Brain Hemorrhages 4 (2023) 13–16

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Brain Hemorrhages
CHINESE ROOTS
GLOBAL IMPACT
journal homepage: www.keaipublishing.com/en/journals/brain-hemorrhages/

Research Article

Reliability of Siriraj stroke score to distinguish between hemorrhagic and

ischemic stroke
Iqra Athar ⇑, Adil Muhammad Malik, Neelma Naz Khattak, Anam Anis, Mansoor Iqbal, Haris Majid,
Mazhar Badshah
FCPS Neurology Pakistan Institute of Medical Sciences, Islamabad, Pakistan

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The aim of study was to establish a quick way to differentiate between hemorrhagic and
Received 11 June 2022 ischemic stroke by using siriraj stroke score and find its specificity and sensitivity by comparing it with
Received in revised form 13 July 2022 CT scan findings.
Accepted 17 July 2022
Study design: Cross-sectional study.
Available online 20 July 2022
Place and duration of study: Department of Neurology Pakistan Institute of Medical Sciences Islamabad
from Jan 2021 to June 2021.
Keywords:
Methodology: Total 110 patients of acute stroke were included. Any patient of > 20 years old, non-
Siriraj stroke score
Stroke
traumatic, focal neurological deficit < 14 days with no obvious reason other than vascular were included.
Hemorrhagic stroke Siriraj stroke score was calculated its findings were compared with a CT scan findings. Data was analyzed
by SPSS ver.23.0.
Results: The mean age of patients was 66.10 ± 14.58 years. There were 54 (49.10 %) males and 56
(50.90 %) females. Hypertension was the most common disease found in 79 (71.8 %). The sensitivity,
specificity, PPV and NPV of Siriraj stroke score was 83.87 %, 66.6 %, 74.2 % and 71.42 % respectively for
hemorrhagic stroke and 93.4 %, 80.95 %, 93.4 % and 37.03 % respectively for non-hemorrhagic stroke.
Conclusion: It is an easy, cost effective and bed side scoring system which can accurately identify the
stroke type without any other radiological investigation. It can be employed in areas where CT scan facil-
ity is not available and treatment can be started early which will definitely lower mortality and morbidity
of stroke patients.
Ó 2023 International Hemorrhagic Stroke Association. Publishing services by Elsevier B.V. on behalf of
KeAi Communications Co. Ltd. This is an open access article under the CC BY-NC-ND license (http://creati-
vecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction promise. Hemorrhagic stroke is secondary to rupture of any brain

Cerebrovascular accident or stroke is sudden development of
neurologic deficit due to sudden loss of blood supply to a part of
brain.1 The mortality rate following stroke is 25 % and is the third
most common cause of death worldwide first and second being the
cancer and ischemic heart disease respectively.2–3 Developing
countries like Pakistan are not only burdened with infectious dis-
eases but also with hypertension, ischemic heart diseases, stroke
and diabetes mellitus. Stroke is a major health issue in poor coun-
tries as it causes physical dependence, depression and mental
health issues both in patients and caretakers and poses a major
economic burden on caretakers. Stroke can be hemorrhagic or
ischemic depending upon the cause which lead to brain flow com-
⇑ Corresponding author at: FCPS Neurology Pakistan Institute of Medical
Sciences, Islamabad, Pakistan.
E-mail address: iqraats.ia@gmail.com (I. Athar).
vessel and accounts for 10–15 % of deaths while in ischemic stroke
blood flow obstructs due to thrombo-embolic phenomenon and is
more common.4.
Early diagnosis and prompt treatment is necessary to reduce
further damage to brain and reducing mortality in stroke patients.
Early Distinction between ischemic and hemorrhagic stroke is nec-
essary to start thrombolytic, antithrombotic treatment or carotid
endartrectomy. Non contrast enhanced CT scan brain is common
and most accurate way to distinguish between ischemic and hem-
orrhagic stroke but its availability is an issue in resource poor
countries like Pakistan.5 So a strong clinical knowledge or some
clinical scoring system is required to make initial diagnosis and
start early prompt treatment. Two commonly used scoring systems
are Guys hospital score6 and siriraj stroke score which was devel-
oped in 1991 by poungvarin et al in Siriraj hospital Thailand.7 The
siriraj stroke score require history and examination while Guys

https://doi.org/10.1016/j.hest.2022.07.002
2589-238X/Ó 2023 International Hemorrhagic Stroke Association. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co. Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
I. Athar, A.M. Malik, N.N. Khattak et al. Brain Hemorrhages 4 (2023) 13–16

hospital score in addition to history and examination require chest Table 1

X-ray and ecg.8 Their clinical use has produced different results in Demographics of patients.

