Stroke: decision-making aids helped differentiate haemorrhage from infarction.

Clinical bottom line (level 1a)

  1. Patients with a stroke who had three or more from the predictors vomiting, severe headache, warfarin therapy, initial systolic blood pressure more than 220 mmHg, coma on arrival or initial blood glucose level more than 170 mg/dL, were more likely to have to have an intracranial haemorrhage (67%), than those with no predictors (5%).
Panzer et al: Archives of Internal Medicine 1985; 145: 1800-1803
Expires May 2003

The study

Setting: general hospital, USA

230 patients (aged mean 73 years, 56% female) new stroke with neurologic deficits of sudden or rapid onset persisting at leat 24 hours and due to occlusion or rupture of a cerebral artery

Excluded if
  • strokes due to neoplastic, traumatic or infectious processes



    • Independent ?blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
    Reference standard:
    • computed tomography scan for the presence or absence of haemorrhage
    Diagnostic test: Clinical findings- predictors were found to include history of vomiting, severe headache or warfarin therapy, physical examination showing initial systolic blood pressure >220 mmHg or coma on arrival and simple laboratory testing showing an initial blood glucose level>170 mg/dL in a patient without a history of diabetes mellitus. Combining these predictors gave a decision-making aid to assess the probability of haemorrhagic stroke.

    The evidence


    differential diagnosis number of patients prevalence
    (95% CI)
    patients with 0 predictors and haemorrhage 7 5.00%
    (1.35% to 8.37%)
    patients with 1 predictor and haemorrhage 11 19.0%
    (8.71% to 28.6%)
    patients with 2 predictors and haemorrhage 7 33.0%
    (13.2% to 53.5%)
    patients with > or = 3 predictors and haemorrhage 4 67.0%
    (28.9% to 104%)

    Comments

    1. The model was validated.
    2. No single predictor identified more than 8 of the 18 haemorrhagic strokes.
    3. No data was given on patients with ischaemic stroke.

    Citation

    1. Panzer RJ, Feibel JH, Barker WH, et al: Predicting the likelihood of hemorrhage in patients with stroke. Archives of Internal Medicine 1985; 145: 1800-1803
    Contributor: Clare Wotton and Musab Hayatli, November 1999
    Reviewer:

    Clinical Question.
    Patient acute focal neurologic deficits after stroke
    Intervention or Exposure clinical findings
    Outcome differential diagnosis of cerebral infarction from intracranial haemorrhage hemorrhage