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Stroke Study: You Gotta Have Imaging

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Clinicians can often make good guesses as to whether stroke patients are suffering from ischemic or hemorrhagic stroke, but no combination of clinical factors is good enough for a definitive diagnosis in all patients. For that, you need imaging.

So conclude two researchers who undertook a systematic review of 19 prospective studies involving 6,438 patients. Shauna Runchey, MD, and Steven McGee, MD, both of the University of Washington Department of Medicine in Seattle, published their findings this month in the Journal of the American Medical Association.

Distinguishing between the two types of stroke can be crucial. If it’s ischemic (caused by an interruption in blood supply), then a blood clot is often the culprit, and immediate thrombolysis treatment can break up the clot and minimize damage. But if it’s caused by hemorrhage, then thrombolysis can make things worse.

The various studies looked at markers of hemorrhagic stroke. For example, the likelihood that the stroke was hemorrhagic increased 6.2-fold if the patient was in a coma, 5.0-fold if neck stiffness was present, 4.7-fold if there were seizures, 4.3-fold if diastolic blood pressure exceeded 110 mmHg, 3.0-fold if there was vomiting, 2.9-fold if there was a headache, and 2.6-fold if the patient lost consciousness.

The Siriraj score, which encompasses some of the above factors as well as others, such as the presence of diabetes, also helped distinguish the two types of stroke. Patients were 5.7-fold more likely to have hemorrhagic stroke if they had a score higher than 1 and 71% less likely if they had a score lower than -1. However, Drs. Runchey and McGee noted that about 20% of patients have scores between 1 and -1, which they termed “diagnostically unhelpful.”

One study found that clinicians’ overall impressions were as accurate as the Siriraj score in diagnosing hemorrhagic stroke.

However, Drs. Runchey and McGee say, “Neither the clinical impression of experienced clinicians nor the most accurate stroke score can improve the post-test probability of hemorrhage to greater than 50%.” They conclude:

While combinations of findings are more predictive than individual findings, diagnostic certainty requires neuroimaging.

Related seminar: State-of-the-Art Imaging and Interventional Radiology


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