different ethnic populations.9. No of patients 110

We have conducted this study to find out the specificity and Age (years) 66.10 ± 14.58
sensitivity of siriraj stroke score in Pakistani population so that a Male 54 (49.10 %)
reliable, cost effective clinical score should be available for early Female 56 (50.90 %)
diagnosis and prompt treatment can be started without any further Mean time of onset of symptoms(hours) 22.37 ± 51.89
Previous Stroke 34 (30.9 %)
delay. Hypertension 79 (71.8 %)
Diabetes Mellitus 51 (46.4 %)
Ischemic Heart Disease 45 (40.9 %)
2. Methodology Chronic Kidney Disease 13 (11.8 %)
Mean Diastolic Blood Pressure 98.78 ± 15.94
We conducted a cross-sectional study in Department of Neurol-
ogy, Pakistan Institute of Medical Sciences Islamabad from Jan
2021 to June 2021 after approval from ethical committee. Sample Table 2
size of 110 cases was estimated by keeping 80 % power of study, Siriraj Stroke Score.
5 % significance level and sensitivity of stroke score i.e. 63.27 %
Variableo Clinical feature score Factor
of ischemic stroke and 72.22 % of hemorrhagic stroke.1 We defined
Level of consciousness Alert 0
stroke according to World health organization definition as
Stupor, drowsy +1 x 2.5
‘‘rapidly developing signs of focal (or global) disturbance of cere- comatose +2
bral function, leading to death or lasting longer than 24 h, with Vomiting No 0 x2
no apparent cause other than vascular’’.10 Inclusion criteria was Yes +1
No 0 x2
any patient of > 20 years of age with rapid onset of focal neurolog-
Headache Yes +1
ical deficit < 14 days with no obvious reason other than vascular, Diastolic blood pressure mm Hg x 0.1
non-traumatic, with no history of any other neurological disease Atheroma markers None 0
or SOL brain and patients not on anticoagulants. Informed written (DM, Angina, Intermittent claudication One or more 1 x 3
consent was taken from all patients/relatives before including Constant – – 12
them in study. Data was collected on proforma by postgraduate
trainees on duty. Siriraj score was calculated by using following
formula. ischemic stroke. Siriraj stroke score was inconclusive for 18
Siriraj Stroke Score (SSS)= (2.5  level of consciousness) + patients (16.4 %). When Ct scan was done and its results were com-
(2  vomiting) + (2  headache) + (0.1  diastolic blood pressure) pared with siriraj stroke score it was found that out of 31 patients
- (3  atheroma markers) 12. which were labeled as hemorrhagic stroke 26 patients (83.87 %)
Score > 1 was labeled as hemorrhagic stroke and score < -1 was had intracerebral and subarachnoid hemorrhage (true positive)
labeled as ischemic stroke. The score between 1 and 1 was while 5 (16.12 %) patients had ischemic stroke (false positive). Sim-
labeled as inconclusive. Later CT scan was done and reporting ilarly out of 61 patients (55.5 %) which were labeled as ischemic
was done by radiology department of the same hospital and its stroke 57 patients (93.4 %) had infarct present on ct scan (true pos-
findings were compared with calculated siriraj stroke score of that itive) and 4 patients (6.6 %) had intracerebral bleed (false positive).
patient. Conversely based on ct scan findings 36 patients (32.7 %) who had
Data was collected and later on entered and analyzed in SPSS v. intracerebral bleed siriraj stroke score predicted 26 patients
23. Mean and standard deviation was calculated for quantitative (72.22 %) as hemorrhagic stroke, 4 patients (11.1 %) as ischemic
variables and frequency and percentages for qualitative variables. stroke and 6 patients (16.66 %) were labeled as uncertain. Similarly
siriraj stroke score was compared with ct scan findings and sensi- out of 74 patients (67.3 %) who were labeled as ischemic stroke 57
tivity, specificity, positive predictive value and negative predictive patients (77.02 %) were predicted by siriraj stroke score as
value was calculated. ischemic stroke, 5 patients (6.7 %) were labeled as hemorrhagic
stroke and 12 patients (16.21 %) as uncertain. Above findings are
mentioned in Table 4.
3. Results
The sensitivity and specificity positive predictive value and neg-
ative predictive value calculated by findings as mentioned in
We included total 110 patients. The mean age of patients was Table 5 is summarized in Table 5.
66.10 ± 14.58 years. There were 54 (49.10 %) males and 56
(50.90 %) females. Mean time of onset of symptoms was 22.37 ± 5
1.89 h. Mean diastolic blood pressure was 98.78 ± 15.94 mmHg. 4. Discussion
Hypertension was the most common disease found in 79 (71.8 %)
patients followed by diabetes mellitus which was present in 51 About 5–10 % patients of acute stroke suffer from cerebral hem-
(46.4 %) patients. 34 patients (30.9 %) had previous history of orrhage in America and Europe but this rate is higher in developing
stroke. Other comorbids and patients demographics are mentioned countries like Pakistan due to poorly controlled blood pressure.11–
12
in Table 1. At siriraj hospital where this score was developed 40–50 % cases
Siriraj stroke score was calculated in all patients by scoring sys- of stroke had cerebral hemorrhage.6 Early identification of stroke
tem as mentioned in Table 2. 23 (20.9 %) patients were alert at the type plays a pivotal role in management of stroke and its outcome
time of presentation while 63 (57.3 %) patients were drowsy and and is necessary to start the prompt treatment to prevent further
24 (48.4 %) patients were in deep coma. 49 (44.5 %) patients had damage to brain tissue. In our study when sensitivity and speci-
vomiting at the time of presentation and 26 (23.6 %) patients had ficity of siriraj stroke score was calculated it was found that Siriraj
headache. Different atheroma markers were present in 77 (70 %) stroke score is 83.87 % sensitive and 66.6 % specific for hemor-
patients. The siriraj variables calculated are mentioned in Table 3. rhagic stroke and 93.4 % sensitive and 80.95 % specific for non-
On basis of siriraj stroke score 31 patients (28.2 %) were labeled hemorrhagic stroke. In our study the positive predictive value for
as hemorrhagic stroke and 61 patients (55.5 %) were labeled as hemorrhagic stroke was 74.2 % and for non-hemorrhagic stroke it
14
I. Athar, A.M. Malik, N.N. Khattak et al. Brain Hemorrhages 4 (2023) 13–16

