|Year : 2014 | Volume
| Issue : 4 | Page : 157-160
Benin stroke score in the diagnosis of acute brain infarct: A pilot study in Senegalese Africans
Imarhiagbe Frank Aiwansoba1, Okaka Enajite Ibiene2, Ugiagbe Rose Ashinedu2, Ogunrin Akindele Olubunmi2, Ndiaye Mansour Mohammadu3
1 Neurology Unit, Department of Medicine, University of Benin Teaching Hospital, Benin City, Nigerian; West African Health Organisation's 2012 PEPL Research Fellow, CHNU, Dakar, Senegal
2 Neurology Unit, Department of Medicine, University of Benin Teaching Hospital, Benin City, Nigerian
3 Department of Neurology, Centre Hospitalier National Universitaire, Dakar, Senegal
|Date of Web Publication||7-Oct-2014|
Imarhiagbe Frank Aiwansoba
Neurology Unit, Department of Medicine, University of Benin Teaching Hospital, P.O.BOX 7184, GPO, Benin City, Nigeria
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The Benin stroke score (BSS) is a validated tool in the diagnosis of intracerebral hemorrhage (ICH) but not in the diagnosis of brain infarct. The aim of this report is to specifically validate the BSS in the clinical diagnosis of acute brain infarct.
Materials and Methods: A total of 60 participants with a presumptive diagnosis of acute stroke in a busy tertiary neurologic care centre in Francophone West Africa were evaluated within 48 h of onset of symptoms with the BSS after basic data were obtained, before computed tomography or magnetic resonance imaging scans was used as gold standard. BSS is a three-item tool that scores age, supine diastolic blood pressure, and Glasgow coma scale with a minimum score of 0 and a maximum score of 3.5. A score of 2.5 or less is diagnostic for a brain infarct.
Results: The sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratios of BSS in the diagnosis of brain infarct were 83.78%, 69.56%, 81.57%, 72.72%, 2.75, and 0.23, respectively. BSS agreed with neuroimaging in the diagnosis of all stroke subtypes significantly on kappa statistics (k = 0.538, P < 0.001) and interrater and intrarater reliability between two cadres of medical personnel in the use of BSS were significant (r = 0.9. 0.95, 0.95, P < 0.001, <0.001, <0.001), respectively.
Conclusion: BSS as a simple clinical tool could be used with appreciable levels of accuracy in the clinical diagnosis of acute brain infarct where neuroimaging may not be available or immediately inaccessible, much the same way it is being used for ICH.
| Abstract in French|| |
Contexte: Score AVC le Bιnin (BSS) est un outil validι pour le diagnostic de l'hιmorragie intracιrιbrale (ICH), mais pas dans le diagnostic d'infarctus du cerveau. Ce rapport vise ΰ valider plus prιcisιment le BSS dans le diagnostic clinique de l'infarctus cιrιbrale aiguλ.
Matιriel et mιthodes: Un total de 60 participants ayant un diagnostic prιsomptif d'accident vasculaire cιrιbral aigu dans un centre de soins neurologiques tertiaires occupι en Afrique de l'Ouest Francophone ont ιtι ιvaluιs dans les 48 heures prιcιdant l'apparition des symptτmes avec le SRS, aprθs que les donnιes de base ont ιtι obtenues, avant calculιes balayages tomodensitomιtrie ou imagerie par rιsonance magnιtique a ιtι utilisι comme ιtalon-or. BSS est un outil de three-item qui scores βge, la pression artιrielle diastolique en position couchιe et coma de Glasgow ΰ l'ιchelle avec une note minimale de 0 et une note maximale de 3,5. Une note ιgale ou infιrieure ΰ 2,5 est diagnostique pour un infarctus du cerveau.
Rιsultats: La sensibilitι, spιcificitι, valeur prιdictive positive, valeur prιdictive nιgative, des rapports de vraisemblance positifs et nιgatifs de BSS dans le diagnostic d'infarctus du cerveau ιtaient respectivement de 83,78 %, 69,56 %, 81,57 %, % de 72,72, 2,75 et 0,23. BSS convenu avec neuro-imagerie dans le diagnostic de tous les sous-types de l'accident vasculaire cιrιbral significativement sur les statistiques de kappa (k = 0,538, P < 0,001) et porter et intrarater fiabilitι entre deux cadres du personnel mιdical dans l'utilisation de BSS ιtaient significatives (r = 0,9. 0,95, 0,95, P < 0,001, < 0,001, < 0,001), respectivement.
Conclusion: BSS comme un simple outil clinique peut κtre utilisι avec des niveaux apprιciables de prιcision dans le diagnostic clinique de l'infarctus cιrιbrale aiguλ oω neuroimagerie peut-κtre pas disponible ou immιdiatement inaccessibles, la mκme maniθre Qu'on l'utilise pour ICH.
