THE RATIONAL

CLINICAL EXAMINATION

CLINICIANS CORNER

Does This Patient Have a Hemorrhagic Stroke?

Clinical Findings Distinguishing Hemorrhagic Stroke
From Ischemic Stroke
Shauna Runchey, MD, MPH
Steven McGee, MD
CLINICAL SCENARIOS
Case 1

A 75-year-old woman with hypertension, hyperlipidemia, and diabetes

mellitus presents to the emergency
department with speech difficulty and
right arm weakness. Her symptoms
appeared abruptly 6 hours earlier,
when she awoke in the morning, but
several hours passed before she could
reach her daughter, who then transported her to the hospital. One year
ago she was diagnosed as having a
transient ischemic attack after presenting with a 10-minute episode of righthand incoordination and numbness;
subsequent neuroimaging and cardiovascular studies at that time were
unrevealing. In the emergency department, her blood pressure is 140/75
mm Hg and her pulse is 70/min and
regular. She is alert and oriented but
struggles to generate words or name
objects. She reports a mild left hemicranial headache. She exhibits right
central facial paralysis and right arm
weakness. Both great toes are downgoing. Do her findings suggest hemorrhagic or ischemic infarction? How
accurate are these findings?
See also Patient Page.
CME available online at
www.jamaarchivescme.com
and questions on p 2304.
2280

Context 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.
Data Sources MEDLINE and EMBASE searches of English-language articles published from January 1966 to April 2010.
Study Selection Prospective studies of adult patients with stroke that compared
initial clinical findings with accepted diagnostic standards of hemorrhagic stroke (computed tomography or autopsy).
Data Extraction Both authors independently appraised study quality and extracted relevant data.
Data Synthesis 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).
Conclusion 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.
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JAMA. 2010;303(22):2280-2286

Case 2

A 62-year-old man presents to the emergency department with new-onset left

arm and leg weakness. While working
in his workshop 2 hours earlier, he experienced abrupt onset of a severe headache. Within 10 to 15 minutes, he had
difficulty holding tools in his left hand

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Author Affiliations: Department of Medicine, University of Washington, Seattle.

Corresponding Author: Shauna Runchey, MD, MPH,
Department of Medicine, University of Washington,
Box 356426, 1959 NE Pacific St, Health Sciences Bldg,
Seattle, WA 98195-6426 (srunchey@u.washington
.edu).
The Rational Clinical Examination Section Editors:
David L. Simel, MD, MHS, Durham Veterans Affairs
Medical Center and Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy
Editor.

2010 American Medical Association. All rights reserved.

DISTINGUISHING HEMORRHAGIC AND ISCHEMIC STROKES

and he required assistance to get to his

car. He has chronic atrial fibrillation and
has been taking aspirin for the past 4
years. In the emergency department, his
blood pressure is 200/108 mm Hg and
his pulse is 104/min and chaotic. He has
a dense left hemiparesis, hemianesthesia, and a Babinski response. During the
examination he becomes progressively drowsy and vomits twice. Do his
findings suggest hemorrhagic or ischemic infarction? How accurate are these
findings?
WHY IS THE CLINICAL
EXAMINATION IMPORTANT?
In the United States, new or recurrent
stroke affects about 795 000 individuals each year and represents the third
leading cause of death.1 The 2 fundamental subtypes of stroke are hemorrhagic stroke (ie, either intracerebral or
subarachnoid hemorrhage) and ischemic stroke (ie, infarction from thrombosis or embolism). In the United
States, 87% of these vascular strokes are
ischemic and 13% are hemorrhagic
(10% are intracerebral hemorrhage; 3%
are subarachnoid hemorrhage),1 although hospital-based surveys from
other countries suggest that the percentage due to hemorrhage may be as
high as 25% to 60%.2,3 Clinicians must
rapidly distinguish these 2 vascular subtypes because they have distinct etiologies, prognoses, and treatments.
Herein, we assume that the clinical
diagnosis of stroke has already been
made, a subject extensively reviewed in
a prior Rational Clinical Examination
article.4 Classic descriptions of stroke
suggest that some clinical features may
differentiate these subtypes: headache, neck stiffness, vomiting, and coma
are more common in hemorrhagic
stroke whereas previous transient ischemic attacks, atrial fibrillation, and
atherosclerosis risk factors are more
common in ischemic stroke. Clinicians frequently examine patients with
these findings in mind to form a clinical impression of whether hemorrhage or ischemia is more likely. Even
so, all patients with new strokes must
undergo immediate computed tomog-

