Brain Hemorrhages 3 (2022) 184–188

Contents lists available at ScienceDirect

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

Research Article

Comparison of accuracy, sensitivity and specifity of Bahrudin score vs

Siriraj score vs Gajah Mada algorithm in diagnosing type of stroke
Mochamad Bahrudin a,⇑, Probo Yudha Pratama Putra b, Dinda Amalia Eka Putri c
a
Department of Neurology, Medical Faculty University of Muhammadiyah Malang, Malang, Indonesia
b
Medical Faculty University of Muhammadiyah Malang, Malang, Indonesia
c
Medical Faculty University of Muhammadiyah Malang, Malang, Indonesia

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

Article history: Introduction: Rapid diagnosis is crucial for stroke patients since it is an emergency that may result in
Received 14 June 2022 morbidity and mortality. The gold standard, which is a CT scan of the brain is not always feasible, hence,
Received in revised form 17 July 2022 Siriraj and Bahrudin Score, as well as Gajah Mada Algorithm are likely to be alternatives.
Accepted 21 July 2022
Objectives: This study aims to determine the specificity and sensitivity of the Siriraj and Bahrudin Score
Available online 26 July 2022
as well as Gajah Mada Algorithm.
Method: A cross-sectional study was undertaken at five network hospitals of the Medical Faculty
Keywords:
University in Muhammadiyah Malang. It involves a sample of 304 medical records used to determine
Bahrudin Score
CT Scan
the sensitivity, specificity, accuracy, and receiver operating characteristic (ROC) curve with output area
Gajah Mada Algorithm under the curve (AUC).
Siriraj Score Result: The result showed that the sensitivity and specificity of Bahrudin and Siriraj Acore, as well as
Stroke Gajah Mada Algorithm for determining infarct stroke was 91.3% vs 89.7% vs 61.2% and 67.7% vs 69.4%
vs 77.4%, respectively. For determining hemorrhagic stroke the values were 67.7% vs 69.4% vs 77.4%
and 91.3% vs 89.7% vs 61.2%, respectively. Furthermore, the area under the curve of Bahrudin and
Siriraj Scores was better than Gajah Mada Algorithm.
Conclusion: In conclusion, Bahrudin and Siriraj Scores have good accuracy, sensitivity, and specificity in
diagnosing stroke than Gajah Mada Algorithm.
Ó 2022 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 license (http://creativecom-
mons.org/licenses/by/4.0/).

1. Introduction combined, accounting for 5.7 % of total DALYs in 2019. Between

World Health Organization (WHO) defined stroke as rapidly
developing clinical symptoms of focal or global disturbance of
the cerebral function, lasting more than 24 h or resulting in death,
with no apparent cause other than vascular origin.1 The American
Heart Association/American Stroke Association revised its official
definition in 2013 to include silent hemorrhages and infarctions
in the cerebral, spinal, and retinal areas.1–2
The global burden of disease study reported 12.2 and 101 mil-
lion incidents and prevalent stroke cases, respectively. It also
reported 143 million disability-adjusted life-years (DALYs) attribu-
table to stroke, and 6.55 million fatalities in 2019. This disease
remained the world’s second-leading cause of death, accounting
for 11.6 %, and the third-leading cause of death and disability
⇑ Corresponding author at: Department of Neurology, Medical Faculty University
of Muhammadiyah Malang, Malang, Indonesia
E-mail address: neurobahrudin@gmail.com (M. Bahrudin).
1990 and 2019, the absolute number of incidents and prevalent
strokes increased by 70 % (67.0–73.0) and 85 % (83.0–88.0), respec-
tively. Mortality and DALYs due to stroke also increased by 43 %
(31.0–55.0) and 32 % (22.0–42.0), respectively.3.
The leading cause of death in Indonesia is stroke, accounting for
328.5 thousand, which is 21.2 % of all mortality in 2012. The coun-
try has the highest rate of stroke deaths in Asia as of 2010, with a
193.3/100,000 person-years age-sex standardized mortality rate.
According to the Indonesian Basich Health Research, the preva-
lence of stroke is 12.1 per million, with North Sulawesi Province
having the highest rate (17.9 %), followed by Yogyakarta (16.9 %).
Furthermore, the risk of stroke increases with age, peaking at 75
or older, and is equally common in both men and women. It is
more common among men across the world, while women are
more severely affected.4–5.
According to several standards, computed tomography remains
the best first-line modality in patients with acute strokes. Although
it is an excellent imaging tool without contrast enhancement for
distinguishing between acute ischemic and hemorrhagic strokes,

https://doi.org/10.1016/j.hest.2022.07.003
2589-238X/Ó 2022 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 license (http://creativecommons.org/licenses/by/4.0/).
M. Bahrudin, P. Yudha Pratama Putra and D. Amalia Eka Putri Brain Hemorrhages 3 (2022) 184–188

its sensitivity in detecting early changes is limited.6 According to Table 1

WHO data on medical equipment availability in 2017, 21 % of The calculation of Siriraj score.