Mots-clιs: Indice de masse corporelle, ιpaisseur de la carotide intima-media, hypertension artιrielle, ιchographie
Keywords: Africans, Benin, diagnosis, infarct, stroke
|How to cite this article:|
Aiwansoba IF, Ibiene OE, Ashinedu UR, Olubunmi OA, Mohammadu NM. Benin stroke score in the diagnosis of acute brain infarct: A pilot study in Senegalese Africans. Ann Afr Med 2014;13:157-60
|How to cite this URL:|
Aiwansoba IF, Ibiene OE, Ashinedu UR, Olubunmi OA, Mohammadu NM. Benin stroke score in the diagnosis of acute brain infarct: A pilot study in Senegalese Africans. Ann Afr Med [serial online] 2014 [cited 2019 Oct 17];13:157-60. Available from: http://www.annalsafrmed.org/text.asp?2014/13/4/157/142278
| Introduction|| |
The Benin stroke score (BSS) is a three-item diagnostic tool previously validated in the diagnosis of spontaneous intracerebral hemorrhage (ICH) with an appreciable level of accuracy; however, its use in the diagnosis of brain infarct at present rests on the exclusion of spontaneous parenchymal hemorrhage in a presumptive case of acute stroke. 
It may be argued that the exclusion of a hemorrhage shores up the chances that a stroke subtype is an infarct except where they coexist or where an infarct transforms into a hemorrhage, but it is pertinent to mention that the usefulness of a diagnostic tool for acute stroke would be better appreciated if it is validated in the diagnosis of both infarct and hemorrhage.
Clinical diagnostic tools for acute stroke perform differently when compared with neuroimaging as the gold standard; however, their usefulness is particularly brought to bear where there is a dearth of neuroimaging modalities like computed tomography (CT) or magnetic resonance imaging (MRI) in the triage of acute stroke patients in the emergency room.  Clinimetric tools generally are more user friendly if they have few items and are easy to use. ,
This study pilot tested the use of the BSS in the diagnosis of acute brain infarct to complement its previous use in the diagnosis of spontaneous ICH.
| Materials and Methods|| |
A total of 60 patients seen in the busy emergency department and outpatient clinics in a tertiary neurologic care hospital in Francophone West Africa in February-March 2012, within 48 h of onset of stroke symptoms had their basic data of age and sex captured by a proforma and all were administered the test instrument-the BSS, translated first into French language and back translated into English language and again to French language to ensure content validity before cranial CT and/or MRI was ordered.
BSS is a previously validated instrument for the diagnosis of spontaneous ICH that scores age of the patient, supine diastolic blood pressure and Glasgow Coma scale on an assigned score of 0, 1, or 1.5. Age above or equal to 80 scores 0, below 80 years scores 1, diastolic blood pressure above or equal to 110 mm Hg scores 1 and 120 mm Hg or above scores 1.5, Glasgow Coma scale score of less than 13 or less than or equal to 9 in aphasic patients scores 1 and above or equal to 13 or above 9 in aphasia scores 0. A total score of less than 2.5 was considered diagnostic for acute brain infarct and results were compared with cranial CT or MRI as gold standard. The use of BSS was compared between a first and a 3 rd year resident doctors in the study center to test for intra- and interrater reliability. Patients who presented after 48 h of onset of stroke symptoms or neuroimaging evidence of hemorrhage coexisting with infarct or diagnosis other than stroke were exclusion criteria. CT was done with a 16 slice machine and MRI was ordered only when CT was inconclusive with a 1.5 Tesla machine at the study center. Study was approved by the institutional review board (ethics committee) of the center.
Basic data were expressed as means, standard deviations, and percentages. Sensitivity, specificity, likelihood ratios, positive and negative predictive values of BSS in the diagnosis of brain infarct were determined. Symmetric agreement between BSS and CT or MRI was tested on kappa statistics and intrarater and interrater reliability between two cadres of medical personnel in the use of BSS was tested with Pearson's correlation. SPSS version 17 was used for analysis and P value of less than 0.05 was taken as significant for all tests.
| Results|| |
A total of 60 patients were studied, mean age was 60.58 (16.58) years, range 19-95, comprising 23 (38.4%) females and 37 (61.6%) males. Mean BSS and diastolic blood pressure were 1.86 (0.883) and 98.40 (22.28) mm Hg, respectively. Stroke subtype was made up of 37 (61.7%) infarct and 23 (38.3%) spontaneous ICH [Table 1].
The sensitivity and specificity of BSS for brain infarct were 83.78% and 69.56%, respectively. The positive and negative predictive values of BSS for infarct were 81.57% and 72.72% and the positive and negative likelihood ratios were 2.75 and 0.23, respectively. BSS compared significantly with neuroimaging (cranial CT and MRI) for all stroke subtypes with a kappa value of 0.538 (P < 0.001) [Table 2].
|Table 2: Sensitivity, specificity, predictive values and likelihood ratios of Benin stroke score in the diagnosis of acute brain infarct|
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The intrarater and interrater reliability of BSS between two cadres of resident doctors in the diagnosis of brain infarct were 0.9, 0.9, and 0.95 (P < 0.001, 0.001, and 0.001), respectively [Table 3].
|Table 3: Reliability in the use of Benin stroke score between two cadres of medical personnel and symmetric agreement (kappa) between Benin stroke score and neuroimaging|
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| Discussion|| |
The mean age and gender distribution of study participants are similar to findings in related studies and the elevated mean diastolic blood pressure suggests the strong association between hypertension and acute stroke as shown earlier in other sub-Saharan African populations. ,,,, The mean BSS value of less than 2.5 is consistent with the preponderance of infarct in the distribution of stroke subtypes compared to hemorrhage. 
