137

Indian Journal of Medical Sciences, Vol. 67, No. 5 and 6, May and June 2013
BEDSIDE UTILITY OF CLINICAL SCORING SYSTEMS IN
CLASSIFYING STROKE
RUDRA PROSAD GOSWAMI, PARTHA SARATHI KARMAKAR, ALAKENDU GHOSH
ABSTRACT
BACKGROUND: The study aimed to validate and compare the Siriraj score,
Guys hospital score, Greek score, and Besson score in a group of stroke
patients. MATERIALS AND METHODS: We assessed the stroke scores and compared
them to computed tomography (CT) scan of brain. RESULTS: Two hundred stroke
patients (129 ischemic stroke) were included. For ischemic stroke, sensitivity and
specificity were 71% and 92% (Siriraj score), 73% and 98% (Greek score), 59% and 87%
(Guys hospital score), and 65% and 98% (Besson score), respectively. For intracranial
hemorrhage, sensitivity and specificity were 84% and 89% (Siriraj score), 80% and 99%
(Greek score), and 63% and 95% (Guys hospital score), respectively. Using receptor
operating characteristic curve, the greatest area under the curve was obtained for
Greek score (0.973). For bedside accurate and safe diagnosis of ischemic stroke, the
best cut off was for Greek score (1.5) which identified 47% of ischemic stroke patients.
CONCLUSIONS: The Greek score appears as the single best score. Using the newly
developed discriminant cut off value; a substantial number of patients may be started
with anti-platelet therapy while awaiting CT scan of brain.
Key words: Allen score, besson score, greek score, siriraj score, stroke
Department of Medicine, Institute of Post Graduate Medical
Education and Research, Kolkata, West Bengal, India
Address for correspondence:
Dr. Rudra Prosad Goswami,
Department of Medicine,
Abhyudoy Housing, Flat - 18/14, ECTP, Ph-IV,
Type-B, EM Bypass, Kolkata, West Bengal - 700 107, India.
E-mail: rudra.goswami@gmail.com
INTRODUCTION
Bedside diagnosis of subtype of stroke is often
lifesaving. But the subtleties and nuances of
overlap of clinical features make this distinction
diffcult. The greatest impact is on the ischemic
stroke, early identifcation of which renders the
physician use a powerful weapon of thrombolysis
or anti-platelet therapy which have been
shown to have mortality beneft.
[1]
Computed
tomography (CT) scan of brain is invaluable
in this regard and is considered an important
measure to exclude hemorrhagic stroke. But
in rural India, where CT scan has not gained
its access, physically and financially, clinical
determinism becomes the most important factor.
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DOI:
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ORIGINAL ARTICLE
138 INDIAN JOURNAL OF MEDICAL SCIENCES
Indian Journal of Medical Sciences, Vol. 67, No. 5 and 6, May and June 2013
There are two famous stroke scores which can
guide the treating physician in such situations,
namely Siriraj score (SS)
[2]
and the Guys hospital
score (GHS) or the Allen score.
[3]
Recently, a
new score proposed by a team from Athens
claimed that the sensitivity, specifcity, positive
predictive value, and negative predictive value
were much better as compared to the previous
scores.
[4]
This Greek score (GS) was only once
tested in Indian population in a relatively small
study.
[5]
Besson, et al. also proposed a scoring
system (Besson score or BS) that could be used
to identify a fairly good proportion of ischemic
stroke patients at the bedside, with good safety
margin for appropriate therapy.
[6]
This score is yet
to be tested in India. Recently another scoring
system (Kurashiki Pre-hospital Stroke Subtyping
Score) has been published, but we could not get
enough information on this system to incorporate
it in our study.
[7]
We therefore aimed to validate and compare
the SS, GHS, GS, and BS in a moderately
large, independently selected group of Indian
patients in a tertiary care referral center in
eastern India.
MATERIALS AND METHODS
All cases with a diagnosis of stroke admitted in
the Department of Medicine, Institute of Post
Graduate Medical Education and Research and
Seth Sukhlal Karnani Memorial Hospital, were
consecutively recruited from October 2010 to
July 2011. We defned stroke according to the
World Health Organization criteria as rapidly
developing signs of focal (or global) disturbance
of cerebral function, leading to death or lasting
longer than 24 h, with no apparent cause other
than vascular.
[8]
Detailed clinical history, physical examination,
and routine tests including electrocardiography,
complete blood count, and CT scan of brain
within 24 h of presentation, but later than 6 h
of onset were performed on each patient. Any
patient presenting later than 24 h of symptom
onset was excluded from this study. Patients
with pure subarachnoid or intraventricular
hemorrhage were excluded.
