417

Indian Journal of Medical Sciences

(INCORPORATING THE MEDICAL BULLETIN)
VOLUME 58

OCTOBER 2004

NUMBER 10

ORIGINAL CONTRIBUTIONS
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

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 score. 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.
KEY WORDS: Siriraj stroke score, Greek stroke score, Allen score, Comparison,
validation.
Department of Medicine, Grant Medical College &
Sir JJ Group of Hospitals, Mumbai - 400008, India.

Correspondence:
S. R. Joshi, B 23, Kamal Pushpa, 6 Bandra Recalamation,
Bandra, Mumbai - 400050, India. E-mail: srjoshi@vsnl.com

Indian J Med Sci Vol. 58 No. 10, October 2004

418

INDIAN JOURNAL OF MEDICAL SCIENCES

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 Guys
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 Guys 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
Indian J Med Sci Vol. 58 No. 10, October 2004

score and Allens 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
ar terial disease, hyper tension, 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

DIAGNOSIS OF INTRACEREBRAL HEMORRHAGE AND INFARCT

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)57
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

419

Table 2: Comparison of Siriraj Stroke Score with

Greek Score

RESULTS

Siriraj Stroke Score

Out of 91 patients, 47 patients (51.64%) had

cerebral infarction and 44 patients (48.35%)
had intracerebral hemorrhage by Computed
Tomography.

Haemorrhage
Infarction
Equivocal

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 Allens 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

Score

Formula

Results

Siriraj Score

Number of points = 2.5* (Level of Consciousness)

+ 2* (Vomiting)
+ 2* (Headache within 2 hrs of onset)
+ 0.1* (Diastolic Blood Pressure)
- 3* (Atheroma Markers)
- 12 (Constant)
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 event (Transient
ischaemic attack) + Heart disease + Constant (-12).
Number of points =
6* (Neurogical deterioration within 3 hours
from admission)
+ 4 * (vomiting)
+ 4 * (WBC >12000)
+ 3 * (decreased level of consciousness)

> +1 Hemorrhage
< - 1 Infarction
+1 to -1 Equivocal

Greek Score

INDIAN JOURNAL OF MEDICAL SCIENCES

statistics program for comparability test.

Table 1: Formula for calculating Siriraj, Allens and Greek Score 5, 6, 7

Allens Score

420

< 4 Infarction
> 24 Hemorrhage
4 24 Equivocal

< 3 Infarction
> 11 Hemorrhage
3 11 Equivocal

Indian J Med Sci Vol. 58 No. 10, October 2004

Greek Score
Haemorrhage Infarction Equivocal
6
0
1

0
28
9

25
10
12

Table 3: Comparison of Allens score with Greek

score

Allens score
Haemorrhage
Infarction
Equivocal

Greek Score
Haemorrhage Infarction Equivocal
6
0
1

0
29
8

5
12
30

Table 4: Comparison of Siriraj stroke score with CT

scan

Siriraj Score

CT Diagnosis
Haemorrhage
Infarction

Haemorrhage
Infarction
Equivocal

24
8
12

7
30
10

Hemorrhage. (Table 4)
The Allens 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),

Indian J Med Sci Vol. 58 No. 10, October 2004

Table 5: Comparison of Allens score with CT scan

Allens Score
Haemorrhage
Infarction
Equivocal

CT Diagnosis
Haemorrhage
Infarction
9
9
26

2
32
13

Table 6: Comparison of Greek Stroke score with CT

scan

Greek Score
Haemorrhage
Infarction
Equivocal

CT Diagnosis
Haemorrhage
Infarction
5
7
32

2
30
15

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 Allens
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 Guys hospital
score was tested by Badam et al in Indian
settings and found that both score are not
sufficiently accurate to identify infarct from

DIAGNOSIS OF INTRACEREBRAL HEMORRHAGE AND INFARCT

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 Allens score and
Greek stroke score had fair comparability.
Using these two scores (Allens score and
Greek stroke score) together can increase the
accuracy but Allens score can only be
calculated at the end of 24 hours hence
combined use is restricted. Even though Greek
Score and Allens score have specificity of 94%
for diagnosing hemorrhage, Greek score is
better than Allens 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

421

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 Allens score in
differential diagnosis of stroke, fur ther
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 inadver tent
anticoagulant use in hemorrhagic stroke the
use of these scoring systems in the presence
of CT scan facilities is unadvisable.

422

2.

3.

4.

5.

INDIAN JOURNAL OF MEDICAL SCIENCES

aid in early diagnosis and treatement of various

stroke syndromes? Am J Med Sci 1998;315:
194-8.
Daga MK, Sarin K, Negi VS: Comparison of Siriraj
Stroke score and Guys Hospital Score to
differentiate supratentorial ischemic and
hemorrhagic stroke in the Indian population; JAPI
1994;42:302-3.
Celani MG, Righetti E, Migliacci R, Zampolini M,
Antiniutti L, Grandi CF, et al. Comparibility and
validity of two clinical scores in the early
differential diagnosis of acute stroke. Clijnica
Neurologica, BMJ 1994;308:1674-6.
Jyoti Wadhwani, Riaz Hussain, PG Raman:
Nature of Lesion in Cerebrovascular Stroke
patients: Clinical Stroke Score and Computed
Tomography Scan Brain Correlation. J Assoc
Physicians India 2002;50;777-81.
Efstathiou SP, Tsioulos DI, Zacharos ID. A new
classification tool for clinical differentiation

CONCLUSION
Greek score and Allens 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
Allens 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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1. Akpononu BE, Mutgi AB, Lee L, Khuder S,
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Poungvarin N, Viriyavejakul: Siriraj Stroke score
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Sandercock PAG, Allan CMC, Corston RN, et al.
Clinical diagnosis of Intracerebral hemorrhage
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Badam P, Solao V, Pai M, Kalantri SP. Poor
accuracy of the Siriraj and Guys hospital stroke
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Natl Med J India 2003;16:8-12.
Kochar DK, Joshi A, Agarwal N, Aseri S, Sharma
BV, Agarwal TD. Poor diagnostic accuracy and
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Physicians India 2000;48:584-8.