Clinical findings such as coma (LR 6.2; 95% CI 3.2-12) and neck stiffness (LR 5.0) increase the probability of hemorrhagic stroke, but diagnostic certainty requires neuroimaging.
Systematic Review (n=6,438)
Does clinical examination accurately distinguish hemorrhagic stroke from ischemic stroke in adult patients with acute stroke?
Certain clinical findings can increase or decrease the probability of intracranial hemorrhage in acute stroke, but neuroimaging remains required for definitive diagnosis.
Effect estimate: LR 6.2 (95% CI 3.2-12)
CONTEXT: The 2 fundamental subtypes of stroke are hemorrhagic stroke and ischemic stroke. Although neuroimaging is required to distinguish these subtypes, the diagnostic accuracy of bedside findings has not been systematically reviewed. OBJECTIVE: To determine the accuracy of clinical examination in distinguishing hemorrhagic stroke from ischemic stroke. DATA SOURCES: MEDLINE and EMBASE searches of English-language articles published from January 1966 to April 2010. STUDY SELECTION: Prospective studies of adult patients with stroke that compared initial clinical findings with accepted diagnostic standards of hemorrhagic stroke (computed tomography or autopsy). DATA EXTRACTION: Both authors independently appraised study quality and extracted relevant data. DATA SYNTHESIS: Nineteen prospective studies meeting inclusion criteria were identified (N = 6438 patients; n = 1528 24% with hemorrhage stroke). Several findings significantly increase the probability of hemorrhagic stroke: coma (likelihood ratio LR, 6.2; 95% confidence interval CI, 3.2-12), neck stiffness (LR, 5.0; 95% CI, 1.9-12.8), seizures accompanying the neurologic deficit (LR, 4.7; 95% CI, 1.6-14), diastolic blood pressure greater than 110 mm Hg (LR, 4.3; 95% CI, 1.4-14), vomiting (LR, 3.0; 95% CI, 1.7-5.5), and headache (LR, 2.9; 95% CI, 1.7-4.8). Other findings decrease the probability of hemorrhage: cervical bruit (LR, 0.12; 95% CI, 0.03-0.47) and prior transient ischemic attack (LR, 0.34; 95% CI, 0.18-0.65). A Siriraj score greater than 1 increases the probability of hemorrhage (LR, 5.7; 95% CI, 4.4-7.4) while a score lower than -1 decreases the probability (LR, 0.29; 95% CI, 0.23-0.37). Nonetheless, many patients with stroke lack any diagnostic finding, and 20% have Siriraj scores between 1 and -1, which are diagnostically unhelpful (LR, 0.94; 95% CI, 0.77-1.1). CONCLUSION: In patients with acute stroke, certain findings accurately increase or decrease the probability of intracranial hemorrhage, but no finding or combination of findings is definitively diagnostic in all patients, and diagnostic certainty requires neuroimaging.
Runchey et al. (Tue,) conducted a systematic review in acute stroke (n=6,438). Clinical examination findings (e.g., coma, neck stiffness, Siriraj score) vs. Absence of findings / Ischemic stroke was evaluated on Diagnostic accuracy for hemorrhagic stroke (LR 6.2, 95% CI 3.2-12). Clinical findings such as coma (LR 6.2; 95% CI 3.2-12) and neck stiffness (LR 5.0) increase the probability of hemorrhagic stroke, but diagnostic certainty requires neuroimaging.