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Original Article

Stroke Scoring ??? Does it have role


Rajouria AD,* Rana KJ, Karki L, Gaire D, Pokheral A
*Clinical tutor, National Academy of Medical Sciences.

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

annual death rate from stroke is 116 per 100000


populations in USA. Those who survive often are left
with mentally and or physically handicapped, requiring
assistance for daily activities-leading to economic
burden to family and society for a long run.2
In third world countries, like ours, where diagnostic
facilities are insufficient and also where available;
due to economic burden to family - utilization of
such facilities are delayed but in contrary it is well
established that management and prognosis of
patients with acute stroke syndrome vary depending
mainly on stroke subtypes: therefore it is necessary for
timely differentiation between them. If stroke patients
are to derive benefit from thrombolytic therapy3 and
antiplatelet drugs,4 cerebral infarction needs to be
diagnosed quickly and correctly.

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Stroke Scoring ??? Does it have role


Hence, it is very much crucial for timely differentiation
between the strokes subtypes, with fair amount of
accuracy would be of great help for timely 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)6 and
Greek Stroke Score (GSS)7 in Nepalese sub population
to differentiate the major stroke subtypes taking CT
scan head as the gold standard.

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

as defined by the WHO patient presenting within


48 hrs of onset of illness1, Age group above 25 were
taken. Exclusion criteria were Patient with history
of head injury within last six months, Patient under
anticoagulants, Patient known to suffer from brain
tumor or space occupying lesions, Patient diagnosed
as Subarachnoid Hemorrhage.
The following CT scan criteria were taken for diagnosis
of stroke: Cerebral infarction- area of decreased
attenuation within the cerebral substance in plain CT
scan head. If no change in attenuation, then also shall
be considered as infarction. Cerebral Hemorrhagearea of increased attenuation within the cerebral
substance in plain CT scan head.
Scoring for SSS, ASS and GSS were calculated as given
in table 1.5,6,7

Table 1. Scoring system

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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

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Stroke Scoring ??? Does it have role

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.

misdiagnosed 8 (21.6%) and 3 (7.9%) of hemorrhagic


and ischemic stroke respectively. On the other hand,
the scoring system was equivocal in 17 (44.7%)
and 7 (18.9%) of hemorrhagic and ischemic stroke
respectively. The SSS had sensitivity of 0.85 with
specificity of 0.73 whereas the positive predictive
value was 0.69, with negative predictive value of 0.88.
Area under receiver operating curve (ROC) (figure 1)
was calculated for the ASS, SSS and GSS in order to
analyze the discrimination of scores using hemorrhage
identified by CT as an independent variable. Area
under the curve for ASS is highest with significant p
value.

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


[hemorrhagic 26 and ischemic 12, with P=0.002 which
was statically significant. Vomiting was present in 31
(41.3%) cases [hemorrhage 24 and 7 ischemic] with
P <0.001 which was statically significant. Headache
was present in 21 (28%) cases [hemorrhagic 14 and 7
ischemic] with P=0.08 which was statically insignificant.
SSS diagnosed correctly 21 (55.3%) and 19 (51.4%)
of hemorrhagic and ischemic stroke respectively. It
misdiagnosed 7 (18.4%) and 9 (24.3%) of hemorrhagic
and ischemic stroke respectively. On the other hand,
the scoring system was equivocal in 10 (26.3%)
and 9 (24.3%) of hemorrhagic and ischemic stroke
respectively. The SSS had sensitivity of 0.73 with
specificity of 0.67 whereas the positive predictive
value was 0.70, with negative predictive value of 0.73.
ASS diagnosed correctly 14 (36.8%) and 21 (56.8%)
of hemorrhagic and ischemic stroke respectively. It
misdiagnosed 4 (10.5%) and 6 (16.2%) of hemorrhagic
and ischemic stroke respectively. On the other hand,
the scoring system was equivocal in 20 (52.6%) and 10
(27%) of hemorrhagic and ischemic stroke respectively.
The SSS had sensitivity of 0.77 with specificity of 0.77
whereas the positive predictive value was 0.70, with
negative predictive value of 0.89.
GSS diagnosed correctly 18 (47.4%) and 22 (59.5%)
of hemorrhagic and ischemic stroke respectively. It

