CORRELATION OF CLINICAL SCORES AND CT SCAN IN PATIENTS OF ACUTE STROKE

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Background.Stroke is defined as "rapidly developing clinical symptoms and/or signs of focal and at times global (applied to patients in deep coma and those with SAH) loss of cerebral function with symptoms lasting for more than 24hrs or leading to death, with no apparent cause other than that of vascular origin" [1].
Stroke is one among the leading cause of death worldwide.Globally 1 in 4 adults over the age of 25 will have a stroke in their lifetime and this number has increased 50% over the past 17 years [2].12.2 million People worldwide will have their first stroke per year one in every three seconds, and 6.5 million will die as a result.The incidence of stroke increases with age, however over 60% of strokes happen to people under the age of 70 yrs [2].The WHO collaborative study showed that both in developed and developing countries nearly 1/3rd of stroke patients died within 3 month and 48% died within 1 year [3].Metabolic risks (high systolic blood pressure (SBP), high bodymass index (BMI), high fasting plasma glucose (FPG), high total cholesterol, and low glomerular filtration rate) account for 71% (64.6-77.1) of stroke burden.Behavioural factors (smoking, poor diet, and low physical activity) account for 47% [41.3 to 54.4] of stroke burden and environmental risks (air pollution and lead exposure) 37.8% [35.0 to 41.0] [4].
It is important to differentiate cerebral infarction and hemorrhage since both differ substantially in their management.The most accurate method of distinguishing cerebral infarction from hemorrhage is CT scan.
Lahari lavanya Nibhanupudi, Swarna Deepak Kuragayala, R. Prahalad In 1984, the Guy's Hospital score was developed as a clinical diagnostic tool for Intracerebral Hemorrhage [5].The calculations involved in this score were too complex for bedside application.Hence, another score was designed at Siriraj Hospital in Thialand and had a greater acceptance.Till these scoring systems fully evolve it is necessary to test them against the gold standard test i.e.CT scan.
In Thailand, a stroke score known as the Siriraj Stroke Score was developed and has been in use throughout Thailand since 1986 [5].Daga et al did a comparison of Siriraj and Guy's Hospital score in 160 patients admitted with acute stroke [6].Celani et al compared the Guy's Hospital stroke score and Siriraj stroke score among 231 consecutive patients and have concluded that when computed tomography is not immediately available and the clinician wishes to start anti-thrombotic treatment, the Siriraj stroke score and Guy's Hospital score can be useful to identify patients at low risk of intracerebral hemorrhage [7].
Siriraj and Guy's Hospital scores can be used to identify patients at a low risk of intracerebral hemorrhage, in randomizing patients in clinical trials of low-risk treatment for the secondary prevention of stroke (in whom CT scanning is not feasible).
This study attempts to test the utility of both these scores in the diagnosis of acute stroke and compare it with CT scan.
Aim: to assess the Siriraj stroke score and Guy's Hospital stroke score in the clinical diagnosis of acute stroke.Study also designed to differentiate cerebral hemorrhage from infarction using the Guy's Hospital score and Siriraj stroke score and to correlate clinical scores with CT brain.

MATERIALS AND METHODS
The study was done in department of Medicine, Apollo Institute of Medical Sciences and Research.70 cases of acute stroke admitted to medical wards were studied for a duration of one year from January 2021 to January 2022.This was a prospective study.

Method of collection of Data
Sampling procedure-purposive sampling Sample size -70 cases.

Inclusion Criteria:
The study group consisted of patients admitted to medical wards with a clinical diagnosis of acute stroke (stroke as defined by WHO definition).A detailed history, thorough clinical examination were performed at admission and at end of 24 hours.Siriraj stroke score and Guy's Hospital stroke score were evaluated.All patients were subjected to CT scan head within 72 hours of admission.
The Guy's Hospital stroke score was calculated at end of 24 hours of admission using thirteen variables.