The stroke scores were calculated from
this data. The scoring systems are adapted
from existing literature and are detailed in
Table 1.
[2-4,6]
The inferences of the scoring
systems were ischemic stroke, hemorrhagic
stroke, or uncertain, except in the BS where
the inferences were ischemic stroke and
non-ischemic stroke. All statistical calculations
were done with SPSS version 16.
RESULTS
Data comprised those of 200 consecutive
eligible patients, which included 129 ischemic
strokes (64.5%) and 71 hemorrhagic strokes
(35.5%). Average age of the popul ati on
was 57.09 years (standard deviation 12.67),
ranging from 26 to 80 years. There were
90 f emal e (45%) and 110 mal e (55%)
participants.
Table 2 shows the sensitivity, specificity,
positive and negative likelihood ratios for
the SS, GS, GHS, and BS for the diagnosis
of ischemic stroke. Table 3 shows these
values of the tests (except BS, which was
originally devised to screen ischemic strokes
onl y) for i ntracrani al hemorrhage. Al l of
the systems have better specificity than
sensitivity in any stroke subtype. The GS has
139 UTILITY OF STROKE SCORING SYSTEMS
Indian Journal of Medical Sciences, Vol. 67, No. 5 and 6, May and June 2013
Table 1: Scoring systems utilized in the study
Scoring system Variable Clinical feature Score Diagnosis
Siriraj scoring system Consciousness (2.5) Alert 0 <-1=Ischemic stroke
>1=Hemorrhagic stroke
Drowsy, stupor 1
Semicoma, coma 2
Vomiting (2) No 0
Yes 1
Headache within 2 h (2) No 0
Yes 1
Diastolic blood
pressure (0.1)
Atheroma markers (3) None 0
Diabetes, angina, intermittent
claudication
One or more 1
Constant 12
Guys hospital scoring
system
Apoplectic onset <4=Ischemic stroke
>24=Hemorrhagic stroke
Loss of consciousness None or one 0
Headache within 2 h Two or more 21.9
Vomiting
Neck stiffness
Level of consciousness
(24 h after admission)
Alert 0
Drowsy 7.3
Unconscious 14.6
Plantar responses Both fexor or single
extensor
0
Both extensor 7.1
Diastolic blood pressure
(24 h after admission) (0.17)
0.17
Atheroma markers
Diabetes, angina, intermittent None 0
Claudication One or more 3.7
History of hypertension Not present 0
Present 4.1
Previous event None 0
Transient ischemic attack Any number of
previous events
6.7
Heart disease None 4.3
Aortic or mitral
murmur
4.3
Cardiac failure 4.3
Cardiomyopathy 4.3
Atrial fbrillation 4.3
Cardiomegaly 4.3
Myocardial infarct
within 6 months 4.3
Constant 12
(Contd...)
140 INDIAN JOURNAL OF MEDICAL SCIENCES
Indian Journal of Medical Sciences, Vol. 67, No. 5 and 6, May and June 2013
acceptable sensitivity (around 80%) and good
specifcity (>95%) in both subgroups. The GHS
appears to be worst of the four. The BS is
particularly specifc for ischemic stroke (>95%).
The test results were uncertain in 29 cases
(14.5%) using SS, in 46 cases (23%) using
the GS, and in 63 cases (31.5%) using the
GHS.
Next we pr epar ed r ecept or oper at i ng
characteristic (ROC) curves for all the four
data sets using CT diagnosis as the criterion
val ue [Fi gure 1]. We generated Youden
Table 1: Contd...
