A Comparative and Validity Study of Allen, Siriraj and Greek Score in Differentiation of Acute Ischemic and Hemorrhagic Stroke

INTRODUCTION: Acute cerebrovascular disease has been known to physicians even before the time of Hippocrates. Soranus of Esephus (AD 98-138) wrote that hemiplegic paralysis was common in old age, seldom occurred in youth. The ancient Indian study of life sciences by Charak Samhitha recognized “pakshavatha” or hemiplegia as one of the 80 disorders caused by disturbances in equilibrium of vata. Acute stroke is increasingly recognized as one of the leading cause of morbidity and mortality worldwide. It is one of the leading causes of long term hospitalization. An early therapeutic decision regarding management of stroke requires accurate diagnosis of stroke subtypes. It is difficult even for a expert physician to clinically differentiate ischemic and hemorrhagic stroke, therefore CT scan brain is now the gold standard tool for diagnosis of stroke subtypes. Time taken to obtain a CT scan brain delays treatment, therefore prehospital screening score systems can be used to differentiate ischemic and hemorrhagic stroke. Many stroke scoring systems have been devised to clinically differentiate ischemic and hemorrhagic stroke in centers with limited brain imaging facilities. The ALLEN, SIRIRAJ and GREEK stroke scores are the main existing model scores devised to differentiate clinically between hemorrhagic and ischemic stroke. AIMS AND OJECTIVES: To compare and validate the ALLEN, SIRIRAJ and GREEK clinical stroke scores in differentiation of acute ischemic and hemorrhagic stroke. The objective is to study the accuracy and validity of this scores in diagnosis of stroke subtype, so that these scores can be used in diagnosis of stroke subtypes in centers where neuroimaging facilities are not available or could not be done due to financial constraints. MATERIALS AND METHODS: Study population: 100 patients admitted with clinical findings suggestive of stroke at Department of General Medicine were included in the study. Study period: March 2012 to October 2012. Study design: cross sectional study. Inclusion criteria: 1. All patients with acute anterior circulation stroke presenting within 24 hours. 2. Age 20 to 75 years. Exclusion criteria: 1. Age 75 years. 2. Patients presenting after 24 hours. 3. Patient with chronic severe Neurological illness. 4. Patients already on antiplatelet therapy. Informed consent was obtained from all patients before enrolling in the study. The study was clearly explained to the patients and relatives in their own language. Parameters assessed: 1. Detailed history of the patient, 2. Examination with detailed neurological examination, 3. Complete blood count, 4. Screening for diabetes, 5. Renal function test, 6. Liver function tests, 7. Bleeding time/clotting time, 8. PT/PTT/INR, 9. Chest X ray, 10. ECG, 11. CT scan brain, 12. Calculation of ALLEN, SIRIRAJ AND GREEK score calculation. Methods: All patients between age 20 to 75years admitted in medical wards with history and clinical findings suggestive of anterior circulation stroke are included in the study. Siriraj and Greek scores was calculated at admission and the Allen score was calculated after 24 hours. CT scan brain was done for all patients at TNMSC CT scan centre, Stanley Medical Hospital. The results of scores and Radiologist report of CT scan brain were compared. They were statistically analyzed. RESULTS: The sample size of our study is 100 patients. All hundred patients those who were clinically diagnosed to have stroke underwent CT scan brain within 24 hours which was considered gold standard. Out of 100 cases 80 were proven to be infarct , 15 were proven to be hemorrhagic stroke by CT scan brain. Among rest 5, one had tuberculoma, one had CNS toxoplasmosis, one patient had cortical vein thrombosis, one had Intracerebral schwanoma and last one had glioma. The five were excluded from the study. CONCLUSION: The Siriraj and Greek stroke score is much simpler, easier to calculate and the time needed to diagnose is much less than Allen’s score, which is difficult to calculate. Moreover Allen score needs detailed clinical evaluation and at least monitoring for 24 hours. • When clinicians wish to start antithrombotic treatment while waiting for the scan results, they can rely on Greek and Siriraj stroke score, as the sensitivity, specificity and negative predictive values to detect hemorrhage is much higher than Allen’s score. • When both the Siriraj and Greek stroke scores considered together in a same patient, sensitivity and specificity for diagnosis of infarction and hemorrhage can be increased. • Further validation studies requiring a large number of participants are needed before wide acceptance of stroke scores as a screening tool in the diagnosis of stroke. • Nevertheless CT scan is the gold standard for differentiating ischemic and hemorrhagic stroke when the facility is available round the clock