Figure 1. ROC curve

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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The present study was carried out in 75 consecutive
new stroke patients attending Bir Hospital and Shree
Birendra Hospital with an aim to assess the validity of
SSS, ASS and GSS to differentiate ischemic stroke from
hemorrhagic stroke in Nepalese sub population.
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 patients, 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 patients
studied out of whom 104 males and 46 females with
male: female 2.3:1 was observed.9 The significant male
prevalence may have been due to the risk factors for
stroke like hypertension, dyslipidemia and smoking
which are more prevalent in male population.
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 findings 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 higher
in other studies; mean age 70.2 10.8 years in study
done by Efstathiou SP, et al7 and similarly in the study
done by Smadja D, et al mean age was 71.214 years11
which probably reflects low life expectancy rate of
Nepalese population.
Most of the community based studies and text
books have shown that ischemic stroke is far more
common than hemorrhagic stroke in a population 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 patients were identified with hemorrhagic
amounting 44 patients (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
chiefly from Bir Hospital and it being tertiary level
referral centre with neuro-surgical team, hemorrhagic

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stroke are often referred. Also hemorrhagic stroke has


dramatic presentations.
Contrary to the study done by Poungvarin N, et al5
which had shown diagnostic sensitivities of the SSS
for cerebral haemorrhage and cerebral infarction
were 89.3% and 93.2% respectively, with an overall
predictive 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 respectively. It
misdiagnosed 7 (18.4%) and 9 (24.3%) of hemorrhagic
and ischemic stroke respectively. On the other hand,
the scoring system was equivocal in 10 (26.3%)
and 9 (24.3%) of hemorrhagic and ischemic stroke
respectively. The SSS had sensitivity of 0.73 with
specificity of 0.67 whereas the positive predictive
value was 0.70, with negative predictive value of 0.73.
(table 3)
Our study was in accordance with the study done
by Soman Aamod et al in India which showed
sensitivity, specificity, positive predictive value and
negative predictive value of 0.75, 0.81, 0.77 and 0.78,
respectively.14
In our study ASS was able to diagnose correctly
14 (36.8%) and 21 (56.8%) of hemorrhagic and
ischemic stroke respectively. It misdiagnosed 4
(10.5%) and 6 (16.2%) of hemorrhagic and ischemic
stroke respectively. On the other hand, the scoring
system was equivocal in 20 (52.6%) and 10 (27%) of
hemorrhagic and ischemic stroke respectively. The ASS
had sensitivity of 0.77 with specificity of 0.77 whereas
the positive predictive value was 0.70, with negative
predictive value of 0.89. (table 2)
Table 2. GSS
GSS CT head
Hemorrhage
<3 3
7.9%
3-11 17 44.7%
>11 18 47.4%
38
Table 3. ASS
ASS
CT head
Hemorrhage
>24
14
36.8%
4-24 20
52.6%
<4
4
10.5%
38

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%

Stroke Scoring ??? Does it have role


Our results were dissimilar to study of Huang JA, et
al1 5 who applied ASS in Chinese population leaving
in Taiwan. They studied 255 stroke cases of which 186
subjects (73%) had ischemic stroke. In they study ASS
had sensitivity of 67% with specificity of 100% whereas
the positive predictive value was 100%, with negative
predictive value of 91%.
Similar results were also obtained in study done by
Sandercock PA, et al16 which showed sensitivity for the
diagnosis of hemorrhage of 81% and 88% in Oxford
and London respectively. Infarction was diagnosed
with a sensitivity of 78% with an overall predictive
accuracy of 78% with an overall London the sensitivity
for infarction was also 78% with an overall predictive
accuracy of 82%.
However our results were similar to the study done by
F Salawu, et al done in Nigeria and showed sensitivity,
specificity, positive predictive value and negative
predictive value for cerebral hemorrhage was 0.64,
0.48, 0.4 and 0.71 respectively.18
In our study GSS was able to diagnose correctly 18
(47.4%) and 22 (59.5%) of hemorrhagic and ischemic
stroke respectively. It misdiagnosed 8 (21.6%) and 3
(7.9%) of hemorrhagic and ischemic stroke respectively.
On the other hand, the scoring system was equivocal in
17 (44.7%) and 7 (18.9%) of hemorrhagic and ischemic
stroke respectively. The SSS had sensitivity of 0.85
with specificity of 0.73 whereas the positive predictive
value was 0.69, with negative predictive value of 0.88.
(table 2)
Table 4. SSS
SSS
CT head
Hemorrhage
>1
21
55.3%
-1 to1 10
26.3%
<-1
7
18.4%
38

