hemorrhagic versus ischemic stroke

8/11/2019 Hemorrhagic Versus Ischemic Stroke

1/5


2/5

CHAPTER 65 HEMORRHAGIC VERSUS ISCHEMIC STROKE 625

the most widely used is the Siriraj stroke score, developed by Poungvarinand others7in 1991 (Table 65-1).

III. CLINICAL SIGNIFICANCEThe data in EBM Boxes 65-1 and 65-2 stem from the analysis of 35 studies

enrolling more than 9000 patients with stroke from across the globe. Thediagnosis of hemorrhagic stroke in these studies includes both intracranialand subarachnoid hemorrhage, although relatively few patients had sub-arachnoid hemorrhage. Diagnostic accuracy of bedside findings is the sameif patients with subarachnoid hemorrhage are excluded.3

A. SYMPTOMS

According to a systematic review,3 the following symptoms increase theprobability of hemorrhagic stroke: seizures accompanying the neurologicdeficit (likelihood ratio [LR] = 4.7), vomiting (LR = 3), severe headache

Small left

basal gangliahemorrhage

Hemiparesis

Continuedbleeding

Rapid neurologic deterioration

Headache and vomiting

Uncal herniation(arrow)orbilateral cerebral

dysfunction

Drowsiness and coma

Neck stiffnessIntraventricularbleeding,leading tosubarachnoidblood

Increased

intracranialpressure

FIGURE 65-1 Additional findings of hemorrhagic stroke (coronary section ofbrain).Top half:There is a small hemorrhage in the left basal ganglia, causing hemiparesis and clini-cal findings indistinguishable from ischemic stroke. Bottom half:Progressive intracranial hemorrhagecauses the additional findings of hemorrhage, including rapid neurologic deterioration, headache,vomiting, coma, and neck stiffness. Intraventricular blood follows the normal path of cerebrospinalcirculation through the median and lateral apertures of the fourth ventricle to reach the subarach-noid space at the base of the brain. (Only rarely does intracerebral hemorrhage directly rupture inthe subarachnoid space.)


3/5

626 PART 13 SELECTED NEUROLOGIC DISORDERS

TABLE 65-1 Siriraj Stroke Score*

Characteristic Points

Mental status

Coma or semicoma + 5Drowsy or stupor + 2.5

Vomiting + 2

Headache within 2 hours + 2

Diastolic blood pressure + 0.1 DBP in mm Hg

Diabetes, angina, or intermittentclaudication

3

Correction factor 12

*From reference 7. Interpretation of total score: >1, hemorrhage;1 to 1, uncertain; 220 mmHg8

17 96 4.0 NS

Systolic BP


4/5

CHAPTER 65 HEMORRHAGIC VERSUS ISCHEMIC STROKE 627

Finding(Reference)

Sensitivity(%)

Specificity(%)

Likelihood Ratio

if Finding IsPresent Absent

Neurologic Deficits

Deviation ofeyes11,12,17,18

27-62 64-81 1.9 0.7

Hemiparesis1012,1719 17-87 12-73 NS NS

Aphasia11,12,17,20 12-35 62-92 NS NS

Hemisensory distur-

bance

1012,17,180-80 40-98 1.3 NS

Hemianopia11,12 35 73 1.3 NS

Ataxia11,12 15 80 NS NS

Other Findings

Cervical bruit9,11,12 1 81-93 0.1 NS

Atrial fibrillation onECG10,15,17,18

1-21 69-91 0.4 1.2

*Diagnostic standard: for hemorrhagic stroke, computed tomography (all studies), sometimes

with magnetic resonance imaging14,21

or autopsy.14,22

Definition of findings: for both toes extensor, the Babinski response ispresenton both feet;for both toes flexor, the Babinski response is absentin both feet.

Likelihood ratio (LR) if finding present = positive LR; LR if finding absent = negativeLR.

ECG, electrocardiogram; NS, not significant.Click here to access calculator.

Probability

+45%+30%+15%15%30%45%

LRs

Decrease Increase

0.1 0.2 0.5 1 2 5 10LRs

HEMORRHAGIC STROKE

Coma

Neck stiffness

Neurologic deterioration duringfirst 3 hours

Systolic blood pressure >220 mm Hg

Both toes extensor

Cervical bruit

Absence of neurologicdeterioration during first

3 hours

EBM BOX 65-1

Hemorrhagic Strokecontd

(LR = 2.9), and loss of consciousness (LR = 2.6). Chronic anticoagulationwith warfarin also increases the probability of hemorrhagic stroke (LR =5.4).8,20A history of prior transient ischemic attack decreases the prob-ability of hemorrhagic stroke (LR = 0.3).
http://coursewareobjects.elsevier.com/objects/elr/ExpertConsult/McGee/diagnosis3e/calculator/http://coursewareobjects.elsevier.com/objects/elr/ExpertConsult/McGee/diagnosis3e/calculator/


5/5

628 PART 13 SELECTED NEUROLOGIC DISORDERS

B. INDIVIDUAL PHYSICAL FINDINGS

According to the LRs in EBM Box 65-1, the physical findings that increasethe probability of hemorrhagic stroke are coma (LR = 6.3), neurologicdeterioration during the first 3 hours (LR = 5.8), neck stiffness (LR = 5.4),systolic blood pressure higher than 220 mm Hg (LR = 4), and Babinskiresponse in both toes (LR = 2.4).

The findings that decrease the probability of hemorrhagic stroke are cer-vical bruit (LR = 0.1) and absence of neurologic deterioration during thefirst 3 hours (LR = 0.2).

As expected (see the section on Findings), the presence or absence ofneurologic deficitshemiparesis, hemisensory disturbance, deviation ofeyes, aphasia, hemianopia, and ataxiafail to distinguish hemorrhagic

stroke from ischemic stroke.

C. COMBINED FINDINGS (SIRIRAJ STROKE SCORE)

A Siriraj score greater than 1 (hemorrhage) increases the probability ofhemorrhagic stroke (LR = 5.4; see EBM Box 65-2), whereas a score lessthan 1 (infarction) decreases the probability (LR = 0.3). Nonetheless, inthese studies, an average of 20% of patients with stroke (range, 8% to 48%)were classified as uncertain by the Siriraj score, a score lacking diagnosticvalue. (LR is not significant.)

The references for this chapter can be found on www.expertconsult.com.

EBM BOX 65-2

Siriraj Score for Hemorrhagic Stroke*

Finding(Reference)

Sensitivity(%)

Specificity(%)

Likelihood Ratio

if Finding IsPresent Absent

Siriraj score hemor-rhage (>1)

23-87 65-99 5.4

Siriraj score uncertain(1 to 1)

1-51 NS

Siriraj score infarction(

hemorrhagic versus ischemic stroke

Documents