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The usefulness in general practice of the Diaz and the Allen Scoring systems to differentiate CVA bleed from infarction.

Author

Edward-Bengie Magsambol,
Jacqueline Dominguez,
Deborah Bernardo,
Alejandro Diaz

Related Institution

Publication Information

Publication Type
Journal
Publication Sub Type
Journal Article, Original
Title
St. Luke's Medical Journal
Frequency
Semi-Annual
Publication Date
January-June 1996
Volume
3
Issue
1
Page(s)
17-26

Abstract

BACKGROUND & PURPOSE: Stroke is a leading cause of morbidity and mortality in the Philippines and the incidence seems to be rising. Inspite of all this, the Filipinos' knowledge about stroke is still very meager resulting in poor compliance to preventive measures and slow response to its clinical onset. To increase the sense of urgency, the term "brain attack" is now recommended instead of stroke. In order to intervene early, on the other hand, physicians must be able to diagnose early. If a CT scan is readily available, a bleed can be immediately ruled out and intervention may be started immediately. In lieu of a scan, scoring protocols like the Diaz and Allen systems were devised to make an early diagnosis. This study therefore, aimed to compare their usefulness in general practice by matching their sensitivities, specificities, positive and negative predictive values and overall accuracy; then compare these with the accuracy of clinical impression alone. The authors also noted if recurrent strokes will significantly alter the accuracy of the scoring scales.


SUBJECTS, METHODS, AND STATISTICAL ANALYSIS: A total of 57 subjects were included in this study. Thirty-four (34) cases came from a retrospective study of stroke patients admitted to St. Luke's Medical Center from January to April 1995. The other 23 cases were admissions through the SLMC-ER or directly to the Neurosciences unit from September to October 1995. Both sexes were adequately represented and the ages ranged from 40 to 90 years. The Diaz and Allen protocols were used to score each case and results were interpreted as either bleed or infarct (Diaz scale) and as bleed, infarct or uncertain (Allen scale). The intern's admitting impression for each case was likewise recorded. All the results were tallied and sensitivity, specificity, positive and negative predictive values and overall accuracy were compared both for first stroke cases and for second/third stroke cases. The Chi-square test was used to check validity of the two scoring systems in assessing CVA infarct or bleed.


RESULTS: The Diaz scoring system was 100% sensitive for the cases of infarcts studied but only 65% sensitive for bleed. The positive and negative predictive values for infarcts were 100% and 80%, respectively. For bleed, positive and negative predictivie values were 80% and 100 respectively. Overall accuracy was 85%. On the other hand, The Allen scoring system was 80% sensitive for CVA infarct and 100% sensitive for CVA bleed. Positive and negative predictive values for CVA infarct were 100% and 90%, respectively; and for bleed, 90% and 100% Overall accuracy as 93%. For the Allen score, however, these values were true in only 47% of the 57 cases where the Allen score committed to a diagnosis of infarct or bleed. In the remaining 53% of the cases, the Allen score's diagnosis was uncertain. The authors considered this percentage of uncertainty quite significant. Clinical diagnosis alone showed a low diagnostic accuracy of only 50% in the retrospective study and 43% in the prospective study. Both the Diaz and Allen scores maintained high accuracy rates even in cases of recurrent strokes.


CONCLUSION: The results of this study showed that the Diaz scoring protocol is a simple, reliable system that will significantly increase accuracy of diagnosis of a stroke especially if the diagnosis was infarction, whether it be first, second or third. Physicians who will benefit from this system are the non-neurologists who do not have easy access to a CT scan. Medical and paramedical trainees would also improve their clinical acumen. All these things would then translate to early intervention and better management of brain attacks in this country.

References

1. Diaz, A . "A scoring system to differentiate cerebral hemorrhage from infarction" Santo Tomas Journal of Medicine 35(3): 168-174, September 1986-December 1986
2. Camarata, P J, Heros, R C, Latchchaw, R E. "Brain attack: The rationale for treating stroke as a medical emergency" Neurosurgery 34(1): 144-158, January 1994
3. Lodder, J , Bamford, J , Kapelle, J , Boiten, J . "What causes false clinical prediction of small deep infarcts?" Stroke 25(1): 86-91, January 1994
4. Carlberg, B , Asplund, K , Hagg, E . "Factors influencing admission blood pressure levels in patients with acute stroke" Stroke 22(4): 427-530, April 1991
5. Celani, M G, Cerravolo, M G, Duca, E , Minciotti, P , Caputo, N , Orlandini, M , Ricci, S , Provinciali, L . "Was it infarction or haemorrhage? A clinical diagnosis by means of the Allen score" Journal of Neurology 239, 411-413, 1992
6. Lyden, P , Lau, G T. "A critical appraisal of stroke evaluation and rating scales" Stroke 22(11): 1345-1351, November 1991
7. Kase, C S, Norving, B , Levine, S R, Babikian, V L, Chodosh, E H, Wolf, A , Welch, KM A. "Cerebellar infarction, clinical and anatomic observation in 66 cases" Stroke 24(1): 76-83, January 1993
8. Toni, D , Del Duca, R , Fiorelli, M , Sacchetti, M L, Bastianello, S , Giubilei, F , Martinazzo, C , Argentino, C . "Pure motor hemiparesis and sensorimotor stroke: Accuracy of very early diagnsos of lacunar stroke" Stroke 25(1): 92-96, January 1994

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Philippine Council for Health Research and Development Box No. 35 Fulltext pdf (Request Document)
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