raphy (CT) of the head, the best test that

rapidly distinguishes intracerebral hemorrhage from ischemia.
In patients presenting early enough to
be considered for thrombolytic therapy,
the clinical priorities are urgent CT
imaging, stabilization of the patient, identification of stroke mimics (eg, migraine,
seizures, hypoglycemia) and contraindications to thrombolysis, and measurement of the neurologic deficit.5 In such
patients, a clinicians impression of hemorrhage vs ischemia is secondary to these
more pressing matters. Nonetheless, 3 of
4 patients presenting to emergency
departments with stroke are already
beyond the narrow time window for
thrombolysis,6 and in these patients the
clinical overall impression may be helpful while awaiting the CT results. The
clinical impression also is essential when
CT is not immediately available.2,3 Finally,
clinical impression is even important in
patients receiving thrombolytics. According to treatment guidelines, the infusion should be immediately discontinued (and imaging repeated) if severe
headache, acute hypertension, nausea, or
vomiting develop,5 a statement implying that these symptoms and signs suggest hemorrhage.
The diagnostic accuracy of clinical
findings in distinguishing hemorrhagic and ischemic stroke has not been
systematically reviewed. In this article, we summarize the diagnostic accuracy of all available clinical information that is easily obtainable to clinicians
at the bedsideinitial patient interview, physical examination, and basic
laboratory tests. In addition, we review the diagnostic accuracy of different stroke scores that combine clinical information to predict the risk of
hemorrhagic infarction.

into the brain, displacing and compressing adjacent tissue, increasing intracranial pressure, and eventually dissecting into the ventricles and subarachnoid
space (FIGURE). Consequently, hemorrhage may cause additional symptoms
beyond neurologic deficits, such as
severe headache (from increased intracranial pressure or meningeal irritation), progressive deterioration after
stroke onset (from continued bleeding), vomiting (from increased intracranial pressure), neck stiffness (from
meningeal irritation), bilateral Babinski signs (from enlargement of the hemorrhage beyond the distribution of a
single vessel), and coma (from bilateral cerebral dysfunction or uncal herniation).
METHODS
Literature Search Strategy

One author (S.R.) searched PubMed

(1970 to April 2010), using MEDLINE,
and EMBASE (1988 to April 2010), using
OVID, to identify English-language studies that evaluated the diagnostic accuracy of clinical history and physical signs
for detecting intracerebral hemorrhage.
The specific search strategy for PubMed
was (Stroke/diagnosis[Mesh] OR Intracranial Embolism and Thrombosis/
diagnosis[Mesh]) AND Intracranial
Hemorrhages/diagnosis[Mesh]) and for
EMBASE was (exp *Stroke/et, di [Etiology, Diagnosis] or exp Brain Hemorrhage/et, di [Etiology, Diagnosis] or exp
Brain Infarction/et, di [Etiology, Diagnosis] and diagnostic accuracy/ or diagnostic value/). Additional articles were
identified from liberal use of the search
tool all related articles in PubMed and
examination of bibliographies of selected articles.
Study Selection

PHYSIOLOGIC ORIGINS
OF SYMPTOMS AND SIGNS
Both cerebral hemorrhage and infarction cause abrupt dysfunction of neurologic tissue, leading to neurologic deficits such as hemiparesis, hemisensory
loss, aphasia, ophthalmoplegia, and visual field cuts. Cerebral hemorrhage, in
contrast, also causes leakage of blood

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Both authors independently read all articles relevant to the study question
and selected those representing unique
patient populations meeting the
following inclusion criteria: (1) The
study prospectively enrolled only
patients presenting to clinicians in a
hospital or emergency department with
a diagnosis of stroke, defined as focal