low and middle-income countries (LMICs) still need a CT scanner. Variable Clinical Feature Score
They are expensive and out of reach for the majority of people, Consciousness (based on Glasgow Coma 15 or no alteration 0  2.5
specifically in low-income nations where insurance is unavailable.7 Scale)
Several hospitals in Indonesia have this modality, necessitating the 9–14 1  2.5
need for an early diagnostic tool to distinguish between hemor- 3–8 2  2.5
Vomiting No 02
rhage and ischemic stroke. Yes 12
The Siriraj, Allen, Bahrudin, Guy’s Hospital Stroke Score, and Gajah Headache (within 2 h) No 02
Mada Algorithm are some of the most often utilized scoring systems Yes 12
in Indonesia. Even though the results differ from CT scans, these Diastolic Blood pressure (mmHg) 0.1
Atheroma markers None 03
grading methods have been tested for accuracy.7–11 This study aims
One or more 13
to evaluate the sensitivity, specificity, and accuracy of the Siriraj Constant 12
Score system, Bahrudin Score, and Gajah Mada Algorithm in diagnos-
ing the type of stroke with CT scans. The system’s accuracy is
designed for daily use in the early management of stroke patients, Table 2
particularly in hospitals without neuroimaging modalities. The calculation of Bahrudin score.

