Stroke scoring

7/24/2019 Stroke scoring

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Volume 12Number 1Jan-Jul 2012 13PMJN

Postgraduate MedicalJournal of NAMS

Sk Sig ??? D i av

Rajouria AD,* Rana KJ, Karki L, Gaire D, Pokheral A

*Clinical tutor, Naonal Academy of Medical Sciences.

INTRODUCTION

Stroke is dened as clinical syndrome of rapid onset

of cerebral decit (usually focal) lasng more than

24 hours or leading to death with no apparent cause

other than a vascular one.1

It is commonest life threatening, neurological disease

requiring hospitalizaon and stands out as one of the

most important causes of severe disability. Stroke is

3rdcommonest cause of death in developed countries.

Cerebrovascular disease predominates in the middle

and late years of life and approximately age adjusted

annual death rate from stroke is 116 per 100000

populaons in USA. Those who survive oen are le

with mentally and or physically handicapped, requiring

assistance for daily acvies-leading to economic

burden to family and society for a long run.2

In third world countries, like ours, where diagnosc

facilies are insucient and also where available;

due to economic burden to family - ulizaon of

such facilies are delayed but in contrary it is well

established that management and prognosis of

paents with acute stroke syndrome vary depending

mainly on stroke subtypes: therefore it is necessary for

mely dierenaon between them. If stroke paents

are to derive benet from thrombolyc therapy3and

anplatelet drugs,4 cerebral infarcon needs to be

diagnosed quickly and correctly.

ABSTRACT

ntroducton:CT scan of head is presumed to be gold standard for the dierenaon between

ishaemic and haemorrhagic stroke. But as CT Scan is not available everywhere hence the study

was carried out for othe opon. The study validate the Siriraj stroke score, Allens stroke score and

Greek stroke score in Nepalese populaon.

ethods:The study was a prospecve observaonal, hospital based study. Study was conducted

at Bir Hospital and Shree Birendra hospital, Kathmandu which involved 75 paents with stroke.

On arrival, paents detailed history and examinaon was carried out. Necessary invesgaon

send and relevant data collected for Siriraj, Allen and Greek stroke score. Calculaon of the score

was done and then compared with CT head using SPSS.

result:75 consecuve cases were taken, 56 male (74.7%). Most of the cases were above 60

years comprising 34/75 cases (45.3%). Hemorrhagic stroke was detected in 38/75 cases (50.7%).

Sensivity, specicity, posive predicve value and negave predicve value was calculated For

SSS which were as 0.73, 0.67 0.70, and 0.73 respecvely; for ASS which was 0.77, 0.77, 0.70 and

of 0.89 respecvely. For GSS 0.85, 0.73, 0.69 and 0.88 respecvely.

concluson:We concluded that ASS, GSS and SSS are not reliable for diagnosis of stroke subtypes. Among the three scoring methods, ASS performed beer than the other two. Hence, CT

scan of head remains as gold standard for dierenal diagnosis of strokes.

Key words:

Original Article

Cp :

Dr. Alark Rajouria Devkota

Email: [email protected]


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Volume 12Number 1Jan-Jul 201214MJN

ostgraduate Medicalurnal of NAMS

as dened by the WHO paent presenng within

48 hrs of onset of illness1, Age group above 25 were

taken. Exclusion criteria were Paent with history

of head injury within last six months, Paent under

ancoagulants, Paent known to suer from brain

tumor or space occupying lesions, Paent diagnosed

as Subarachnoid Hemorrhage.

The following CT scan criteria were taken for diagnosis

of stroke: Cerebral infarcon- area of decreased

aenuaon within the cerebral substance in plain CT

scan head. If no change in aenuaon, then also shall

be considered as infarcon. Cerebral Hemorrhage-

area of increased aenuaon within the cerebral

substance in plain CT scan head.

Scoring for SSS, ASS and GSS were calculated as givenin table 1.5,6,7

Hence, it is very much crucial for mely dierenaon

between the strokes subtypes, with fair amount of

accuracy would be of great help for mely diagnosis

of such cases.

The present study has been under taken with aim of

determining validity of Siriraj Stroke Score(SSS)5, Guys

Hospital Stroke Score (Allens Stroke Score, ASS)6and

Greek Stroke Score (GSS)7in Nepalese sub populaon

to dierenate the major stroke subtypes taking CT

scan head as the gold standard.