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%

Table 5. ROC = Area under curve


Test Area Std. P
Asymptomatic 95%
Error
Confidence Interval
Lower
Upper Bound
Bound
ASS .698 .066 .018 .569
.827
SSS .640 .073 .095 .497
.783
GSS .604 .079 .216 .448
.760

Similar to our study was observed in the study done by


Soman Aamod, et al at Indian;14 they found sensitivity,
specificity, positive predictive value, negative predictive
value for GSS were 0.42(95% CI: 0.23,0.53), 0.93(95%
CI: 0.87,0.98), 0.71(95% CI:0.39,0.91), 0.81(95%
CI:0.75,0.85) respectively.14
Contrary to our study; study done by S.P. Efstathiou
et al, which had studied 168 subjects (85 males),
sensitivity, specificity, positive predictive value and
negative predictive value were 97%, 99%, 97% and
99% respectively.7
In our study using kappa statistic the overall
comparability of GSS with SSS was kappa 0.41 with
P<0.001 and similarly GSS with ASS was kappa 0.10 with
P 0.20. When similar comparability was done between
SSS with ASS, the kappa was 0.35 with P<0.001. This
was in accordance to the study done by Soman Aamod
et al which showed using kappa statistics the overall
comparability for certain cases of GSS with SSS was fair
(K=0.27) and with ASS was good (K=0.51).14 ((table 6,
table 7,table 8)
Table 6. Cross tabulation: GSS and SSS. Kappa=0.41
GSS SSS
Total
>1
-1 to 1
<-1
<3 20 66.7% 1 5.3% 5 19.2% 26 34.7%
3-11 7 23.3% 11 57.9% 6 23.1% 24 32.0%
>11 3 10.0% 7 36.8% 15 57.7% 25 33.3% P <
0.001
30
19
26
75
Table 7. Cross tabulation: GSS and ASS. Kappa=0.10
GSS ASS
Total
>24
4-24
<4
<3 7 35.0% 14 46.7% 5 20.0% 26 34.7%
3-11 9 45.0% 9 30.0% 6 24.0% 24 32.0%
>11 4 20.0% 7 23.3% 14 56.0% 25 33.3% P=
0.20
20
30
25
75
Table 8. Cross tabulation: SSS and ASS. Kappa= 0.35
SSS ASS
Total
>24
4-24
<4
>1 14 70.0% 16 53.3% 0 0%
30 40.0%
-1 to 4 20.0% 9 30.0% 6 24.0% 19 25.3%
P<
1
<-1 2 10.0% 5 16.7% 19 76.0% 26 34.7% 0.001
20
30
25
75
Similarly in the study done by Ozeren A, et al overall
comparability of the Allen and Siriraj scores were

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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 al
in India where they observed agreement between
the two scores was modest (kappa = 0.51), but very
good (kappa = 0.93) after exclusion of equivocal score
results.19
In our study area under receiver operating curve
was calculated for the ASS, SSS and GSS which were
0.6980.066, 0.6400.073 and 0.6040.079 (table
2) respectively in order to analyze the discrimination
of scores using hemorrhage identified by CT as an
independent variable. Area under the curve for ASS
is highest with significant p value. Hence ASS is found
significantly discriminating 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 better 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 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.

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