Table 3
Patient’s characteristics and variables.

Variable Clinical feature Hemorrhagic stroke Ischemic stroke Uncertain Total

Gender Male 18 (58.1) 33 (54.1) 3 (16.7) 54 (49.1)
female 13 (41.9) 28 (45.9) 15 (83.3) 56 (50.9)
Level of consciousness Alert 1 (3.2) 22 (36.1) – 23 (20.9)
Stupor, drowsy 15 (48.4) 33 (54.1) 15 (83.3) 63 (57.3)
comatose 15 (48.4) 6 (9.8) 3 (16.7) 24 (48.4)
Vomiting Yes 23 (74.2) 17 (27.9) 9 (50) 49 (44.5)
Headache Yes 16 (51.6) 6 (9.8) 4 (22.2) 26 (23.6)
Atheroma markers Yes 19 (61.3) 48 (78.7) 10 (55.6) 77 (70)
(DM, Angina, Intermittent claudication

Table 4
Cross tabulation.

Ct scan findings
Hemorrhagic ischemic Total
Siriraj stroke score Hemorrhagic 26 (83.9 %) 5 (16.1 %) 31 (28.2 %)
Ischemic 4 (6.6 %) 57 (93.4 %) 61 (55.5 %)
uncertain 6 (33.3 %) 12 (66.7 %) 18 (16.4 %)
Total 36 (32.7 %) 74 (67.3 %) 110

Table 5
Sensitivity and Specificity of Siriraj Stroke Score.

Type of stroke Sensitivity Specificity Positive predictive value Negative predictive value
Hemorrhagic stroke 83.87 66.66 74.2 71.42
Non hemorrhagic stroke 93.4 80.95 93.4 37.03

