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ORIGINAL ARTICLE
Year : 2004 | Volume : 58 | Issue : 10 | Page : 417-422

Greek stroke score, Siriraj score and allen score in clinical diagnosis
of intracerebral hemorrhage and infarct: Validation and comparison
study

Aamod Soman, Shashank R Joshi, Sanjay Tarvade, S Jayaram
Department of Medicine, Grant Medical College & Sir JJ Group of Hospitals, Mumbai - 400008, India
Correspondence Address:
Department of Medicine, Grant Medical College & Sir JJ Group of Hospitals, Mumbai - 400008, India
Abstract

AIM: To compare Greek stroke score with available previous two stroke scores for the
diagnosis of cerebral ischemia and hemorrhage in acute stroke patients, and validate the
Greek stroke scorzzze. SETTING: A tertiary hospital in India. MATERIALS AND METHODS: In
a prospective study acute stroke patients were evaluated with Greek stroke score, Allen
score and Siriraj stroke score. Comparability (Kappa Statistics) and validity (sensitivity,
specificity, negative predictive value and positive predictive value) of the Greek stroke score
and previous scores were tested. RESULT: Out of the 91 patients enrolled in the study, 47
patients had cerebral infarction and 44 patients had hemorrhage by CT scan. Allen score
was uncertain / equivocal in 39 patients, Siriraj Stroke score in 22 and Greek stroke score in
47 patients. Sensitivity, Specificity, positive predictive value, negative predictive value for
Allen score were 0.5(95% CI:0.34,0.58), 0.94(95% CI:0.86,0.98), 0.81(95%
CI:0.56,0.95), 0.78(95% CI: 0.71,0.81) for Siriraj score were 0.75(95% CI: 0.63,0.84),
0.81(95% CI: 0.71,0.89), 0.77(95% CI: 0.65,0.86), 0.78(95% CI 0.69,0.86) and for Greek
Score 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. Greek stroke score was compared with previous
scores using kappa statistics which revealed substantial strength of agreement between the
Allen Score for certain results. CONCLUSION: The overall comparability of Greek stroke
score and Allen score was better as compared to Greek stroke score and Siriraj stroke
score. Greek Stroke score was more specific in diagnosing hemorrhage as compared to
Siriraj score. However, all these stroke scores lack accuracy hence could not be applied
safely to guide the physician in management of stroke.

How to cite this article:
Soman A, Joshi SR, Tarvade S, Jayaram S. Greek stroke score, Siriraj score and allen score in clinical
diagnosis of intracerebral hemorrhage and infarct: Validation and comparison study. Indian J Med Sci
2004;58:417-22


How to cite this URL:
Soman A, Joshi SR, Tarvade S, Jayaram S. Greek stroke score, Siriraj score and allen score in clinical
diagnosis of intracerebral hemorrhage and infarct: Validation and comparison study. Indian J Med Sci
[serial online] 2004 [cited 2014 Jul 8];58:417-22. Available
from: http://www.indianjmedsci.org/text.asp?2004/58/10/417/12940



Introduction



There are two famous stroke scores which can guide the treating physician in clinical
distinction of hemorrhagic and ischemic stroke: Siriraj Scoring System and the Guys
Hospital Scoring System, which have been studied at various centers in India for efficacy.

Akpunonu et al studied the accuracy of Siriraj Stroke score and concluded that the
sensitivity was 36% for the hemorrhagic stroke and 90% for the non hemorrhagic stroke,
and the positive predictive values were 77% and 61% respectively.[1]

Comparison of the two scores has been done in many studies. These studies have concluded
that the Siriraj score is better than the Guy's hospital score but at the same time the
sensitivity of the Siriraj score has been in the range of 80 - 90%.[2],[3] However, a recently
conducted study by Wadhwani Jyoti, et al showed that the sensitivity of Siriraj stroke score
was 92.54% in diagnosing infarction and 87% for hemorrhage and its overall accuracy was
91.11%. The Guy's hospital score had a sensitivity of 93.42% in diagnosing infarction,
66.66% for hemorrhage and overall accuracy of the score was 87%.[4]

Recently, a new score proposed by a team from Athens claimed that the sensitivity,
specificity, positive predictive value and negative predictive value were much better as
compared to the previous scores.[5] This Greek Score has not been validated in India.

Our aim was to compare new scoring system (Greek stroke score) with the Siriraj stroke
score and Allen's stroke score and validate the new stroke score in Indian settings.


Materials and methods



Ninety one patients of acute cerebrovascular accidents, admitted in a single Tertiary care
Hospital in India were randomly enrolled in this study for duration of one year (Jan to Dec
2002). Inclusion criteria were: patients whose neurodeficit lasted for more than 24 hours
and CT scan showed supratentorial cerebral infarction or intracerebral hemorrhage.
Exclusion criteria used were: patients with stroke due to other causes like tuberculosis,
tumors or trauma, patients who had insufficient data to calculate scores and patients with
subarachnoid hemorrhage were excluded. Approval of Ethics committee of the hospital was
sought prior to starting the study. Written informed consent was signed by patients before
enrolling. Authors collected the data and stroke scores were calculated for each patient
independently.

The following patient variables were recorded: age, gender, history of previous stroke, TIA,
IHD, Rheumatic heart disease, peripheral arterial disease, hypertension, diabetes, smoking,
alcohol consumption, hyperlipidemia, clinical signs, and symptoms (onset of deficit,
headache, vomiting, blood pressure, Glasgow Coma Scale, pupil and plantar response, neck
stiffness, level of consciousness, neurological deterioration within the first 24 hours) and
basic laboratory data (ECG, WBC count). Data was also utilized to study epidemiology of
stroke.