Remarkably, BSS is sensitive and specific in the diagnosis of acute brain infarct, with values comparable to some other diagnostic stroke scores with more items. ,,,, Its predictive values are also appreciable.
Importantly, BSS compares significantly with neuroimaging for all stroke subtypes. The significant reliability between two cadres of medical personnel in the application of BSS underscores the simplicity of its application.  It bears reiteration that the BSS is a three-item tool and that clinimetric tools generally are more appealing when the items are whittled to as few as possible devoid of redundant items. 
It is safe to conclude that the BSS as a simple clinimetric tool could as well be used in the diagnosis of brain infarct as it is for ICH with appreciable levels of accuracy.  BSS could be easily applied in other populations with similar sociodemographic features and resource constrain as in most parts of sub-Saharan Africa with a huge dearth of the gold standard diagnostic equipment to aid early detection and triage of acute stroke subtypes.
The relatively small sample size may be a limitation in this study as well as the dearth of related citations, but this is extenuated by the fact that the BSS is a new tool being pilot tested in the diagnosis of brain infarct, thereby broadening its scope as a tool in the clinical diagnosis of stroke.
| Acknowledgement|| |
We appreciate the doctors and staff at service de Neurologie, Centre Hospitalier National Universitaire, Fann, Dakar, Senegal.
| References|| |
|1.||Imarhiagbe FA, Akemokwe FM, Unuigbe EI, Ndiaye MM. Clinical diagnosis of intracerebral haemorrhage: Validation of a simple scoring tool in West Africans. West Afr J Med 2012;31:172-5. |
|2.||Llanes JN, Kidwell CS, Starkman S, Leary MC, Eckstein M, Saver JL. The Los Angeles Motor Scale: A new measure to characterize stroke severity in the field. Prehosp Emerg Care 2004;8:46-50. |
|3.||Lemogoum D, Degaute JP, Bovet P. Stroke prevention, treatment and rehabilitation in sub-Saharan Africa. Am J Prev Med 2005;29 (5 Suppl 1):95-101. |
|4.||Qari FA. Profile of stroke in a teaching University Hospital in the western region. Saudi Med J 2000;21:1030-3. |
|5.||Lisk DR. Hypertension in Sierra Leone stroke population. East Afr Med J 1993;70:284-7. |
|6.||Osuntokun BO, Bademosi O, Akinkugbe OO, Oyediran AB, Carlisle R. Incidence of stroke in an African City: Results from the stroke registry at Ibadan, Nigeria, 1973−1975. Stroke 1979;10:205-7. |
|7.||Cruickshank JK, Mbanya JC, Wilks R, Balkau B, Forrester T, Anderson SG, et al. Hypertension in four African-origin populations: Current ′Rule of Halves′, quality of blood pressure control and attributable risk of cardiovascular disease. J Hypertens 2001;19:41-6. |
|8.||Ogun SA, Oluwole O, Fatade B, Ogunseyinde AO, Ojini FI, Odusote KA. Comparison of siriraj stroke score and the WHO criteria in the clinical classification of stroke subtypes. Afr J Med Med Sci 2002;31:13-6. |
|9.||Yamashita S, Kimura K, Iguchi Y, Shibazaki K, Watanabe M, Iwanaga T. Kurashiski Prehospital Stroke Subtyping Score (KP3S) as a means of distinguishing ischemic from hemorrhagic stroke in emergency medical services. Eur Neurol 2011;65:233-8. |
|10.||Poungvarin N, Viriyavejakul A, Komontri C. Siriraj stroke score and validation study to distinguish supratenetorial intracerebral haemorrhage from infarction. BMJ 1991;302:1565-7. |
|11.||Runchey S, McGee S. Does this patient have a hemorrhagic stroke?: Clinical findings distinguishing hemorrhagic stroke from ischemic stroke. JAMA 2010;303:2280-6. |
|12.||Besson G, Robert C, Hommel M, Perret J. Is it clinically possible to distinguish nonhemorrhagic infarct from hemorrhagic stroke? Stroke 1995;26:1205-9. |
|13.||Lovelock CE, Redgrave JN, Briley D, Rothwell PM. The SCAN rule: A clinical rule to reduce CT misdiagnosis of intracerebral haemorrhage in minor stroke. J Neurol Neurosurg Psychiatry 2010;81:271-5. |
[Table 1], [Table 2], [Table 3]