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DISTINGUISHING HEMORRHAGIC AND ISCHEMIC STROKES

Figure. Explanation of Additional Symptoms of Intracerebral Hemorrhage

Pathophysiological events

Clinical findings

Initial hemorrhage
AXIAL VIEW

CORONAL VIEW

Lateral
ventricle

Lateral
ventricle
Lateral
ventricle

Hemiparesis

Continued bleeding, compression of adjacent tissues, and increased intracranial pressure

AXIAL VIEW

Lateral
ventricle

Lateral
ventricle

Lateral
ventricle

S A G I T TA L V I E W

CORONAL VIEW

Lateral ventricle

Third ventricle
Headache
Tentorium
cerebelli

Third
ventricle

Vomiting
Hemiplegia
Drowsiness

Subarachnoid
space

Fourth
ventricle
Brainstem

Median
aperture

Dissection of blood into the ventricles and extension of blood into the subarachnoid space; uncal herniation
AXIAL VIEW

CORONAL VIEW

S A G I T TA L V I E W

Subarachnoid
space
Lateral
ventricle
Neck stiffness
Coma

Subarachnoid
space
Tentorium Uncal
cerebelli
herniation

Brainstem

Extension of blood
via lateral aperture

In the top panel, a small hemorrhage in the right basal ganglia causes left hemiparesis and a clinical presentation indistinguishable from ischemic stroke. As intracerebral
bleeding continues (middle panel), expansion of the hemorrhage exerts a mass effect on the brain, increasing intracranial pressure and causing a midline shift. Clinical
findings characteristic of hemorrhagic stroke manifest, such as progressive neurological deficits, headache, and vomiting. Eventually, blood may dissect into the ventricles and extend into the subarachnoid space via the median and lateral apertures of the fourth ventricle (bottom panel), leading to neck stiffness. In severe hemorrhagic stroke, intracerebral expansion of the hemorrhage may result in coma from bilateral cerebral dysfunction or uncal herniation.
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DISTINGUISHING HEMORRHAGIC AND ISCHEMIC STROKES

Table 1. Definitions and Diagnostic Accuracy of Stroke Scores Detecting Hemorrhage: Pooled Results a
Score
Siriraj stroke
score13,15-17,26-34

Besson
score10,14

No. of
Patients

Hemorrhages,
No. (%)

3439

1051 (31)

261

46 (18)

Definition b
(2.5 semicoma or 5 coma) (2 vomiting)
(2 headache within 2 h) (0.1 diastolic
blood pressure) (3 1 of diabetes, angina,
intermittent claudication) 12
(2 alcohol consumption) (1.5 plantar response
both extensor) (3 headache) (3 history
of hypertension) (5 history of transient
ischemic attack) (2 peripheral arterial disease)
(1.5 history of hyperlipidemia) (2.5 atrial
fibrillation on admission)

Threshold
Values

LR for Hemorrhage
(95% CI)

1: infarction
1 to 1: uncertain
1: hemorrhage

0.29 (0.23-0.37)
0.94 (0.77-1.1)
5.7 (4.4-7.4)

1: infarction
1: hemorrhage

0.23 (0.01-5)
1.4 (0.92-2.2)

Abbreviations: CI, confidence interval; LR, likelihood ratio.

a See eTable 2 for results from the individual studies.
b Within each set of parentheses is the number of points awarded if the criterion following the times sign is satisfied. For example, in the Siriraj score, (2.5semicoma or 5coma) means
2.5 points are awarded if the patient has semicoma or 5 points if the patient has coma.

