study. Nonetheless, this bias can be found in all previous studies reporting variable difference of misdiagnosis. Regarding the possibility of recent changes in incidence because of differences in diagnostic standards and treatment regimens, we did not see this in our cohort. Comparing the period 2017 to 2012 with 2011 to 2007, for example, the incidence of SAH misdiagnosis in our setting is very similar (28% versus 24%, P=0.254). We agree with the idea of the incidence of SAH misdiagnosis being mostly affected by differences in health systems and the diagnostic strategies of each center. However, we do not think that the multidisciplinary collaboration to which Dr Chen refers is a factor in our results. Our study was conducted in a public health system (Catalonia), where the 5 tertiary stroke centers are coordinated to provide SAH patients with full 24-hour attention by experienced multidisciplinary teams (vascular neurologist, neurointensivist, interventional neuroradiologist, and neurosurgeons) 365 days a year. All centers are coordinated with primary care centers, and all medical information is shared within all the Catalan territory through the electronic medical records of our universal health care system. Misdiagnosis was mainly found in patients with mild headache without severe neurological symptoms (Hunt-Hess 1-2), who received a diagnosis such as cervicogenic or tension-type headache. Although pain intensity is not considered a red flag in any current headache guideline, we think that presenting with a mild headache reduces the suspicion of a severe cause such as SAH. Previous studies have shown that the key attributes of SAH headache are sudden onset with maximum intensity reached within minutes, along with nucal rigidity in the clinical exam. However, those characteristics might not always be noted in the medical evaluation of patients presenting with headache. In an effort to disseminate the key findings of our study and to encourage discussion of new strategies to reduce SAH misdiagnosis in our population, we have prepared an educational program that incorporates our study results and is addressed to all health personnel involved in SAH management.