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Diagnostic certainty for type of stroke requires neuroimaging

Clinical Question:
What clinical signs and symptoms are useful in distinguishing hemorrhagic stroke from ischemic stroke?

Bottom Line:
Although various findings from the history and physical examination of patients presenting with symptoms of acute stroke are useful in distinguishing hemorrhagic from ischemic type, neuroimaging is still recommended for diagnostic certainty. (LOE = 2a)

Reference:
Runchey S, McGee S. Does this patient have a hemorrhagic stroke? Clinical findings distinguishing hemorrhagic stroke from ischemic stroke. JAMA 2010;303(22):2280-2286.  [PMID:20530782]

Study Design:
Systematic review

Funding:
Unknown/not stated

Setting:
Various (meta-analysis)

Synopsis:
These investigators wanted to evaluate the diagnostic accuracy of the clinical history and physical examination for distinguishing hemorrhagic stroke from ischemic stroke. One author thoroughly searched multiple databases and bibliographies of selected articles for English-language studies meeting eligibility criteria. These included prospective enrollment of patients presenting acutely with a diagnosis of stroke meeting standard clinical criteria, and the performance of either neuroimaging (with CT or MRI) or autopsy to distinguish hemorrhage from ischemia. Two individuals independently evaluated included studies for methodologic quality on the basis of adequate sample size, consecutive enrollment, and comparison with the diagnostic gold standard. Differences were resolved by consensus. From an initial 109 citations, 19 (n = 6438) met inclusion criteria. The overall prevalence of hemorrhagic stroke was 24%, but was lower in the United States (13%). The following findings significantly increased the probability of hemorrhagic stroke: coma (positive likelihood ratio [LR+] = 6.2; 95% CI, 3.2-12), neck stiffness (LR+ = 5.0; 1.9-12.8), seizure with neurologic deficits (LR+ = 4.7; 1.6-14), diastolic blood pressure greater than 110 mmHg (LR+ = 4.3; 1.4-14), vomiting (LR+ = 3.0; 1.7-5.5), headache (LR+ = 2.9; 1.7-4.8), and loss of consciousness (LR+ = 2.6; 1.6-4.2). Although rarely performed in this clinical situation, xanthochromia during lumbar puncture also increased the probability of hemorrhagic stroke (LR+ = 15; 7.7-29). Findings that significantly decreased the risk of hemorrhagic stroke and increased the probability of ischemic stroke included: the presence of cervical bruit (negative likelihood ratio [LR-] = 0.12; 0.03-0.47), absence of xanthochromia on lumbar puncture (LR- = 0.31; 0.19-0.49), history of transient ischemic attack (LR- = 0.34; 0.18-0.65), history of peripheral artery disease (LR- = 0.41; 0.2-0.83), and history of atrial fibrillation (LR- = 0.44; 0.25-0.78). The authors also assessed stroke risk calculators using various combinations of the history and physical and they found that none could improve the posttest probability of hemorrhage to greater than 50%. Thus, these investigators continue to recommend neuroimaging for diagnostic certainty.

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