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

Article  in  Indian Journal of Medical Sciences · November 2004

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 417 418 INDIAN JOURNAL OF MEDICAL SCIENCES

INTRODUCTION score and Allen’s stroke score and validate the

Indian Journal of Medical Sciences new stroke score in Indian settings.
There are two famous stroke scores which can
(INCORPORATING THE MEDICAL BULLETIN)
guide the treating physician in clinical MATERIALS AND METHODS
VOLUME 58 OCTOBER 2004 NUMBER 10 distinction of hemorrhagic and ischemic stroke:
Siriraj Scoring System and the Guys Hospital Ninety one patients of acute cerebrovascular
ORIGINAL CONTRIBUTIONS
Scoring System, which have been studied at accidents, admitted in a single Tertiary care
various centers in India for efficacy. Hospital in India were randomly enrolled in this
GREEK STROKE SCORE, SIRIRAJ SCORE AND ALLEN SCORE IN
study for duration of one year (Jan to Dec
CLINICAL DIAGNOSIS OF INTRACEREBRAL HEMORRHAGE AND
Akpunonu et al studied the accuracy of Siriraj 2002). Inclusion criteria were: patients whose
INFARCT: VALIDATION AND COMPARISON STUDY Stroke score and concluded that the sensitivity neurodeficit lasted for more than 24 hours and
AAMOD SOMAN, SHASHANK R. JOSHI, SANJAY TARVADE, S. JAYARAM was 36% for the hemorrhagic stroke and 90% CT scan showed supratentorial cerebral
ABSTRACT for the non hemorrhagic stroke, and the infarction or intracerebral hemorrhage.
positive predictive values were 77% and 61% Exclusion criteria used were: patients with
AIM: To compare Greek stroke score with available previous two stroke scores for the respectively.1 stroke due to other causes like tuberculosis,
diagnosis of cerebral ischemia and hemorrhage in acute stroke patients, and validate tumors or trauma, patients who had insufficient
the Greek stroke score. SETTING: A tertiary hospital in India. MATERIALS AND Comparison of the two scores has been done data to calculate scores and patients with
METHODS: In a prospective study acute stroke patients were evaluated with Greek in many studies. These studies have concluded subarachnoid hemorrhage were excluded.
stroke score, Allen score and Siriraj stroke score. Comparability (Kappa Statistics) and that the Siriraj score is better than the Guy’s Approval of Ethics committee of the hospital
validity (sensitivity, specificity, negative predictive value and positive predictive value) hospital score but at the same time the was sought prior to starting the study. Written
of the Greek stroke score and previous scores were tested. RESULT: Out of the 91
sensitivity of the Siriraj score has been in the informed consent was signed by patients
patients enrolled in the study, 47 patients had cerebral infarction and 44 patients had
range of 80 - 90%. 2,3 However, a recently before enrolling. Authors collected the data and
hemorrhage by CT scan. Allen score was uncertain / equivocal in 39 patients, Siriraj
conducted study by Wadhwani Jyoti, et al stroke scores were calculated for each patient
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), showed that the sensitivity of Siriraj stroke independently.
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 score was 92.54% in diagnosing infarction and
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), 87% for hemorrhage and its overall accuracy The following patient variables were recorded:
0.78(95% CI 0.69,0.86) and for Greek Score were 0.42(95% CI: 0.23,0.53), 0.93(95% was 91.11%. The Guy’s hospital score had a age, gender, history of previous stroke, TIA,
CI: 0.87,0.98), 0.71(95% CI:0.39,0.91), 0.81(95% CI:0.75,0.85) respectively. Greek sensitivity of 93.42% in diagnosing infarction, IHD, Rheumatic heart disease, peripheral
stroke score was compared with previous scores using kappa statistics which revealed 66.66% for hemorrhage and overall accuracy ar terial disease, hyper tension, diabetes,
substantial strength of agreement between the Allen Score for certain results. of the score was 87%.4 smoking, alcohol consumption, hyperlipidemia,
CONCLUSION: The overall comparability of Greek stroke score and Allen score was clinical signs, and symptoms (onset of deficit,
better as compared to Greek stroke score and Siriraj stroke score. Greek Stroke score
Recently, a new score proposed by a team headache, vomiting, blood pressure, Glasgow
was more specific in diagnosing hemorrhage as compared to Siriraj score. However,
from Athens claimed that the sensitivity, Coma Scale, pupil and plantar response, neck
all these stroke scores lack accuracy hence could not be applied safely to guide the
physician in management of stroke.
specificity, positive predictive value and stiffness, level of consciousness, neurological
negative predictive value were much better as deterioration within the first 24 hours) and
KEY WORDS: Siriraj stroke score, Greek stroke score, Allen score, Comparison, compared to the previous scores.5 This Greek basic laboratory data (ECG, WBC count). Data
validation. Score has not been validated in India. was also utilized to study epidemiology of
stroke.
Department of Medicine, Grant Medical College & Correspondence: Our aim was to compare new scoring system
Sir JJ Group of Hospitals, Mumbai - 400008, India. S. R. Joshi, B 23, Kamal Pushpa, 6 Bandra Recalamation,
Bandra, Mumbai - 400050, India. E-mail: srjoshi@vsnl.com (Greek stroke score) with the Siriraj stroke A form containing variables for all the three