METHOD

This is a prospecve, observaonal, hospital based

study involving 75 paents who presented with stroke

to Bir hospital and Shree Birendra army hospitalKathmandu from July 2008 ll adequate number of

cases were reached. Inclusion criteria were Stroke

Stroke Scoring ??? Does it have role

Table 1. Scoring system

Score Formula Interpretaon

Siiaj

Score

Number of points=

2.5* (Level of Consciousness)+

2* (Voming)+

2* (Headache within 2hrs of onset)+0.1* (Diastolic Blood Pressure)-

3* (Atheroma Markers)-

12 (Constant)

> +1 Haemorrhage

< - 1 Infarcon

+1 to -1 Equivocal

A

Score

Number of points=

Apoplecc onset +

Level of consciousness +

Plantar responses +

(Diastolic blood pressure 24 hours aer admission X 0.17) +

Atheroma markers +

History of hypertension +

Previous events (transient Ischemic aack) +Heart disease -

12 (constant)

> 24 Haemorrhage

< 4 Infarcon

4 to 24 Equivocal

Gk

Score

Number of points=

6 * (neurological deterioraon within 3 h from admission) +

4 * (voming) +

4 * (WBC > 12 000) +

3 * (decreased level of consciousness).

> 11 Haemorrhage

< 3 Infarcon

3 to 11 Equivocal


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RESULTS

Total enrolled cases were 102; 27 cases were dropped

as 10 paents expired before the compleon of data

collecon, 8 paents le against medical advice

before compleon of data collecon, 4 paent later

gave history of previous stroke, 3 were later diagnosed

as having intracranial space occupying lesion and 2

paents family refused to perform CT head.

In our study male cases were 56 (74.7%) and 19

females (25.3%) with male: female of 2.9:1. Male

occupied 31 cases (55.4%) of hemorrhagic stroke and

25 (44.6%) ischemic. In contrast, female constuted

7 (36.8%) cases of hemorrhagic stroke and in other

hand 12 (63.2%) cases of ischemic stroke. Of the 75

subjects studied, similar number of cases was seenamong hemorrhagic and ischemic stroke which were

38 (50.7%) and 37 (49.37%) respecvely.

Loss of consciousness was noted in 38 (50.7%) cases

[hemorrhagic 26 and ischemic 12, with P=0.002 which

was stacally signicant. Voming was present in 31

(41.3%) cases [hemorrhage 24 and 7 ischemic] with

P


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The present study was carried out in 75 consecuve

new stroke paents aending Bir Hospital and Shree

Birendra Hospital with an aim to assess the validity of

SSS, ASS and GSS to dierenate ischemic stroke from

hemorrhagic stroke in Nepalese sub populaon.

In our study male cases were 56 (74.7%) and 19

females (25.3%) with male: female of 2.9:1. This was in

accordance to the study done by Mumtaz AM, et al in

Pakistan; out of eighty-eight paents, 62 (70.5%) males

and 26 (29.5%) females with stroke were included in

their study with male: female of 2.4:1.8 Similar results

were also seen in the stroke study done in Nepal

by Naik, et al in which, total of 150 stroke paents

studied out of whom 104 males and 46 females with

male: female 2.3:1 was observed.9The signicant male

prevalence may have been due to the risk factors for

stroke like hypertension, dyslipidemia and smoking

which are more prevalent in male populaon.

Study done in Nepal by Krishna CD, et al where they

found the mean age was 61.65 14.9 years, ranging

from 20 to 100 years and above 60 years cases were

24/61 (39.4%).10 The ndings were similar to our

study in which maximum numbers of stroke cases

were above the age of 60 years-34/75 cases (45.3%).

Minimal age was 25 years and maximum being 92

years with mean of 5918 years. Mean age was higherin other studies; mean age 70.2 10.8 years in study

done by Efstathiou SP, et al7and similarly in the study

done by Smadja D, et al mean age was 71.214 years11

which probably reects low life expectancy rate of

Nepalese populaon.

Most of the community based studies and text

books have shown that ischemic stroke is far more

common than hemorrhagic stroke in a populaon with

ischemic to hemorrhagic being 5.6:1 (85%:15%).1,12,13

But in contrast to those studies, our result has shown

hemorrhagic stroke to be more, which was 38 cases

(50.7%) which however agrees with the results of the

study carried out in India by Soman et al. In they study

91 stroke paents were idened with hemorrhagic

amounng 44 paents (48.4%)14 Similarly in study

done by Naik, et al, haemorrhagic (42%) cases were

found.9 The exact cause is however not known, but

probably, it can be speculated that as our data is

chiey from Bir Hospital and it being terary level

referral centre with neuro-surgical team, hemorrhagic

stroke are oen referred. Also hemorrhagic stroke has

dramac presentaons.