was 93.4 %. Sherin A et al conducted a study in Karachi which Ethical approval

showed 67.74 %, sensitivity, 94.2 % specificity and 84 % positive
predictive value for hemorrhagic stroke and sensitivity of
78.26 %, specificity of 90.32 % and 94.73 % positive predictive value
for ischemic stroke in Pakistani population.13 Similarly a study by
shah FU et al showed a sensitivity of 71 % and specificity of 85 %
for cerebral infarction and for intracerebral hemorrhage, sensitivity
was 73 % and specificity was 90 % the positive predictive value for
cerebral infarction and cerebral hemorrhage were 87 % and 83 %
respectively.14 A study conducted by Pavan MR et al in south India
showed that the sensitivity of Siriraj score for detecting infarction
was 87.93 % and 77.27 % for hemorrhagic stroke. The specificity
was 77. 27 % for detecting infarction and for hemorrhage specificity
was 87.93 %.15 Rahman A et al showed in their study that sensitiv-
ity, specificity, and Positive Predictive Value for hemorrhagic
stroke was 71.4 %, 81.3 % and 79.7 % respectively.16 A study by
kabir R et al showed that sensitivity of Siriraj score for ischemic
stroke was 88.9 %, specificity was 97.1 % and a positive predictive
value of 88.9 %.The sensitivity of Siriraj score for hemorrhagic
stroke was 97.1 %, specificity was 88.9 %, and a positive predictive
value of 97.1 %.17 In our study the positive predictive value for
hemorrhagic stroke was 74.2 % and for non-hemorrhagic stroke it
was 93.4 %.
5. Conclusion
We conclude that siriraj stroke score is highly sensitive and
specific to identify the type of stroke in Pakistani population how-
ever it cannot replace CT Scan. It is an easy, cost effective and bed
side scoring system which can accurately identify the stroke type
without any other radiological investigation. It can be employed
in areas where CT scan facility is not available and treatment can
be started early which will definitely lower mortality and morbid-
ity of stroke patients.
The study was approved by the ethics committee of FCPS Neu-
rology Pakistan Institute of Medical Sciences. All clinical practices
and observations were conducted in accordance with the Declara-
tion of Helsinki.
Patient consent
Informed written consent was taken from all patients/ relatives
before including them in study.
Declaration of Competing Interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared
to influence the work reported in this paper.
References
1. Amjad Z, Nadeem M, Mustafvi SA, Baqai HZ. Accuracy of Siriraj Stroke Score in
Ascertaining the Type of Stroke. Journal of Islamabad Medical & Dental College
(JIMDC).. 2015;4(4):167–170.
2. Clarke CRA. Neurological diseases. In: Kumar P, Clark M, eds. Clinical
Medicine. London: Elsevier Saunders; 2006:1173–1273.
3. Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet. 2008;371
(9624):1612–1623.
4. Broderick J, Connolly S, Feldmann E, et al. Guidelines for the management of
spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline
from the American Heart Association/American Stroke Association Stroke
Council, High Blood Pressure Research Council, and the Quality of Care and
Outcomes in Research Interdisciplinary Working Group. Circulation. 2007;116
(16):e391–e413.
5. Eze CU, Okaro AO, Ohagwu CC. Pattern of computed tomography findings in
cerebrovascular accident patients in south eastern Nigeria – a retrospective
study of 480 patients. Eur J Sci Res.. 2009;34:104–109.
6. Ozeren A, Bicakci S, Burqut R, Sarica Y, Bozedemir H. Accuracy of bedside
diagnosis versus Allen and Siriraj Score in Turkish Patients. Eur J Neurol.
2006;13(6):611–615.

15
I. Athar, A.M. Malik, N.N. Khattak et al.
7. Poungvarin N, Viriyavejakul A, Komontri C. Siriraj stroke score and validation
study to distinguish supratentoral haemorrhage from infarction. BMJ. 1991;302
(6792):1565–1567.
8. Connor MD, Modi G, Warlow CP. Accuracy of the Siriraj and Guy’s hospital
stroke scores in urban South Africans. Stroke. 2007;38(1):62–68.
9. Hwong WY, Bots ML, Selvarajah S, Kappelle LJ, Abdul Aziz Z, Sidek NN, Vaartjes
I. Use of a diagnostic score to prioritize computed tomographic (CT) imaging for
patients suspected of ischemic stroke who may benefit from thrombolytic
therapy. PloS one. 2016 Oct 21;11(10):
10. Coupland AP, Thapar A, Qureshi MI, Jenkins H, Davies AH. The definition of
stroke. J R Soc Med. 2017 Jan;110(1):9–12.
11. Neelamegam M, Looi I, Cheah WK, Narayanan P, Hamid AM, Ong LM. Stroke
incidence in the south west district of the Penang island, Malaysia: PEARLs:
Penang acute stroke research longitudinal study. Prev Med. 2013 Jan;1(57):
S77–S79.
12. Khan SN, Vohra EA. Risk factors for stroke: a hospital based study. Pak J Med Sci.
2007;23(1):17–22.
16
Brain Hemorrhages 4 (2023) 13–16
13. Sherin A, Khan A, Rehman S, Shah NH, Shabbier G, Zarif M. Comparability and
validity of Siriraj stroke score and Allen stroke score in differentiation of acute
ischemic and haemorrhagic stroke. J Postgrad Med Inst. 2011;25(3):206–216.
14. Shah FU, Salih M, Saeed MA, Tariq M. Validaty of Siriraj Stroke Scoring.
Journal of the College of Physicians and Surgeons–pakistan : JCPSP.. 2003;13
(7):391–393.
15. Pavan MR, Madi MD, Achappa B, Unnikrishnan B. Comparison of Siriraj stroke
score with computerized tomography in ascertaining stroke type among South
Indians. Int J Biol Med Res.. 2012;3(3):1930–1933.
16. Rahman A, Jamal Q. Comparison of Siriraj stroke score with computerized
tomography in the type of the stroke among Pakistani population. Neurology.
2015;84(14 Suppl.). P. 1.078.
17. Kabir R, Pramanik MA, Haque SE, Tabassum M, Sultana F. Superiority of Siriraj
Stroke Score Over Guy’s Hospital Score in Diagnosing Acute Hemorrhagic
Stroke at Bedside. KYAMC Journal.. 2021;12(3):142–146.