Scoring system Variable Clinical feature Score Diagnosis
Greek score Neurological deterioration
within 3 h of admission
6 <3=Ischemic stroke
>11=Hemorrhagic stroke
Vomiting 4
Total leukocyte count in
peripheral blood >12,000/l
4
Decreased level of
consciousness at admission
3
Besson score Alcohol consumption Absent 0 <1=Ischemic stroke
Present 2
Plantar response (1.5) Bilateral fexor 0
Extensor ipsilateral to
defcit
1
Extensor contralateral
to defcit
2
Both extensors 3
Headache Absent 0
Present 3
History of transient
neurological defcit
Absent
Present
0
5
Hyperlipidemia Absent
Present 1.5
Atrial fbrillation at admission Absent
Present 2.5
Table 2: Comparison of SS, GHS, GS, and BS against CT scan of brain for the diagnosis of ischemic stroke
Diagnosis CT diagnosis Sensitivity % (CI) Specifcity % (CI) Positive likelihood ratio
(CI)
Negative likelihood ratio
(CI)
IS Not IS
SS
IS 92 5 71.32 (62.58-78.06) 92.96 (83.65-7.37) 10.12 (4.32-23.74) 0.31 (0.23-0.41)
Not IS 37 66
GS
IS 95 1 73.64 (65.02-80.82) 98.59 (91.35-99.92) 52.28 (7.45-367.08) 0.27 (0.20-0.35)
Not IS 34 70
GHS
IS 77 9 59.69 (50.67-68.12) 87.32 (76.80-93.68) 4.71 (2.52-8.81) 0.46 (0.37-0.57)
Not IS 62 52
BS
IS 85 1 65.89 (56.96-73.86) 98.59 (91.35-99.92) 46.78 (6.655-328.84) 0.34 (0.27-0.44)
Not IS 44 70
SS=Siriraj score, GS=Greek score, GHS=Guys hospital score, BS=Besson score
141 UTILITY OF STROKE SCORING SYSTEMS
Indian Journal of Medical Sciences, Vol. 67, No. 5 and 6, May and June 2013
index for each cut off value of each test and
the cut off value with the highest Youden
index was taken as optimum. The cut off
values and the respective sensitivities and
specifcities are detailed in Table 4. The area
under the curve (AUC) was also estimated
for each test. These are also summarized
in Table 4. The highest AUC was that of
GS (0.973), followed by SS (0.929), BS (0.911),
and GHS (0.873) [P val ue: SS vs. GS
(two tailed) = 0.03].
Next we tried to determine the discriminant cut
off vale of each test defned as the value of the
system which provides no false-negative results
with maximum achievable specifcity when applied
to diagnose ischemic stroke patients. These are
summarized in Table 4. At the given cut off values
for optimal discrimination, the proportions of
ischemic stroke patients identifed are 40 (31%),
61 (47.28%), 13 (10%), and 47 (36.43%) for SS,
GS, GHS, and BS, respectively (P values: GS vs.
BS = 0.07; GS vs. SS = 0.007).
DISCUSSION
Management of stroke largely depends on
differentiation of hemorrhagic from ischemic
stroke. Clinical stroke score can help in this
direction. The ideal score to predict stroke type
Table 3: Comparison of SS, GHS, GS, and BS against CT scan of brain for the diagnosis of hemorrhagic stroke
Diagnosis CT diagnosis Sensitivity % (CI) Specifcity % (CI) Positive likelihood ratio
(CI)
Negative likelihood ratio
(CI)
ICH Not ICH
SS
ICH 60 14 84.51 (73.54-91.65) 89.15 (82.15-93.72) 4.28 (2.64-6.96) 0.09 (0.05-0.17)
Not ICH 11 115
GS
ICH 57 1 80.28 (68.80-88.42) 99.22 (95.12-99.95) 103.56 (14.64-732.11) 0.19 (0.12-0.32)
Not ICH 14 128
GHS
ICH 45 6 63.38 (51.05-74.05) 95.35 (89.72-98.09) 13.62 (6.11-30.36) 0.38 (0.28-0.52)
Not ICH 26 123
ICH= Intracranial haemorrhage, SS=Siriraj score, GS=Greek score, GHS=Guys hospital score
Table 4: ROC curve analysis of all the scoring systems
Scoring system AUC (standard error) Optimal cut off Sensitivity/specifcity Discriminant cut off Specifcity (%)
SS 0.929 (0.019) 1 84.5/91.4 3.2 30.5
GS 0.973 (0.013) 6.5 97.2/87.8 1.5 47.9
GHS 0.873 (0.029) 13.2 76.1/87.5 5 10.9
BS 0.911 (0.020) 3.25 85.9/84.4 0 35.9
SS=Siriraj score, GS=Greek score, GHS=Guys hospital score, BS=Besson score
Figure 1: Comparison of diagnostic accuracy of the
stroke scoring systems (ROC method)
142 INDIAN JOURNAL OF MEDICAL SCIENCES
Indian Journal of Medical Sciences, Vol. 67, No. 5 and 6, May and June 2013
should have a good balance between validity,
simplicity, and utility.
[9]
With these qualities, a
scoring system might become an important
tool for timely decision making in rural areas
of developing countries where facilities like CT
scanning are sparse.
Amongst the available four systems, the SS
and GHS have been tested in the past decade
many times against each other and against the
gold standard test (CT scan of brain).