Contrary to the study done by Poungvarin N, et al5

which had shown diagnosc sensivies of the SSS

for cerebral haemorrhage and cerebral infarcon

were 89.3% and 93.2% respecvely, with an overall

predicve accuracy of 90.3%. But in our study SSS was

able to diagnose correctly 21 (55.3%) and 19 (51.4%)

of hemorrhagic and ischemic stroke respecvely. It

misdiagnosed 7 (18.4%) and 9 (24.3%) of hemorrhagic

and ischemic stroke respecvely. On the other hand,

the scoring system was equivocal in 10 (26.3%)

and 9 (24.3%) of hemorrhagic and ischemic stroke

respecvely. The SSS had sensivity of 0.73 with

specicity of 0.67 whereas the posive predicve

value was 0.70, with negave predicve value of 0.73.

(table 3)

Our study was in accordance with the study done

by Soman Aamod et al in India which showed

sensivity, specicity, posive predicve value and

negave predicve value of 0.75, 0.81, 0.77 and 0.78,

respecvely.14

In our study ASS was able to diagnose correctly

14 (36.8%) and 21 (56.8%) of hemorrhagic and

ischemic stroke respecvely. It misdiagnosed 4

(10.5%) and 6 (16.2%) of hemorrhagic and ischemic

stroke respecvely. On the other hand, the scoring

system was equivocal in 20 (52.6%) and 10 (27%) of

hemorrhagic and ischemic stroke respecvely. The ASS

had sensivity of 0.77 with specicity of 0.77 whereas

the posive predicve value was 0.70, with negave

predicve value of 0.89. (table 2)

Table 2. GSS

GSS CT head Total P


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Our results were dissimilar to study of Huang JA, et

al1 5 who applied ASS in Chinese populaon leaving

in Taiwan. They studied 255 stroke cases of which 186

subjects (73%) had ischemic stroke. In they study ASS

had sensivity of 67% with specicity of 100% whereas

the posive predicve value was 100%, with negave

predicve value of 91%.

Similar results were also obtained in study done by

Sandercock PA, et al16 which showed sensivity for the

diagnosis of hemorrhage of 81% and 88% in Oxford

and London respecvely. Infarcon was diagnosed

with a sensivity of 78% with an overall predicve

accuracy of 78% with an overall London the sensivity

for infarcon was also 78% with an overall predicve

accuracy of 82%.

However our results were similar to the study done by

F Salawu, et al done in Nigeria and showed sensivity,

specicity, posive predicve value and negave

predicve value for cerebral hemorrhage was 0.64,

0.48, 0.4 and 0.71 respecvely.18

In our study GSS was able to diagnose correctly 18

(47.4%) and 22 (59.5%) of hemorrhagic and ischemic

stroke respecvely. It misdiagnosed 8 (21.6%) and 3

(7.9%) of hemorrhagic and ischemic stroke respecvely.

On the other hand, the scoring system was equivocal in

17 (44.7%) and 7 (18.9%) of hemorrhagic and ischemicstroke respecvely. The SSS had sensivity of 0.85

with specicity of 0.73 whereas the posive predicve

value was 0.69, with negave predicve value of 0.88.

(table 2)

Table 4. SSS

SSS CT head Total P 0.006

Hemorrhage Ischemic

>1 21 55.3% 9 24.3% 30 40.0%

-1 to1 10 26.3% 9 24.3% 19 25.3%


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fair (K = 0.27).18 But when the result of CT-scan was

assumed as a true state, the agreement in diagnosing

ischemic stroke and intracerebral hemorrhage of the

ASS and SSS was high (K = 0.81). Agreement between

the ASS and SSS was also studied by Badam P, et alin India where they observed agreement between

the two scores was modest (kappa = 0.51), but very

good (kappa = 0.93) aer exclusion of equivocal score

results.19

In our study area under receiver operang curve

was calculated for the ASS, SSS and GSS which were

0.6980.066, 0.6400.073 and 0.6040.079 (table

2) respecvely in order to analyze the discriminaon

of scores using hemorrhage idened by CT as an

independent variable. Area under the curve for ASSis highest with signicant p value. Hence ASS is found

signicantly discriminang hemorrhage as compared

to SSS and GSS. This was comparable with the study

done by Ozeren A, et al in which ASS was found to

be beer predictor than the SSS system studied.18 In

their study area under the curve for SSS was 0.796 and

0.8162 for ASS.

CONCLUSION

ASS, GSS and SSS are not reliable for diagnosis ofstroke sub types and needs further improvement in

parameters to increase its reliability in our sengs.

Among the three scoring methods, ASS (area under

the curve for ASS is highest with 0.698.066 and

signicant p value) performed beer than the other

two scoring methods although it requires 24 hours

from presentaon ll compilaon of its parameters.

Hence, CT scan of head remains as gold standard for

dierenal diagnosis of strokes.

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Stroke scoring