title: Accuracy of clinical stroke scores for distinguishing stroke subtypes in resource poor settings: A systematic review of diagnostic test accuracy.
abstract: BACKGROUND
  Stroke is the second leading cause of death globally. Computerized tomography is used to distinguish between ischemic and hemorrhagic subtypes, but it is expensive and unavailable in low and middle income countries. Clinical stroke scores are proposed to differentiate between stroke subtypes but their reliability is unknown.
  
  
  METHODS
  We searched online databases for studies written in English and identified articles using predefined criteria. We considered studies in which the Siriraj, Guy's Hospital, Besson and Greek stroke scores were compared to computerized tomography as the reference standard. We calculated the pooled sensitivity and specificity of the clinical stroke scores using a bivariate mixed effects binomial regression model.
  
  
  RESULTS
  In meta-analysis, sensitivity and specificity for the Siriraj stroke score, were 0.69 (95% CI 0.62-0.75) and 0.83 (95% CI 0.75-0.88) for ischemic stroke and 0.65 (95% CI 0.56-0.73) and 0.88 (95% CI 0.83-0.91) for hemorrhagic stroke. For the Guy's hospital stroke score overall sensitivity and specificity were 0.70 (95% CI 0.53-0.83) and 0.79 (95% CI 0.68-0.87) for ischemic stroke and 0.54 (95% CI 0.42-0.66) and 0.89 (95% CI 0.83-0.94) for hemorrhagic stroke.
  
  
  CONCLUSIONS
  Clinical stroke scores are not accurate enough for use in clinical or epidemiological settings. Computerized tomography is recommended for differentiating stroke subtypes. Larger studies using different patient populations are required for validation of clinical stroke scores.
authors.affiliation: Department of Surgery, Thika Level 5 Hospital, Thika, South Africa ; Evidence Synthesis and Translation Unit, Afya Research Africa, A Joanna Briggs Institute Affiliate Center, South Africa.
authors.forename: Clifford C
authors.initials: CC
authors.lastname: Mwita
authors.affiliation: Department of Neurology, Stellenbosch University, South Africa.
authors.forename: Duncan
authors.initials: D
authors.lastname: Kajia
authors.affiliation: Evidence Synthesis and Translation Unit, Afya Research Africa, A Joanna Briggs Institute Affiliate Center, South Africa ; Department of Medical Physiology, School of Health Sciences, Kenyatta University, Nairobi, Kenya.
authors.forename: Samson
authors.initials: S
authors.lastname: Gwer
authors.affiliation: Department of Clinical Research, Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kenya.
authors.forename: Anthony
authors.initials: A
authors.lastname: Etyang
authors.affiliation: Department of Clinical Research, Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kenya ; Department of Neurosciences, Institute of Child Health, University College London, United Kingdom ; Department of Psychiatry, University of Oxford, Oxford, United Kingdom.
authors.forename: Charles R
authors.initials: CR
authors.lastname: Newton
keywords: Besson score; Greek stroke score; Guy's hospital stroke score; Siriraj stroke score; stroke