[5,10-15]

The results have varied widely from one
researcher to another, but overall they have
been shown to have acceptable sensitivity
and fair specifcity [Table 5]. In this regard,
it is to be noted that the Indian studies have
found fairly consistent sensitivity (80%) and
specifcity (7080%) of SS.
[5,14,15]
GS has been
evaluated in only one study and was found to
be highly specifc (94%) but with disappointing
sensitivity (42%).
[5]
Our results are in agreement
with the previous studies. The sensitivities
calculated in the present study are all in the
range of 70-80% except that for GHS. But the
specifcities of GS and GHS in our data are
excellent (98.59%) for diagnosing ischemic
stroke. Though all the systems in the present
study have good specificities to diagnose
hemorrhagic stroke, GS has the most satisfying
value of 99.22%. SS has consistently been
shown to be superior to GHS. There are only
two studies which show GHS to be superior to
SS, one from New Zealand
[11]
and another from
Turkey.
[16]
Our results are in agreement with the
majority of the studies and we conclude that
GHS is inferior to SS in this regard.
The superiority of the SS over the Allen score
is related to its better discrimination, evident
in statistical analysis, simplicity in application,
and the fact that the score can be applied at
presentation of the patient unlike that for GHS
which requires 24 h to be calculated.
[9]
All these
criteria are shared by GS. The fact that GS
is superior to all other scoring systems as an
early screening tool is also augmented by the
ROC curve analysis in which the AUC for GS
is signifcantly higher than any other system.
This is the first Indian study which utilized
the BS to specifcally discriminate ischemic
stroke from non-ischemic ones. BS was
originally devised for this express purpose.
[6]

We have successfully validated the said
utility of BS through our data. BS had a high
specificity and high positive likelihood ratio
for identifying ischemic strokes though the
sensitivity of the system was somewhat less.
Table 5: Literature review of population application of the scoring systems
Scoring
systems
South Africa
[10]

(222)
New Zealand
[11]
(485)
UK
[12]
(482)
Italy
[13]
(193)
India 1
[5]
(91)
India 2
[14]
(139)
India 3
[15]

(159 for SS and 147 for GHS)
SS
Sensitivity 60 48 67 61 75 78 85
Specifcity 88 85 71 94 81 71 73
GHS
Sensitivity 34 31 78 98 50 81 91
Specifcity 95 95 81 71 94 76 60
GS
Sensitivity 42
Specifcity 94
SS=Siriraj score, GS=Greek score, GHS=Guys hospital score
143 UTILITY OF STROKE SCORING SYSTEMS
Indian Journal of Medical Sciences, Vol. 67, No. 5 and 6, May and June 2013
Using the original cut off (1), a large number of
ischemic stroke patients could be diagnosed at
bedside (65.89%), but with the risk of wrongly
classifying 1.41% hemorrhagic stroke patients
as ischemic stroke patients.
It has been suggested that these scoring
systems should be used as rule-out measures
rather than rule-in measures for methodical
evaluation of stroke patients.
[9]
Indeed for
the majority of our patients, thrombolytics
are not a therapeutic option, either due to
logistic or fnancial reasons. Using a score that
could exclude intracranial hemorrhage with a
reasonable degree of medical certainty would
encourage physicians in remote areas to initiate
an early aspirin therapy.
Previous literature has shown that at a cut off
value of 4 for SS, nearly 38% of all stroke
patients could be treated safely without the
need for CT scan which could be an immensely
important costbenefit advantage.
[10]
In the
original work, Besson, et al. claimed to identify
43% of ischemic stroke patients at bedside safely
without the need of CT scan.
[6]
Our cut off values
for this discrimination were 3.2 for SS, 1.5 for
GS, 5 for GHS, and 0 for BS. GS (47%) and
BS (36%) identifed signifcantly greater number
of ischemic stroke patients compared to the
other two systems, who could be started with
anti-platelet therapy before a CT scan of brain
could be performed safely. This is a considerable
improvement in identifcation of such patients
compared to previous data which used SS.
CONCLUSIONS
The scores have moderate sensitivity and
good specifcity for the diagnosis of subtypes
of stroke. The GS appears as the single best
score. Using the newly developed discriminant
cut off value, a substantial number of patients
may be started with anti-platelet therapy while
awaiting CT scan of brain.
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How to cite this article: Goswami RP, Karmakar PS, Ghosh A.
Bedside utility of clinical scoring systems in classifying stroke.
Indian J Med Sci 2013;67:137-45.
Source of Support: Nil. Confict of Interest: None declared.