(or at times global) neurologic impairment of sudden onset and of presumed vascular origin (World Health
Organization definition).7 (2) The study
used either neuroimaging (CT or magnetic resonance imaging) or autopsy to
distinguish hemorrhage from ischemia (all but 1 study8 exclusively used
CT). (3) Intracranial hemorrhage referred only to intracerebral hemorrhage (studies enrolling patients with
subarachnoid hemorrhage were excluded). (4) The study presented sufficient information to create 22 tables
and calculate sensitivity, specificity, and
likelihood ratios (LRs). Each study was
assigned a quality grade similar to other
articles in the Rational Clinical Examination series9 according to whether
sample sizes were adequate, cases were
consecutive, and comparison with the
diagnostic standard was independent
(in assigning quality grades, we considered studies with 100 total patients and 30 patients with hemorrhage to be large; see eTable 1 [available
at http://www.jama.com]). In all studies, patients were enrolled at the time
of presentation and clinical data were
collected before the criterion standard
for the subtype of stroke (hemorrhage
vs ischemia). No patient received
thrombolytic medications. Several investigators8,10-18 supplied additional unpublished information from their original studies.
Statistical Analyses

Both authors independently extracted

data from each study to calculate sen-

sitivity, specificity, and positive and

negative LRs using standard definitions.19 Any differences in data entry
were settled by consensus. If any cell
in the 22 table had the value of zero,
0.5 was added to all cells before calculating LRs or pooled estimates. Pooled
estimates were calculated using the DerSimonian and Laird random-effects
model.20 Data are presented using LRs
because they function as diagnostic
weights that are easily translated to
posttest probability of disease.21 Excel
2007 (Microsoft, Redmond, Washington) was used for statistical analyses.
RESULTS
Study Characteristics

We retrieved 109 citations for fulltext review, 19 of which met our inclusion criteria and presented data from
6438 patients worldwide with stroke
(eFigure and eTable 1). The methods
and enrollment of these studies varied
widely. The maximal allowed interval
between onset of neurologic symptoms and CT scanning was less than 3
days in 68% of studies, less than 15 days
in 16%, and 15 days or more or unknown in 16%.
We identified 6 stroke scores that
combined clinical findings to calculate probability of hemorrhagic
stroke.10,17,22-25 Three were excluded
because they lacked extensive external validation beyond the original
cohort.22,23,25 A fourth score, the once
popular Allen (Guys Hospital) score,
was excluded because it required
clinical information first available 24

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hours after presentation, which is

clinically unrealistic.24 The definitions
of the included stroke scores appear
in TABLE 1.
Prevalence of Hemorrhage Stroke
in Patients Presenting With Stroke

The prevalence of hemorrhagic stroke

in these studies was 24% (n = 1528),
with individual study prevalences
ranging from 12% to 57% (randomeffects summary prevalence, 29%;
95% confidence interval [CI], 24%35%). In general, the prevalence of
hemorrhage is lower in studies from
the United States and Europe (summary prevalence, 15%; 95% CI, 13%18%) than in those from Asia and
Africa (summary prevalence, 34%;
95% CI, 27%-41%). Some of this difference probably reflects real differences around the world but it also
may indicate referral bias (ie, in countries with more limited access to CT
and thrombolytic therapy, patients
thought to have hemorrhage may be
more likely referred for CT). A small
number of patients (range, 2.0%2.9%) experienced a stroke mimic that
was neither hemorrhagic nor ischemic
(eg, attributable to tumor, subdural
hematoma, or tuberculosis).13,26,27,35
Individual Findings

Several findings significantly increase

the probability of hemorrhagic stroke
(LR 95% CI does not cross 1.0). In order of their LRs (the higher the value
of the LR, the greater the increase in
probability of hemorrhagic stroke),

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DISTINGUISHING HEMORRHAGIC AND ISCHEMIC STROKES

these findings include coma (LR, 6.2;

95% CI, 3.2-12), neck stiffness (LR, 5.0;
95% CI, 1.9-12.8), seizures accompanying 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), headache (LR, 2.9; 95% CI,
1.7-4.8), and loss of consciousness (LR,

2.6; 95% CI, 1.6-4.2) (TABLE 2 and

eTable 3 ). The finding of xanthochromia during lumbar puncture also
greatly increases the probability of hemorrhage (LR, 15; 95% CI, 7.7-29), although this test is no longer routinely
performed to identify intracranial hemorrhage. The findings of diastolic blood
pressure greater than 110 mm Hg, loss

of consciousness, and xanthochromia

were each investigated in only a single
study.
Several findings significantly decrease the probability of hemorrhagic
stroke, thus increasing the probability
of ischemic stroke. These findings include the presence of a cervical bruit
(LR, 0.12; 95% CI, 0.03-0.47), ab-

