IS IT CLINICALLY POSSIBLE TO DISTINGUISH NONHEMORRHAGIC INFARCT FROM HEMORRHAGIC STROKE

Background and Purpose Diagnosis of the nonhemorrhagic ischemic type of stroke by analysis of patients' clinical features is considered unreliable because no clinical feature is specific. The diagnosis is so difficult to establish that we cannot hope to use the same method to make a reliable diagnosis in all stroke cases. In this study, we propose a simple scoring system with a positive predictive value of close to 100% to distinguish nonhemorrhagic infarct from hemorrhagic stroke. This scoring is available for all physicians in bedside diagnosis even if this score can be applied to a subgroup of patients. Methods Twenty-six clinical variables that might potentially distinguish cerebral hemorrhage from infarction were recorded in patients consecutively admitted to our stroke unit for stroke lasting more than 24 hours with at least unilateral motor weakness affecting face and/or arm and/or leg (internal validity study). Patients previously receiving anticoagulant therapy were excluded. We used CT scan as the gold standard. We used multivariate logistic regression to establish a clinical score from which we derived the classification rule. This rule was validated with data from the next 200 consecutive patients hospitalized in the stroke unit (external validity study). Results Three hundred sixty-eight patients were enrolled in the internal study. The obtained score was (2xalcohol consumption)+(1.5xplantar response)+(3xheadache)+(3xhistory of hypertension)-(5xhistory of transient neurological deficit)-(2xperipheral arterial disease)-(1.5xhistory of hyperlipidemia)-(2.5xatrial fibrillation on admission). All patients with a score less than 1 (n=123) had a nonhemorrhagic infarct tie, 40% of the 305 patients with a nonhemorrhagic infarct). No threshold was found to diagnose cerebral hemorrhage with a sufficiently high positive predictive value. Among the 200 patients enrolled in the external validity study, 72 patients with a score below 1 had a nonhemorrhagic infarct tie, 43% of patients with a nonhemorrhagic infarct). Conclusions Diagnosis of nonhemorrhagic infarct can be made in 36% (95% confidence interval [CI], 29 to 43) of patients with a high level of accuracy (100% in the external validity study, which gives a 95% CI of 93 to 100). Thus, 43% (95% CI, 36 to 50) of patients with a nonhemorrhagic infarct could receive a bedside diagnosis. The score is simple and can be calculated from information available to all physicians.