Indian J Med Sci Vol. 58 No. 10, October 2004 Indian J Med Sci Vol. 58 No. 10, October 2004
 DIAGNOSIS OF INTRACEREBRAL HEMORRHAGE AND INFARCT 419 420 INDIAN JOURNAL OF MEDICAL SCIENCES

scores was filled by authors, and the definitions statistics program for comparability test. Table 2: Comparison of Siriraj Stroke Score with Table 5: Comparison of Allen’s score with CT scan
Greek Score
and guidelines were followed as per the Allen’s Score CT Diagnosis
original scores. CT scan was done in all the RESULTS Siriraj Stroke Score Greek Score Haemorrhage Infarction
patients. Haemorrhage Infarction Equivocal Haemorrhage 9 2
Out of 91 patients, 47 patients (51.64%) had Haemorrhage 6 0 25 Infarction 9 32
Infarction 0 28 10 Equivocal 26 13
The scores were calculated from the above cerebral infarction and 44 patients (48.35%) Equivocal 1 9 12
variables (Formulas for calculation in Table 1)5- had intracerebral hemorrhage by Computed
Table 6: Comparison of Greek Stroke score with CT
7
and they were compared in ‘certain’ results Tomography. Table 3: Comparison of Allen’s score with Greek scan
i.e. percentages of scores in which the scores score
Greek Score CT Diagnosis
predicted ischemia or hemorrhage according Using Kappa statistics the overall comparability Allen’s score Greek Score Haemorrhage Infarction
to the cutoffs suggested in the original papers. for certain cases of Greek Score with Siriraj Haemorrhage Infarction Equivocal
Haemorrhage 5 2
Results were considered to be certain when stroke score was fair. (K=0.27) (Table 2) and Haemorrhage 6 0 5 Infarction 7 30
Allen score was <4 and >24, <-1 and >1 for with Allen’s score was good (K=0.51) (Table 3) Infarction 0 29 12 Equivocal 32 15
Equivocal 1 8 30
Siriraj stroke score and Greek Score was <3
and >11. Kappa statistics were determined for The Siriraj Stroke score diagnosed 38 patients specificity of 0.94 (95% CI: 0.87, 0.98), positive
Table 4: Comparison of Siriraj stroke score with CT
agreement between two scores for certain as cerebral infarction and 31 patients as predictive value of 0.71 (95% CI: 0.39, 0.91)
scan
cases. Intracerebral Hemorrhage while 22 patients and a negative predictive value of 0.81 (95%
Siriraj Score CT Diagnosis CI: 0.75, 0.85) for diagnosis of Intracerebral
were in equivocal category. Thus the Score
Haemorrhage Infarction
The results of three scores were compared had a sensitivity of 0.75 (95% CI: 0.63, 0.84), Hemorrhage. (Table 6)
Haemorrhage 24 7
with results of CT scan study. Sensitivity, specificity of 0.81 (95% CI: 0.71, 0.89), positive Infarction 8 30
specificity. Positive predictive value and predictive value 0.77 (95% CI: 0.65, 0.86) and Equivocal 12 10 Equivocal cases were 51% for Greek Score,
negative predictive value were calculated for a negative predictive value of 0.78 (95% CI 24% for Siriraj Stroke score and 42% for Allen’s
diagnosis of hemorrhage. We used Kappa 0.69, 0.86) for diagnosis of Intracerebral Hemorrhage. (Table 4) score.