Table 2. Accuracy of Findings for Diagnosing Hemorrhagic Stroke a

No. of
Patients

Hemorrhage,
No. (%)

Sensitivity, %
(95% CI)

Specificity, %
(95% CI)

Positive LR
(95% CI)

Negative LR
(95% CI)

1510
178
3107

237 (16)
27 (15)
635 (20)

50 (43-56)
48 (29-67)
57 (53-61)

70 (68-73)
70 (62-77)
51 (47-54)

1.7 (1.4-1.9)
1.6 (1-2.5)
1.2 (1.1-1.3)

0.71 (0.63-0.82)
0.75 (0.51-1.1)
0.85 (0.77-0.94)

Hypertension10,11,16-18,28,35
Cigarette smoking11,28
Diabetes mellitus11,13,16,28,29,35
Prior stroke17,35
Hyperlipidemia10,11,16
Coronary artery disease11,16,35
Atrial fibrillation11,16,35
Peripheral artery disease10,35
Prior transient ischemic
attack10,11,16,35
Symptoms
Seizures accompanying neurologic
deficit11,18,35
Vomiting13,16-18,29,35
Headache10,11,13,16-18,29,35
Loss of consciousness17
Acute onset of deficit11
Physical signs
Kernig sign, Brudzinski sign,
or both29
Level of consciousness:
coma11,17,18
Neck stiffness17,29

4193
1187
3866
1622
2028
3420
3420
1710
3478

776 (19)
216 (18)
681 (18)
295 (18)
300 (15)
523 (15)
523 (15)
270 (16)
523 (15)

68 (60-75)
38 (22-55)
17 (9-25)
11 (4-18)
7 (0-15)
6 (0-13)
4 (0-7)
3 (1-5)
7 (3-11)

40 (33-47)
52 (45-79)
74 (66-81)
79 (67-91)
78 (68-89)
83 (67-100)
90 (89-91)
91 (86-96)
79 (75-84)

1.1 (1.0-1.2)
0.79 (0.45-1.4)
0.64 (0.43-0.95)
0.59 (0.17-2.0)
0.48 (0.2-1.1)
0.44 (0.31-0.61)
0.44 (0.25-0.78)
0.41 (0.2-0.83)
0.34 (0.18-0.65)

0.88 (0.77-1.01)
1.2 (0.79-1.8)
1.1 (1.0-1.2)
1.1 (0.88-1.4)
1.1 (1.1-1.1)
1.1 (1.0-1.3)
1.1 (1.05-1.1)
1.1 (1.0-1.1)
1.2 (1.1-1.3)

2497

385 (15)

9 (6-12)

98 (97-100)

2947
3974
174
887

577 (20)
708 (18)
75 (43)
109 (12)

34 (17-52)
46 (41-52)
47 (35-58)
44 (35-53)

93 (90-96)
82 (75-89)
82 (74-89)
32 (29-35)

3.0 (1.7-5.5)
2.9 (1.7-4.8)
2.6 (1.6-4.2)
0.65 (0.52-0.81)

0.73 (0.59-0.91)
0.66 (0.56-0.77)
0.65 (0.52-0.82)
1.7 (1.4-2.1)

50

23 (46)

15 (0-29)

98 (93-100)

8.2 (0.44-150)

0.87 (0.73-1.0)

1161

223 (19)

35 (19-50)

94 (89-99)

6.2 (3.2-12)

223

97 (43)

20 (12-28)

97 (93-100)

5.0 (1.9-12.8)

0.83 (0.75-0.92)

Diastolic blood pressure

110 mm Hg29
Level of consciousness:
drowsy11,17,18
Plantar response: both extensor10,17
Plantar response:
single extensor10,17
Hemiparesis11,16,35
Plantar response: both flexor10,17
Level of consciousness: alert17,18
Cervical bruit35

50

23 (46)

48 (27-68)

89 (77-100)

4.3 (1.4-14)

0.59 (0.39-0.89)

1161

223 (19)