A form containing variables for all the three scores was filled by authors, and the definitions
and guidelines were followed as per the original scores. CT scan was done in all the
patients.

The scores were calculated from the above variables (Formulas for calculation in [Table -
1])[5],[6],[7] and they were compared in 'certain' results i.e. percentages of scores in which
the scores predicted ischemia or hemorrhage according to the cutoffs suggested in the
original papers. Results were considered to be certain when Allen score was <4 and >24, <-
1 and >1 for Siriraj stroke score and Greek Score was <3 and >11. Kappa statistics were
determined for agreement between two scores for certain cases.

The results of three scores were compared with results of CT scan study. Sensitivity,
specificity. Positive predictive value and negative predictive value were calculated for
diagnosis of hemorrhage. We used Kappa statistics program for comparability test.


Results



Out of 91 patients, 47 patients (51.64%) had cerebral infarction and 44 patients (48.35%)
had intracerebral hemorrhage by Computed Tomography.

Using Kappa statistics the overall comparability for certain cases of Greek Score with Siriraj
stroke score was fair. (K=0.27) [Table - 2] and with Allen's score was good (K=0.51) [Table - 3]

The Siriraj Stroke score diagnosed 38 patients as cerebral infarction and 31 patients as
Intracerebral Hemorrhage while 22 patients were in equivocal category. Thus the Score had
a sensitivity of 0.75 (95% CI: 0.63, 0.84), specificity of 0.81 (95% CI: 0.71, 0.89), positive
predictive value 0.77 (95% CI: 0.65, 0.86) and a negative predictive value of 0.78 (95% CI
0.69, 0.86) for diagnosis of Intracerebral Hemorrhage. [Table - 4]

The Allen's stroke score diagnosed 41 patients as cerebral infarction and 11 patients as
Intracerebral Hemorrhage while 39 patients were in equivocal category. Thus the score had
sensitivity of 0.50 (95% CI: 0.34, 0.58) specificity of 0.94 (95% CI: 0.86, 0.98), positive
predictive value of 0.81 (95% CI: 0.56, 0.95), and negative predictive value of 0.78 (95%
CI: 0.71, 0.81) for diagnosis of Intracerebral Hemorrhage. [Table - 5]

The Greek Score diagnosed 37 patients as intracerebral hemorrhage, 7 patients as cerebral
infarction and 47 patients were in equivocal category. Thus the Greek Score had a
sensitivity of 0.416 (95% CI: 0.23, 0.53), specificity of 0.94 (95% CI: 0.87, 0.98), positive
predictive value of 0.71 (95% CI: 0.39, 0.91) and a negative predictive value of 0.81 (95%
CI: 0.75, 0.85) for diagnosis of Intracerebral Hemorrhage. [Table - 6]

Equivocal cases were 51% for Greek Score, 24% for Siriraj Stroke score and 42% for Allen's
score.


Discussion



Management of stroke largely depends on differentiation of hemorrhagic from ischemic
stroke. Clinical stroke score can help in the differential diagnosis of stroke in areas with
limited CT scan facilities. These scores are simple, screening diagnostic tools at the bedside,
especially in rural hospitals. However, it has been found that the scoring systems are
relatively inefficient in differentiating strokes.

Recently Siriraj stroke score and Guy's hospital score was tested by Badam et al in Indian
settings and found that both score are not sufficiently accurate to identify infarct from
hemorrhage.[8]

Kochar et al studied both the scores in an Indian setting and found that Siriraj stroke score
had specificity of 73% and Allens score had specificity of 91% in diagnosing
hemorrhage.[9] Our study has also shown similar results.

Our study showed that Siriraj Stroke score and Greek stroke score were not comparable in
certain results whereas Allen's score and Greek stroke score had fair comparability. Using
these two scores (Allen's score and Greek stroke score) together can increase the accuracy
but Allen's score can only be calculated at the end of 24 hours hence combined use is
restricted. Even though Greek Score and Allen's score have specificity of 94% for diagnosing
hemorrhage, Greek score is better than Allen's as it can be calculated immediately on
admission. When physician wants to ascertain diagnosis of hemorrhage at admission, use of
Greek score is advisable.

Siriraj stroke score was relatively easy to calculate and it can be calculated on admission.
Greek Score has utilized hematological investigation of WBC count for calculating score.

This is the first validation study in India for Greek stroke score. Sensitivity, specificity,
positive predictive value and negative predictive value calculated were inferior to original
study from Greek. As our study had a small cohort further study is required with large
sample of patients to validate this score in India.

Systematic diagnostic approaches studied here can be used as guide to treating physicians
where computed tomography facility is not available. Our study shows that these clinical
scoring systems do not exhibit enough accuracy to be applied safely if the use of
antithrombotic treatment is to be considered. And use of these clinical stroke scores can
only be limited to clinically classify strokes for academic purpose where CT scan facility is
not available.

Though the Greek Score is better than the Siriraj Stroke score and Allen's score in
differential diagnosis of stroke, further improvement will have to be done in the future
Stroke scores to increase their specificity. In view of low specificity of stroke scores and
complications involved in inadvertent anticoagulant use in hemorrhagic stroke the use of
these scoring systems in the presence of CT scan facilities is unadvisable.


Conclusion



Greek score and Allen's score has similar specificity in diagnosing hemorrhage but the later
can be calculated only at the end of 24 hours hence, the Greek score is better that Allen's
score. The CT scan remains as a gold standard in differential diagnosis of stroke and scoring
systems are used as a guide in management only when resources are limited and CT scan
facilities are not available. These scoring systems require further improvement to increase
specificity.
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