Variable Clinical Score

2. Material and methods Feature
Awareness based on Glasgow Coma Scale) 15 0
A cross-sectional study was conducted at five network hospitals <15 1
Vomiting No 0
of the Medical Faculty University of Muhammadiyah Malang in
Yes 1
East Java, Indonesia, between October 2018 and December 2019. Headache (within 2 h) No 0
It involved 304 samples acquired and recorded in a medical record. Yes 1
The inclusion criteria are all stroke patients in the hospital net- Blood pressure (mmHg), Systolic  180 and No 0
work, first attack stroke, onset less than one week (acute phase), Diastolic  100 or Systolic only  180 or Diastolic
only  100
all age criteria, both male and female, and a CT scan of the brain
Yes 1
was used to confirm the diagnosis of hemorrhagic stroke or infarc-
tion. On the other hand, the exclusion criteria are brain tumor, two
clinical hemorrhagic and infarction based on CT-scan, and border-
4. Result
line score on both Siriraj and Bahrudin.
A diagnostic test was used to analyze the data, and the results
The result showed that from a total of 304 patients, 242 (79.4 %)
were compared for sensitivity, specificity, positive predictive value
suffered from infarction and 62 (20.4 %) were reported with the
(PPV), negative predictive value (NPV), positive probability ratio
diagnosis of hemorrhagic stroke. In addition, the incidence of
(PLR), negative likelihood ratio (NLR), accuracy, and receiver operat-
stroke increases after the age of 40 years (95.2 %), with a high per-
ing characteristic (ROC) curve with output area under the curve
centage reported at 51–60 years (30.5 %).
(AUC) to determine the strength of the tested score diagnostic value.
This study found that the incidence of stroke was higher in
ROC is used to represent the strength of a diagnostic value and
males than females. As observed from gender stratification, a total
the obtained area under the curve (AUC) reflects the trade-off
male and female of 174 (57.24 %) and 130 (42.76 %) admitted with
between sensitivity and specificity. The clinical and statistical tech-
diagnosis of stroke, 138 (57.2 %) and 104 (42.98 %) had infarction
niques for AUC interpretation are used. The strength of the diag-
stroke, and 36 (58.06 %) and 26 (41.94 %) had a hemorrhagic stroke,
nostic value is classified statistically as greater than 50 % 60 %,
respectively. Loss of consciousness was more common in hemor-
60 %- 70 %, 70 % 80 %, 80 % 90 %, and 90 % 100 % for Very
rhagic stroke 32 (51.61 %) than in infarct patients 41 (16.94 %) with
Weak, Weak, Moderate, Good, and Very Good, respectively. The
P < 0.005. Patients with headache symptoms significantly report
diagonal line that emerges from this ROC process denotes the
high in hemorrhagic than infarction accounting for 69.35 % and
points where the sensitivity and specificity are always 50 %. A diag-
25.21 %, respectively, with P < 0.005. Vomiting symptoms were
nostic instrument’s AUC value that is less than or equal to 50 % is
also high in hemorrhagic stroke (64.52 %) than in infarction
considered poor.12–13
patients (7.85 %). However, hypertension is less in infarction stroke
Siriraj score was calculated using the formula: (2.5  level of
than in hemorrhagic patients accounting for 61.98 % and 85.48 %,
consciousness) + (2  headache) + (2  [vomiting] + [0.1  diastol
respectively. These results are shown in Table 3.
ic blood pressure] –12– [3  atheroma marker]). A score of –1 and
The sensitivity and specificity of Bahrudin and Siriraj Scores, as
+1 was taken to suggest infarction and hemorrhage, respectively,
well as Gajah Mada Algorithm were compared in subjects with
while 1 to +1 was considered intermediate or borderlines. The
acute infarction stroke, their values were 91.3 % vs 89.7 % vs
variable is shown in Table 1.14 Furthermore, Bahrudin Score was
61.2 % and 67.7 % vs 69.4 % vs 77.4 %, respectively. Furthermore,
calculated using the formula (1  consciousness) +
PPV and NPV of Bahrudin, Siriraj, and Gajah Mada’s scores were
(1  Vomiting) + (1  Headache) + (1  blood pressure). A score >2
91.7 % vs 91.9 % vs 91.4 % and 66.7 vs 63.4 vs 33.8 %, respectively.
and <2 suggest hemorrhagic stroke and infarction, while = 2 is con-
In patients with acute hemorrhagic stroke, the sensitivity and
sidered intermediate or borderline. The calculation of Bahrudin
specificity were 67.7 % vs 69.4 % vs 77.4 % and 91.3 % vs 89.7 %
Score is shown in Table 2 7 and Gajah Mada Algorithm is demon-
vs 61.2 %. PPV of Bahrudin, Siriraj, and Gajah Mada score were
strated in Fig. 1.
66.7 % vs 63.4 % vs 33.8 % and the NPV were 91.7 % vs 91.9 % vs
91.4 %. In addition, the tool’s accuracy in both diagnoses was
3. Data analysis 86.5 %, 85.5 %, and 64.5 % for Bahrudin, Siriraj, and Gajah Mada
Algorithm, respectively.
Data were analyzed using the statistical package for social The ROC result for Bahrudin and Siriraj Scores, as well as Gajah
sciences (SPSS) version 26.0 (IBM Corporation, Armonk, NY, USA). Mada Algorithm above is greater than 50 %, indicating that this
185
M. Bahrudin, P. Yudha Pratama Putra and D. Amalia Eka Putri
Fig. 1. Gajah Mada stroke algorithm.
system is a reliable substitute for a CT scan when it is unavailable
(Fig. 2). The AUC value of Bahrudin’s and Siriraj’s scores are identi-
cal at 79.5 %, which can be rounded up to 80 %, with 95 % CI for
Bahrudin’s diagnostic value ranging from 72.2 % to 86.8 % and Siri-
raj’s score ranging from 72.3 % to 86.7 %. These results indicate the
diagnostic value of Bahrudin and Siriraj Scores is potent. Further-
more, Gajah Mada Algorithm has an AUC value of 69.3, which
can be rounded up to 70 %, with a 95 % CI range of 62.2 % to
76.4 % for Gajah Mada Algorithm’s diagnostic value. This result
indicates that the algorithm has a moderate diagnostic value.
5. Discussion
This is the first cross-sectional study in Indonesia that examines
the sensitivity, specificity, and accuracy of Bahrudin, Siriraj, and
Gajah Mada Algorithms in diagnosing stroke. The three diagnostic
tools were compared in this study due to their widespread use in
Indonesia. The result showed that the incidence of infarct stroke
was greater than hemorrhagic. Furthermore, infarction is ten times
more common than hemorrhagic stroke in Western nations, mak-
ing their statistical validation difficult.15.
186
Brain Hemorrhages 3 (2022) 184–188
Based on gender, this study report of 58.06 % male is consistent
with the result of Mita et al, which showed that male suffers more
from strokes than female (66.3 %).16 Aging and population growth
have increased the absolute number of strokes, particularly among
the oldest, which is predicted to rise significantly in the future
years. Furthermore, more stroke survivors were reported due to
improved treatment, increasing recurrent occurrences. To address
this epidemiological threat, immediate action is required.17
According to this study, the incidence of stroke increases after
the age of 40 years (95.2 %).
This present study found hypertension among patients with
infarct and hemorrhagic stroke, which is its most common risk fac-
tor. The causes of stroke and its hemodynamic implications are
diverse, making blood pressure control in patients difficult, hence,
accurate diagnosis and specific therapy description targets are
required.18–19.
In recent studies, the loss of consciousness was found more in
hemorrhagic stroke than infarction. However, they can cause alter-
ation, cerebral infarction, and hemorrhage covering large sections
of both hemispheres, or confined regions. The bilateral mesial
regions, paramedian diencephalon, and upper brainstem also cause
consciousness issues.20 Headache and vomiting were also found
M. Bahrudin, P. Yudha Pratama Putra and D. Amalia Eka Putri Brain Hemorrhages 3 (2022) 184–188

Table 3
Demographic characteristic patients.

