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ABSTRACT
Introduction: CT scan of head is presumed to be gold standard for the differentiation between
ishaemic and haemorrhagic stroke. But as CT Scan is not available everywhere hence the study
was carried out for othe option. The study validate the Siriraj stroke score, Allens stroke score and
Greek stroke score in Nepalese population.
Methods: The study was a prospective observational, hospital based study. Study was conducted
at Bir Hospital and Shree Birendra hospital, Kathmandu which involved 75 patients with stroke.
On arrival, patients detailed history and examination was carried out. Necessary investigation
send and relevant data collected for Siriraj, Allen and Greek stroke score. Calculation of the score
was done and then compared with CT head using SPSS.
Result: 75 consecutive 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%).
Sensitivity, specificity, positive predictive value and negative predictive value was calculated For
SSS which were as 0.73, 0.67 0.70, and 0.73 respectively; for ASS which was 0.77, 0.77, 0.70 and
of 0.89 respectively. For GSS 0.85, 0.73, 0.69 and 0.88 respectively.
Conclusion: We concluded that ASS, GSS and SSS are not reliable for diagnosis of stroke sub
types. Among the three scoring methods, ASS performed better than the other two. Hence, CT
scan of head remains as gold standard for differential diagnosis of strokes.
Key words:
INTRODUCTION
Stroke is defined as clinical syndrome of rapid onset
of cerebral deficit (usually focal) lasting 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 hospitalization and stands out as one of the
most important causes of severe disability. Stroke is
3rd commonest cause of death in developed countries.
Cerebrovascular disease predominates in the middle
and late years of life and approximately age adjusted
Correspondence :
Dr. Alark Rajouria Devkota
Email: adr_np@gmail.com
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METHOD
This is a prospective, observational, hospital based
study involving 75 patients who presented with stroke
to Bir hospital and Shree Birendra army hospital
Kathmandu from July 2008 till adequate number of
cases were reached. Inclusion criteria were Stroke
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Score
Formula
Interpretation
Siriraj
Score
Number of points=
2.5* (Level of Consciousness)+
2* (Vomiting)+
2* (Headache within 2hrs of onset)+
0.1* (Diastolic Blood Pressure)3* (Atheroma Markers)12 (Constant)
> +1 Haemorrhage
< - 1 Infarction
+1 to -1 Equivocal
Allens
Score
Number of points=
Apoplectic onset +
Level of consciousness +
Plantar responses +
(Diastolic blood pressure 24 hours after admission X 0.17) +
Atheroma markers +
History of hypertension +
Previous events (transient Ischemic attack) +
Heart disease 12 (constant)
> 24 Haemorrhage
< 4 Infarction
4 to 24 Equivocal
Greek
Score
Number of points=
6 * (neurological deterioration within 3 h from admission) +
4 * (vomiting) +
4 * (WBC > 12 000) +
3 * (decreased level of consciousness).
> 11 Haemorrhage
< 3 Infarction
3 to 11 Equivocal
RESULTS
Total enrolled cases were 102; 27 cases were dropped
as 10 patients expired before the completion of data
collection, 8 patients left against medical advice
before completion of data collection, 4 patient later
gave history of previous stroke, 3 were later diagnosed
as having intracranial space occupying lesion and 2
patients 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 constituted
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 seen
among hemorrhagic and ischemic stroke which were
38 (50.7%) and 37 (49.37%) respectively.
DISCUSSION
Stroke, a commonest life threatening neurological
disease requiring hospitalization and stands out as
one of the most important cause of severe disability.
It is second commonest cause of death after coronary
heart disease worldwide.1,2
Management of stroke largely depends on
differentiation of hemorrhagic and ischemic stroke and
so is the prognosis. Clinical stroke scoring can help in
the differential diagnosis of stroke in areas with limited
CT scan facilities. Theses scores are simple, screening
diagnostic tools at the bedside and dont consume
time. However it has been found that the scoring
systems are relatively inefficient in differentiating
stroke sub types.
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Total P<0.001
Ischemic
22 59.5%
7
18.9%
8
21.6%
37
25
24
26
75
33.3%
32.0%
34.7%
Total P <0.001
Ischemic
6
16.2%
10 27.0%
21 56.8%
37
20
30
25
75
26.7%
40.0%
33.3%
Total P 0.006
Ischemic
9
24.3%
9
24.3%
19 51.4%
37
30
19
26
75
40.0%
25.3%
34.7%
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CONCLUSION
ASS, GSS and SSS are not reliable for diagnosis of
stroke sub types and needs further improvement in
parameters to increase its reliability in our settings.
Among the three scoring methods, ASS (area under
the curve for ASS is highest with 0.698.066 and
significant p value) performed better than the other
two scoring methods although it requires 24 hours
from presentation till compilation of its parameters.
Hence, CT scan of head remains as gold standard for
differential diagnosis of strokes.
REFERENCE
1 Hatano S. Experience from a multicentre stroke
register -a preliminary report. Bull World Health Organ.
1976;54:41-53.
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Lancet.
15 Huang JA, Wang PY, Chang MC, Chia LG, Yang DY, Wu
TC. Allen score in clinical diagnosis of intracranial
hemorrhage. Zhonghua Yi Xue Za Zhi. 1994;54(6):407-11.
2 Bonita R. Epidemiology
1992;339(8789):342-4.
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of
stroke.
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