Does this patient have a hemorrhagic stroke?: clinical findings distinguishing hemorrhagic stroke from ischemic stroke.
BACKGROUND
The 2 fundamental subtypes of stroke are hemorrhagic stroke and ischemic stroke. Although neuroimaging is required to distinguish these subtypes, the diagnostic accuracy of bedside findings has not been systematically reviewed.


OBJECTIVE
To determine the accuracy of clinical examination in distinguishing hemorrhagic stroke from ischemic stroke.


METHODS
MEDLINE and EMBASE searches of English-language articles published from January 1966 to April 2010.


METHODS
Prospective studies of adult patients with stroke that compared initial clinical findings with accepted diagnostic standards of hemorrhagic stroke (computed tomography or autopsy).


METHODS
Both authors independently appraised study quality and extracted relevant data.


RESULTS
Nineteen prospective studies meeting inclusion criteria were identified (N = 6438 patients; n = 1528 [24%] with hemorrhage stroke). Several findings significantly increase the probability of hemorrhagic stroke: coma (likelihood ratio [LR], 6.2; 95% confidence interval [CI], 3.2-12), neck stiffness (LR, 5.0; 95% CI, 1.9-12.8), seizures accompanying the neurologic deficit (LR, 4.7; 95% CI, 1.6-14), diastolic blood pressure greater than 110 mm Hg (LR, 4.3; 95% CI, 1.4-14), vomiting (LR, 3.0; 95% CI, 1.7-5.5), and headache (LR, 2.9; 95% CI, 1.7-4.8). Other findings decrease the probability of hemorrhage: cervical bruit (LR, 0.12; 95% CI, 0.03-0.47) and prior transient ischemic attack (LR, 0.34; 95% CI, 0.18-0.65). A Siriraj score greater than 1 increases the probability of hemorrhage (LR, 5.7; 95% CI, 4.4-7.4) while a score lower than -1 decreases the probability (LR, 0.29; 95% CI, 0.23-0.37). Nonetheless, many patients with stroke lack any diagnostic finding, and 20% have Siriraj scores between 1 and -1, which are diagnostically unhelpful (LR, 0.94; 95% CI, 0.77-1.1).


CONCLUSIONS
In patients with acute stroke, certain findings accurately increase or decrease the probability of intracranial hemorrhage, but no finding or combination of findings is definitively diagnostic in all patients, and diagnostic certainty requires neuroimaging.
Department of Medicine, University of Washington, Box 356426, 1959 NE Pacific St, Health Sciences Bldg, Seattle, WA 98195-6426, USA. srunchey@u.washington.edu
Shauna
S
Runchey
Steven
S
McGee
D000208:Acute Disease; D000368:Aged; D002545:Brain Ischemia / Q000150:complications / Q000175:diagnosis*; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D020300:Intracranial Hemorrhages / Q000150:complications / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis* / Q000209:etiology