Pearls and pitfalls in emergency CT neuroangiography through the lens of bias and error

Abstract

Computed tomography angiography (CTA) of the head and neck is central in emergency department (ED) evaluation of clinically suspected acute stroke and intracranial hemorrhage. Timely and accurate detection of acute findings is crucial for best clinical outcomes; missed or delayed diagnosis can be devastating. Our pictorial essay presents twelve CTA cases that provided significant diagnostic dilemmas to on-call trainees while reviewing current bias and error classifications in radiology. Among others, we discuss anchoring, automation, framing, satisfaction of search, scout neglect and zebra-retreat bias. Each imaging vignette depicts a potential diagnostic "pitfall" while introducing types of cognitive bias/error before concluding with a concrete "pearl" for CTA interpretation. We believe that familiarity with bias and error is particularly important in the ED setting where high case volume, high acuity and radiologist fatigue intersect. Particular attention to personal cognitive biases and these potential CTA pitfalls may help emergency radiologists transition from habit-driven pattern recognition to analytical thinking, ultimately improving diagnostic decision making.

Keywords: Bias; CT Angiography; CT neuroangiography; Emergency CTA; Error; Head and neck.