A Comparative Study of Clinical Scoring System of Cerebrovascular Accident with CT Scan
Abstract
OBJECTIVE: Stroke is the second most common cause of death and major cause of disability worldwide. Low and middle income countries account for 85.5% of total stroke deaths worldwide and the number of disability-adjusted life years in these countries is seven times that in high income countries. CT scan is a safe and non-invasive procedure for differentiating between cerebral infarction and haemorrhage. However, in India and other developing countries the availability of CT scan facilities in rural and peripheral centres is low but cost of scanning precludes its routine usage by the poorer society. So this study aims at differentiating ischaemic and haemorrhagic strokes at bedside by using clinical scoring systems and to compare the accuracy of clinical scoring with the CT scan findings.
METHODS: This was a prospective clinical study on 100 patients who presented to the hospital within 72 hours of onset of symptoms of stroke. Siriraj and Allen stroke score were calculated using various parameters, subsequently all of these patients underwent CT scan of brain and accuracy of clinical scoring system with the CT scan was compared.
RESULTS: Most number of affected patients belonged to the age-group 61-70 with a male preponderance. 66% of the stroke cases were ischaemic, most common presenting symptom was hemiplegia followed by altered sensorium. Midline shift in CT scan was seen more in haemorrhagic stroke patients. On comparison of Siriraj score with CT scan findings correct correlation was seen in 82% of cases while Allen score showed correct correlation only in 67% of cases so the diagnosis of stroke subtype was best predicated by Siriraj score as compared to Allen score.
CONCLUSION: Present study shows that Siriraj score had good sensitivity and positive predictive value for ischaemic stroke (91.93% and 90.47%) while for haemorrhagic stroke sensitivity and positive predictive value was less (80.6% and 83.33%). Allen’s score also showed good sensitivity and positive predictive value (96.2% and 91.22%) for ischaemic stroke however for haemorrhagic stroke it had poor sensitivity and positive predictive value (75% and 88.23%). So overall Siriraj score is a better tool for bedside early clinical diagnosis of stroke and to start anti-ischaemic therapy
where immediate CT scan facilities are not available but these scores cannot be used for deciding thrombolysis using recombinant tissue plasminogen activators (r-tPA) which requires exclusion of haemorrhage by CT scan.
References
2. Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet. 2008 ;10;371(9624): 1612-23.
3. Fisher M, Norrving B. 1st Global Conference on Healthy. Lifestyles and Non communicable diseases Control. Moscow, April 28-29, 2011.
4. Steinwachs DM, Collins-Nakai RL, Cohn LH, Garson A Jr, Wolk MJ. The future of cardiology: utilization and costs of care. Am Coll Cardiol. 2000; 35(5 Suppl B):91B- 98B.
5. Mathers CD, Lopez AD, Murray CJL. The burden of disease and mortality by condition: data, methods,and results for 2001. In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, editors. Global Burden of Disease and Risk Factors. Washington (DC): World Bank; 2006. Chapter 3.
6. WHO, Bulletin 1980; 58: 113-130.Hatano S, Experience from a multicentre stroke register: A preliminary report. Bulletin, WHO 1976;54:541-43.
7. Poungvarin V, Viriyavejakul A, Komontri C, Siriraj stroke score and validation study to distinguish supratentorial intracranial haemorrhage from infarction. BMJ. 1991; 302:1567-7.
8. Allen CMC. Clinical diagnosis of acute stroke syndrome. AMJ. 1983;208:515-23.
9. Rohatgi A, Gupta H L, Narula M K et al. Correlation of clinical scoring (Siriraj stroke score) and CT scan in patients of stroke. JAPI. 1999;47: 1.
10. Daga M K, Sarin K, Negi V S, et al. Comparison of Siriraj and Guy’s Hospital Score to differentiate supratentorial ischaemic and hemorrhagic strokes in the Indian population. JAPI. 1994;12:302-3.
11. Wadhwani J, Hussain R, Raman PG. Nature of lesion in cerebrovascular stroke patients: Clinical stroke score and CT scan brain correlation. JAPI. 2003; 50: 777-781.
12. Celani M G, Righetti E, Migciacci R, Zampolini M, Antonuitti C, Grandi F C, Ricci S. Comparability and validity of two clinical scores in the earlydifferential diagnosis of acute stroke. BMJ. 1994;308:1674-6.
13. Badam P, Solao V, Pai M, Kalantri SP. Poor accuracy of the Siriraj and Guy’s hospital stroke scores in distinguishing haemorrhagic from ischaemic stroke in a rural, tertiary care hospital. The National Medical Journal of India. 2003;16(1).
14. Goswami RP, Karmakar PS, Ghosh A. Bedside utility of clinical scoring systems in classifying stroke. IJMS. 2013;67(5):137-145.