32 (20-44)

82 (69-96)

2.0 (1.0-3.9)

370
370

106 (29)
106 (29)

16 (9-23)
62 (44-81)

92 (89-96)
39 (27-51)

1.8 (0.99-3.4)
1 (0.87-1.2)

3420
370
274
1510

523 (15)
106 (29)
114 (42)
237 (16)

63 (25-100)
11 (5-17)
23 (15-30)
1 (0-2)

33 (0-66)
74 (69-80)
31 (12-51)
93 (91-94)

0.96 (0.9-1.0)
0.45 (0.25-0.81)
0.35 (0.24-0.5)
0.12 (0.03-0.47)

1.1 (1.0-1.2)

231

41 (18)

71 (57-85)

95 (92-98)

15 (7.7-29)

0.31 (0.19-0.49)

1087

142 (13)

2 (0-4)

82 (64-100)

0.19 (0.06-0.59)

1.2 (1.0-1.5)

300

111 (37)

76 (68-84)

88 (83-92)

6.2 (4.2-9.3)

0.28 (0.20-0.39)

Finding
Risk factors
Age 60 y35
Alcohol consumption10
Male16-18,28,35

Laboratory
Xanthochromia in cerebrospinal
fluid8
Atrial fibrillation on
electrocardiogram10,11
Clinicians overall impression
Hemorrhage most likely diagnosis28

4.7 (1.6-14)

0.93 (0.9-0.96)

1.1 (1.0-1.1)

Abbreviations: CI, confidence interval; LR, likelihood ratio.

a See eTable 3 for results from the individual studies.

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DISTINGUISHING HEMORRHAGIC AND ISCHEMIC STROKES

sence of xanthochromia on lumbar

puncture (LR, 0.31; 95% CI, 0.190.49), history of transient ischemic
attack (LR, 0.34; 95% CI, 0.18-0.65),
peripheral artery disease (LR, 0.41; 95%
CI, 0.2-0.83), and history of atrial fibrillation (LR, 0.44; 95% CI, 0.250.78). The finding of cervical bruit was
investigated in only 1 study.
Combinations of Findings

The diagnostic accuracies of the Besson score (2 studies) and the Siriraj
score (13 studies) are shown in Table 1.
The Siriraj score is most accurate, increasing the probability of hemorrhage when it indicates hemorrhage
(LR, 5.7; 95% CI, 4.4-7.4) and decreasing it when it indicates ischemic infarction (LR, 0.29; 95% CI, 0.230.37). Nonetheless, in all patients
presenting with stroke, 20% were classified as uncertain by the Siriraj score
(LR, 0.94; 95% CI, 0.77-1.1), a diagnostically unhelpful result because it
changes probability of hemorrhage little
or not at all (LRs near the value of 1.0
do not change probability).
Overall Clinical Impression

In a single study, clinician overall impression of hemorrhage (LR, 6.2; 95%

CI, 4.2-9.3) or ischemia (LR, 0.28; 95%
CI, 0.20-0.39), without using explicit
rules or allowing classification into an
uncertain category, was as accurate
as the Siriraj score. This suggests that
these experienced clinicians are using
findings not addressed in our study,
combining them in nonlinear ways, or
deriving greater accuracy from more
thorough familiarity with the actual patients seen in these studies.
Limitations

One potential limitation is the methodological diversity of these studies,

making it unwise to pool results, but
when we reexamined the Siriraj score
in various subgroupspatients receiving CT within 72 hours, studies meeting grade 1 criteria, or studies meeting grade 2 or 3 criteriathe LRs were
largely unchanged (eTable 4). Also, we
found no correlation between preva-