Table 1: Formula for calculating Siriraj, Allen’s and Greek Score 5, 6, 7

The Allen’s stroke score diagnosed 41 patients DISCUSSION
Score Formula Results as cerebral infarction and 11 patients as
Siriraj Score Number of points = 2.5* (Level of Consciousness) > +1 Hemorrhage Intracerebral Hemorrhage while 39 patients Management of stroke largely depends on
+ 2* (Vomiting) < - 1 Infarction were in equivocal category. Thus the score had differentiation of hemorrhagic from ischemic
+ 2* (Headache within 2 hrs of onset) +1 to -1 Equivocal
+ 0.1* (Diastolic Blood Pressure) sensitivity of 0.50 (95% CI: 0.34, 0.58) stroke. Clinical stroke score can help in the
- 3* (Atheroma Markers) specificity of 0.94 (95% CI: 0.86, 0.98), positive differential diagnosis of stroke in areas with
- 12 (Constant)
Allen’s Score Number of points = Apoplectic onset + Level of consciousness predictive value of 0.81 (95% CI: 0.56, 0.95), limited CT scan facilities. These scores are
+ Plantar responses + [Diastolic blood < 4 Infarction and negative predictive value of 0.78 (95% CI: simple, screening diagnostic tools at the
pressure (24 hours after admission) X 0.17] > 24 Hemorrhage
0.71, 0.81) for diagnosis of Intracerebral bedside, especially in rural hospitals. However,
+ Atheroma markers + History of 4 – 24 Equivocal
hypertension + Previous event (Transient Hemorrhage. (Table 5) it has been found that the scoring systems are
ischaemic attack) + Heart disease + Constant (-12). relatively inefficient in differentiating strokes.
Greek Score Number of points =
6* (Neurogical deterioration within 3 hours < 3 Infarction The Greek Score diagnosed 37 patients as
from admission) > 11 Hemorrhage intracerebral hemorrhage, 7 patients as Recently Siriraj stroke score and Guy’s hospital
+ 4 * (vomiting) 3 – 11 Equivocal
+ 4 * (WBC >12000)
cerebral infarction and 47 patients were in score was tested by Badam et al in Indian
+ 3 * (decreased level of consciousness) equivocal category. Thus the Greek Score had settings and found that both score are not
a sensitivity of 0.416 (95% CI: 0.23, 0.53), sufficiently accurate to identify infarct from

Indian J Med Sci Vol. 58 No. 10, October 2004 Indian J Med Sci Vol. 58 No. 10, October 2004
 DIAGNOSIS OF INTRACEREBRAL HEMORRHAGE AND INFARCT 421 422 INDIAN JOURNAL OF MEDICAL SCIENCES

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.
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, 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.
CONCLUSION
aid in early diagnosis and treatement of various
stroke syndromes? Am J Med Sci 1998;315:
194-8.
2. Daga MK, Sarin K, Negi VS: Comparison of Siriraj
Stroke score and Guy’s Hospital Score to
differentiate supratentorial ischemic and
hemorrhagic stroke in the Indian population; JAPI
1994;42:302-3.
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.
4. 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.
5. Efstathiou SP, Tsioulos DI, Zacharos ID. A new
classification tool for clinical differentiation
between haemorrhagic and ischaemic stroke. J
Intern Med 2002;252:121.
6. Poungvarin N, Viriyavejakul: Siriraj Stroke score
and validation study to distinguish supratentorial
Intracerebral hemorrhage from infarction, BMJ
1991;302:1565-7.
7. Sandercock PAG, Allan CMC, Corston RN, et al.
Clinical diagnosis of Intracerebral hemorrhage
using Guy’s Hospital Score. BMJ 1986;292:173.
8. Badam P, Solao V, Pai M, Kalantri SP. Poor
accuracy of the Siriraj and Guy’s hospital stroke
scores in distinguishing haemorrhagic from
ischaemic stroke in a rural, tertiary care hospital.
Natl Med J India 2003;16:8-12.
9. Kochar DK, Joshi A, Agarwal N, Aseri S, Sharma
BV, Agarwal TD. Poor diagnostic accuracy and
applicability of Siriraj stroke score, Allen score
and their combination in differentiating acute
haemorrhagic and thrombotic stroke. J Assoc
Physicians India 2000;48:584-8.

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.
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.
REFERENCES

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1. Akpononu BE, Mutgi AB, Lee L, Khuder S,
Systematic diagnostic approaches studied Federman DJ, Roberts C. Can a clinical score

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