Siriraj Score as a Tool for Clinical Diagnosis of Stroke

Siriraj stroke

Cerebrovascular accident or stroke is the third leading cause of death after ischemic heart dr ease and cancer.The annual incidence is two per thousand mo tly affecting those under 65 years of age '.
te can be classified pathologically as of hernorrhagi I hemi type.Cases diagnosed as stroke turn out to be i hemic and 20% hemorrhagic"., Intracerebral hemorrhage I en in onset, with signs and symptoms of headache -izure .vomiting and rapid loss of consciousness.All these reatures may not be present in every patient.Whereas.
efinitive source of embolism, sudden onset neurological eficit.maximum at beginning promotes the diagnosis of ISchemic (embolic) stroke.Stroke developing with his ry of evolution in hours and days is ischemic stroke due 0 thrombosis'.
The first medical contact of an a ute stroke victim is often a non-neurologist.
In majonry of cases nonneurologist either GPs or Emergency ervice physicians can make a correct diagnosis with a validation of91%4.In order to minimize the use of CT brain an and to assist physicians in areas without access to CT brain scan to diagnose the pathological types of srroke accurately, scoring systems were devised namely Guy's hospital score or Allen score and Siriraj stroke score [I]e Allen score is calculated by clinical variables like onscious level, planter response, and onset of neurologic deficit, headache, diastolic blood pressure.angina and heart failure.This score is not easy to calculate on bedside.and below + 14 considered as infarction.The higher the score, the higher the probability for hemorrhage.In my study, a total of 32 patients were taken, 28/32 were correctly diagnosed 11 were orrectl diagnosed as having haemorrhage and [ were orrectly diagnosed as having infarction, 2/32 patien -'ere diagnosed as infarction and they turned out to morrhage.In 2/32 patients clinical data formulated e ivocal score for which CT brain scan was requir ,Q\'erail predictive accuracy was 28/32 (87.-%), for emorrhage it was 84.61 % and for infarction it was 9.~.The e findings are closer to Poungvarin et al than Allen C IC I and Daga et a1 8 .
When my study is compared wi the study of Siriraj stroke score by Daga et al in Indian ulation, that study showed overall predictive accuracy 0 iriraj stroke score as 80%.In that study it was conclu d that accuracy of Siriraj stroke score and Guy's Ho I I score may be affected due to difference in prevale e of hemorrhagic stroke between the white and Indian po ulation 8 ,  In western countries only 10% patients with stroke tend to have heamorrhage 6 . 7• 8 . 9.In my study there is also higher prevalence of ischemic stroke than hemorrhagic stroke.It is difficult to conclude whether i is due to better control of blood pressure or other factors are also responsible for that.
Diagnosis of stroke on the basis of linical features and later on verified by CT scan showed a predictive accuracy of 78.9% in case of heamorrhage in our population.Four patients were misdiagnosed as thrombotic stroke.While CT scan howed hemorrhage.Predictive accuracy in the clinical diagnosis of infarction was 90.3% whereas, 3 patients were misdiagnosed.These results correspond well with my rudy, in whi h I have used a stroke system.
In the studies conducte on various stroke s ores the variables are taken into ac 1.In a study conducted by Daga et al (1994) for the co arison of Siriraj and Guys hospital stroke score, it was on luded that diastolic blood pressure and symptoms of dache and vomiting were important contributing facto for diagnosing stroke in Siriraj scoring system.In -alidation stud of Guys Hospital score.', it was dis -ed that absen e of few symptoms as headache, \'0011 =. loss of conscious push the score towards infarction their presence formulated In my study the major risk fa tor was hypertension with prevalence of 62.5%.In all the hemorrhagic strokes hypertension was seen in (61.53%) 13.And in all the ischemic strokes hypertension observed in 12119 (63.15%).It can be concluded that hypertension is major risk factor for both hemorrhagic and ischemic stroke.
The limitations of the scoring ystern should be under stood.If a patient or a relative of patient cannot give a clear description of the symptoms, the score will tend to over-estimate the likelihood of irIfarction.Many of the symptoms used in the score as loss of consciousness headache and vomiting are discriminative for heamorrhage.If presence or absence of such symptoms is unknown they can be recorded as absent and the prior probability weighing given to infarction would then tend to place the patient in the ischemic group.I These scoring system can be used e.g. for data bank, which are very important in describing cerebrovascular disease.Hospital based studies show more severe strokes and those occurrirIg in young whereas population based studies shown a different picture.'.Using the assistance of a diagnostic score by a physician should be decided by themselves.These scoring systems should be left to epidemiological studies and first bedside screening test before ordering a cr scan in areas where CT scan is not available or far off.
uti-coagulants or thrombolytic, should only be re erved for patients having an infarction on CT scan.

Conclusion
Despite already mentioned limitations in my opinion some practical applications of iriraj stroke score my be; 1.First bedside screenirIg test to decide whicli patien; should have priority for CT scan.2. A retrospective analysis of stroke patients can be done by Siriraj Stroke score where CT scan is not available.3. Scoring system can be adopted alternatively by attending physicians irIstead of diagnosing patients according to their clinical experience.

I
In 1985, the validated Guys Ho pnal s ore has an overall predictive accuracy of 78% in Oxford and 82% In London I.The validation of the iriraj stroke score as compared to the diagnosis b on the results of computerized brain scan was armed in 1991 by Poungvarin et al7 .heclinical diag 0 I by Allen score and Siriraj stroke score was compared in Indian Population in 1993.The results thus formula ed vere in favor of Siriraj stroke score.Tn that series predi rive curacy of Siriraj stroke score stands at 83% for mfarc on and 80% for hemorrhage as compared to 69 0 0 for infarction and 66% for hemorrhage according to Guy Hospital score respectively.
Latter scoring system i.e.Siriraj stroke score was developed in Thailand 4 It's validation and prediction accuracy for infarction is 93.2% and for hemorrhage it is 89.3%3.Resident doctors in countryside in Thailand use Siriraj score card as a routine.It has various clinical variables as level of consciousness, diastolic blood pressure, atheroma markers as diabetes mellitus and isch mic heart disease.',: hen the score is less than -1 it is i hemic stroke and when it is more than +1 it indicates hemorrhagic stroke.When 6%) and for infarction is 19/21 (90.5%).
with no apparent cause other than of vascular origin [I OJ.All patients should have had a completed stroke and must have a CT brain scan within 30 days.