lence of hemorrhage in a particular

study and that studys hemorrhage LR
(P = .38 by Pearson correlation) or ratio of hemorrhage LR to infarction LR,
an indicator of overall discriminatory
power (P=.47).
Another concern might be the definition of stroke used by most investigators, a post hoc definition by the
World Health Organization requiring
that neurologic deficits persist for longer
than 24 hours. This raises the possibility that our conclusions may not apply to patients presenting to emergency departments with only 1 to 2
hours of symptoms. Nonetheless, we
believe that the patients in these studies are similar to those with shorter duration of symptoms for the following
reasons. First, the 24-hour time limit
was based on an outdated and arbitrary distinction between transient ischemic attack and stroke that no longer
is applicable and probably was misleading because most patients with transient ischemic attack have less than 30
minutes of symptoms and their symptoms are unwitnessed by physicians.36
Second, few patients with only 1 to 2
hours of symptoms experience complete resolution by 24 hours (unless
they receive treatment). In the placebo group of the National Institute of
Neurological Disorders and Stroke trial
of recombinant human tissue plasminogen activator, only 2% of patients presenting with less than 3 hours of neurologic deficits had resolution of
findings at 24 hours.37
SCENARIO RESOLUTION
Case 1

The patients findings suggest ischemic stroke. Her pretest probability of

hemorrhagic stroke is 13% (in the
United States), and the findings of previous transient ischemic attack, alert
mental status, and absence of severe hypertension or Babinski sign decrease the
probability of hemorrhagic stroke even
further. Even with the presence of headache, her calculated Siriraj score is 5.5,
which is test-positive for ischemic infarction (scores 1: LR, 0.29), decreasing her probability of hemor-

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rhagic infarction from 13% to 4%. Her

CT scan reveals an infarction in the left
posterior frontal lobe.
Case 2

The patients findings of headache, severe hypertension, emesis, drowsiness, and rapid neurologic progression all strongly suggest hemorrhagic
stroke, and the calculated Siriraj score
is 5.3, which is test-positive for hemorrhage (scores 1: LR, 5.7), a result
that increases the probability of hemorrhage from 13% to 46%. In this patient, urgent CT scanning reveals an intracerebral hemorrhage centered in the
right basal ganglia, with surrounding
edema and shift of the midline structures to the left.
CLINICAL BOTTOM LINE
Other than previous transient ischemic attack, classic risk factors for cerebral atherosclerosissuch as diabetes mellitus, hyperlipidemia, cigarette
smoking, and hypertensionfail to distinguish the 2 subtypes of stroke, either
because the risk factor is only weakly
linked to ischemic stroke (eg, in the
Framingham Stroke Profile,38 a tool for
assessing risk of stroke, diabetes or cigarette smoking increases the risk of
stroke only half as much as atrial fibrillation) or because the risk factor is
linked to both hemorrhage and ischemia, thus nullifying its diagnostic value
(eg, hypertension is linked to both cerebral atherosclerosisand, thus, ischemiaand intracerebral hemorrhage).
We conclude that in patients with
stroke, additional clinical findings characteristic of hemorrhageheadache,
vomiting, severe hypertension, neck
stiffness, and comaincrease the probability of hemorrhagic stroke. Even so,
many patients with hemorrhage lack
any distinctive findings or are unclassifiable by stroke scores. Neither the
clinical impression of experienced clinicians nor the most accurate stroke
score can improve the posttest probability of hemorrhage to greater than
50%. While combinations of findings
are more predictive than individual

(Reprinted) JAMA, June 9, 2010Vol 303, No. 22

2285

DISTINGUISHING HEMORRHAGIC AND ISCHEMIC STROKES

findings, diagnostic certainty requires

neuroimaging.
Author Contributions: Drs Runchey and McGee had
full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Runchey, McGee.
Acquisition of data: Runchey, McGee.
Analysis and interpretation of data: Runchey, McGee.
Drafting of the manuscript: Runchey, McGee.
Critical revision of the manuscript for important intellectual content: Runchey, McGee.
Statistical analysis: Runchey, McGee.
Study supervision: McGee.
Financial Disclosures: None reported.
Online-Only Material: The eFigure and eTables 1
through 4 are available online at http://www.jama
.com.
Additional Contributions: We appreciate the expertise and assistance of Sherry Dodson, University of Washington, who helped conduct the literature search. Michael
Fitch, MD, PhD, Wake Forest University School of Medicine, and Amanda Green, MD, Paris Regional Medical
Center, provided helpful advice on earlier versions of
the manuscript. No compensation was received.
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