RESULTS AND DISCUSSION
Seventy cases of acute stroke admitted to Department of Medicine Apollo institute of medical sciences and research were studied.Siriraj stroke score and Guy's Hospital stroke score were calculated and correlated with CT scan.
The maximum incidence was between 60-70 yrs (32%) in both infarction and hemorrhage groups.There was 1 patient who was in the age group < 30yrs (Table 1).Males accounts higher than females (67.14% vs 32.85%).
Lahari lavanya Nibhanupudi, Swarna Deepak Kuragayala, R. Prahalad  Variables of guy's hospital stroke score: 80% of patients in hemorrhage group had apoplectic onset whereas no patient in infarction group had apoplectic onset (P<0.001).80% of patients in hemorrhage group were drowsy / unconscious as compared to 66.66% in infarction group (P=0.001).
100% patients in infarction had bilateral extensor plantar response while 77.5% of patients in hemorrhage group had bilateral extensor plantar response (P=0.023)(Table 3).
Lahari lavanya Nibhanupudi, Swarna Deepak Kuragayala, R. Prahalad Mortality from stroke: Overall mortality of stroke patients included in the study was 27.14% with 40% in haemorrhagic group and 10% in ischemic group (P=0.005)(Table 7).Out of 40 patients diagnosed as hemorrhage by CT scan head Guy's hospital stroke score was suggestive of hemorrhage in 36 cases.In 3 cases the score was equivocal and it wrongly diagnosed 1 case of hemorrhage as infarction.The sensitivity of Guy's score for hemorrhagic stroke is 97.30%, specificity is 100% and positive predictive value is 100%.Lahari lavanya Nibhanupudi, Swarna Deepak Kuragayala, R. Prahalad Seventy cases of acute stroke admitted to Apollo Institute of Medical College were studied.Both Siriraj stroke score and Guy's Hospital stroke score were calculated and correlated with CT scan.
In our study, the maximum incidence of stroke was between 60 to 70 years of age (64.28%).There were 47 males and 23 females in the study group.Alcohol consumption was the most common risk factor (52.85%) especially in hemorrhage group (70%).40% of patients were hypertensives.48.57% of patients were smokers.27.14% of patients had history of diabetes mellitus, 17.14% had hypercholesterolemia, and 14.28% of patients had associated cardiovascular disease.The risk factor found in the study group were alcohol consumption, smoking, hypertension, diabetes mellitus, hypercholesterolemia, cardiovascular disease in decreasing order of frequency.
In a ICMR study, hypertension, smoking, diabetes mellitus and low hemoglobin were identified as risk factor for stroke in Indian patients.8A study have observed that more than one third of stroke cases had hypertension, cardiovascular disease was seen in 42.8%, 51% were smokers, 18.9% were diabetics and hyperlipidemia was seen in 16.3% [9].
Mortality: 3 patients in infarction group (10%) and 16 in hemorrhage group (40%) expired.The mortality in the study group was more in hemorrhage group than in ischemic group (P<0.005).Nilamadhab Kar et al observed 30% mortality in stroke population of which 38% were due to non-neurological causes [10].
Siriraj stroke score and CT correlation: CT scan showed cerebral infarction in 30 cases and cerebral hemorrhage in 40 cases in our study.

CONCLUSION
CT scan head is an accurate, safe and noninvasive procedure for differentiating between cerebral hemorrhage and infarction.However, when CT scan facilities are not available, we suggest Siriraj stroke score as a simple method of screening patients for intra cerebral haemorrhage, as it is easier to use at bedside and has similar accuracy in diagnosing hemorrhage as Guy's Hospital score.Guy's Hospital score is not useful because it can be assessed only after 24 hours of onset of stroke.This deprives the management to all thrombotic patients in speculated time window of modern management.These scores can also be used as screening in patients with low risk of stroke for secondary prevention of stroke in whom CT scan is not feasible.
Conflict of interest.The authors of this manuscript claim that there is no conflict of interest during the research and writing of the manuscript.
Sources of funding.The execution of this study and the writing of the manuscript were accomplished without external funding.

Table 2 Variables of Guy's Score Variables Clinical features Score
Constant-12.6

Table 10 Guy's Hospital Stroke score and CT correlation for ischemic stroke Guy's Score CT Scan Diagnosis
**Highly significant.

Table 11 Guy's hospital stroke score and CT correlation for haemorrhagic stroke
**Highly significant.

Table 12 Comparison of sensitivity of Siriraj score, predictive value of a positive test, Sensitivity of Guy's Hospital Stroke score, Positive predictive value of Guy's Hospital Stroke score in the diagnosis of infarction and hemorrhage Comparison of sensitivity of Siriraj score
Siriraj stroke score as and Guy's Hospital stroke score as screening tools in clinical diagnosis of acute stroke.