15. Raghuram PM, Biradar MS, Jeganathan J. Comparison of the Siriraj stroke Score and the Guy’s Hospital Score in South India. 2012;6(5):851-854
16. Weir CJ, Murray GD, Adams FG, Muir KW, Grosset DG, Lees KR. Poor accuracy of stroke scoring systems for differential clinical diagnosis of intracranial haemorrhage and infarction. Lancet. 1994;344:999–1002
17. Hawkins GC, Bonita R, Joanna B Broad JB et al. Inadequacy of clinical scoring systems to differentiate stroke subtypes in a population based study. Stroke.1995;26: 1338- 1342.
18. Besson G, Robert C, Hommel M et al. Is it clinically possible to distinguish non-hemorrhagic infarct from hemorrhagic stroke? Stroke. 1995;26: 1205-1209.
19. Efstathiou SP, Tsioulos DI, Zacharos ID. A new classification tool for clinical differentiation between hemorrhagic and ischaemic stroke. J Intern Med. 2002;252:121.
20. Bhattacharya S, Prasarsaha S, Basu A, Das K. A 5 year prospective study of incidence, morbidity and mortality stroke profile on stroke in a rural community of Eastern
India. J Indian Med Assoc. 2005;103(12):655-9.
21. Dalal PM, Malik S, Bhattacharjee M, Trivedi ND, Vairale J, Bhat P, Deshmukh S, Khandelwal K, Mathur VD. Population-bases stroke survey in Mumbai, India: Incidence and 28-day case fatality. Neuroepidemiology. 2008;31:254-61.
22. Sridharan SE, Unnikrishnan JP, Sukumaran S, Sylaja PN, Nayak SD, Sarma PS, Radhakrishnan K. Incidence, types, risk factors and outcome of stroke in a developing country: the Trivandrum Stroke Registry. Stroke. 2009;40:1212-18.
23. Nagaraja D, Gururaj G, Girish N, Panda S, Roy AK, Sarma GR, et al. Feasibility study of stroke surveillance: Data from Bangalore, India. Indian J Med Res.
2009;130:396–403.)
24. KuperH, AdaniHO, Theorell T. The socioeconomic gradient in the incidence of stroke: a prospective study in middle-aged women in Sweden. Stroke. 2007;38:27–33.
25. Joshi R, Cardona M, Iyengar S, Sukumar A, RaviRaju C, Rama Raju K, Raju K, Reddy KS, Lopez A and Neal B. Chronic diseases now a leading cause of death in rural India – mortality data from the Andhra Pradesh Rural Health Initiative. International Journal of Epidemiology. 2006:35:1522-1529.
26. Tripathy A, Jeemon P, Ajay V, Prabhakaran D, Reddy K. CVD profile of India. IC Health and WHO. 2007;APW SE/06/226543.
27. Planning commission,Government of india press note on poverty estimates 2011-2012,New Delhi. July 2013 p-2.
28. Chirayu V. Vaidya, Drusty K. Majmudar. A retrospective study of clinical profile of stroke patients from GMERS Medical College and Hospital, Gandhinagar Gujrat. Int J Clin Trials. 2014;1(2): 62-66.
29. ShintonR A, Gill J S, Zezulka A V et al. The frequency of epilepsy preceding stroke.Case‐control study in 230 patients. Lancet1987. i11–13.13.
30. Szaflarski JP, Rackley AY, Kleindorfer DO, Khoury J, Woo D, Miller R, Alwell K, Broderick JP, KisselaBM. Incidence of seizures in the acute phase of stroke: a population- based study. Epilepsia. 2008;49(6):974-81.
31. Qureshi AI, Ezzeddine MA, Nasar A, Suri MF, Kirmani JF, Hussein HM, Divani AA, Reddi AS. Prevalence of elevated blood pressure in 563,704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med. 2007;25(1):32-8.
32. Lawrence ES, Coshall C, Dundas R, Stewart J, Rudd AG, Howard R, Wolfe CD. Estimates of the Prevalence of Acute Stroke Impairments and Disability in a Multiethnic Population. Stroke. 2001;32:1279-1284.
33. Dobkin B. The rehabilitation of elderly stroke patients. ClinGeriatrMed.1991;7:507–523.
34. Kochar DK, Joshi A, Agarwal N, Aseri S, Sharma BV, Agarwal TD. Poor diagnostic accuracy and applicability of Siriraj stroke score, Allen score and their combination in differentiating acute hemorrhagic and thrombotic stroke. J Assoc Physicians India. 2000; 48:584–8.
35. Semir N, Riadh B, Wahid B, Soudani D et al. Accuracy of two scores in the diagnosis of stroke subtype in a multicenter cohort study. Ann Emerg Med. 2009; 53:373-378.
36. Parikh JH, Nanavati MA, Sojintra A. Clinical profile of cerebrovascular stroke and its correlation with Siriraj scoring system IJSR. 2014;12(3):1-3.