Stroke Patient Characteristics CT Scan Total Stroke P Value

Infarction Hemorrhagic
Patient Age
40 yrs 11 (4,55%) 2 (3,23%) 13 (4,28%) 0.027
41 – 50 yrs 47 (19,42%) 24 (38,71%) 71 (23,36%)
51 – 60 yrs 85 (35,12%) 19 (30,65%) 104 (34,21%)
61 – 70 yrs 69 (28,51%) 13 (20,97%) 82 (26,97%)
71 yrs 30 (12,4%) 4 (6,45%) 34 (11,18%)
Total 242 (100%) 62 (100%) 304 (100%)

Gender
Male 138 (57,02%) 36 (58,06%) 174 (57,24%) 0.997
Female 104 (42,98%) 26 (41,94%) 130 (42,76%)
Total 242 (100%) 62 (100%) 304 (100%)

Loss of consciousness symptomps

Loss of consciousness 41 (16,94%) 32 (51,61%) 73 (24,01%) 0.000
Without loss of consciousness 201 (83,06%) 30 (48,39%) 231 (75,99%)
Total 242 (100%) 62 (100%) 304 (100%)

Headache symptoms
Headache 61 (25,21%) 43 (69,35%) 104 (34,21%) 0.000
Without headache 181 (74,79%) 19 (30,65%) 200 (65,79%)
Total 242 (100%) 62 (100%) 304 (100%)

Symptoms of Vomiting
Vomit 19 (7,85%) 40 (64,52%) 59 (19,41%) 0.000
Without Vomit 223 (92,15%) 22 (35,48%) 245 (80,59%)
Total 242 (100%) 62 (100%) 304 (100%)

Blood pressure
normal 92 (38,02%) 9 (14,52%) 101 (33,22%) 0.000
Hypertension 150 (61,98%) 53 (85,48%) 203 (66,78%)
Total 242 (100%) 62 (100%) 304 (100%)

more in hemorrhagic stroke, suggesting elevation of intracranial

pressure, which commonly accompanies cerebellar hematoma.21.
Based on the results, Bahrudin and Siriraj Scores were found to
be equivalent in sensitivity and specificity, with the AUC of 86.8 %
and 86.7 %, respectively. The diagnostic bahrudin score has an
accuracy of 86.5 %, with a difference of only 1 % when compared
with the Siriraj score. The accuracy of Gajah Mada Algorithm was
64.5 %, while another study reported good accuracy in Siriraj and
Bahrudin scores.7,14 Babinski’s reflect is a factor that can impact
the analysis results and is inferior to Bahrudin and Siriraj Scores.
Furthermore, Qu et al reported that 32.8 % of Babinski’s sign of
all ischemic strokes was in the acute stage. The study’s results
showed that poor functional outcomes for acute stroke patients
at the 3-month follow-up do not depend on the presence of the
Babinski sign. Conclusively, the Babinski sign’s existence or
absence cannot be utilized to forecast a patient’s prognosis for an
acute ischemic stroke.22 Meanwhile, the ROC of these three diag-
nostic tools was greater than 50 %, indicating that they may be uti-
lized when CT scans are not accessible.
This study excluded patients who use the anticoagulant because
it can cause an increased risk of hemorrhagic transformation,23,24
which may affect the outcomes of the three studied diagnostic
tools. The availability of CT scans at a reasonable cost in most LMIC
hospitals is a necessity that cannot be overstated. Therefore, the
government and the administration of tertiary and secondary hos-
pitals should make effort to provide this facility at a reasonable
cost.

6. Conclusion

In conclusion, Bahrudins and Siriraj Scores have good accuracy,

sensitivity, and specificity to diagnose stroke than Gajah Mada
Algorithm. Furthermore, Bahrudin Score has the highest accuracy
Fig. 2. ROC diagram. when compared to other two modalities.
187
M. Bahrudin, P. Yudha Pratama Putra and D. Amalia Eka Putri
Ethical approval
Ethics approval for this study was granted by the Medical Fac-
ulty University of Muhammadiyah Malang Ethics Research Com-
mittee (No.E.5.a/018/KEPKUMM/I/2020). Informed consent was
waived because of the retrospective nature of this study, which
was approved by the Medical Faculty University of Muhamma-
diyah Malang Ethics Research Committee. The study was
conducted in accordance with the Declaration of Helsinki.
Funding
This study received no specific grant from any funding agency
in the public, commercial, and not-for-profit sectors.
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.
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