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Clinical diagnosis of subarachnoid hemorrhage (SAH) is frequently misdiagnosed with intracerebral hemorrhage (ICH) or cerebral infarction (CI), which delays appropriate referral. This study was undertaken to create a clinical index to select, among stroke patients, those with the highest probability of having a SAH. Clinical data of patients with acute stroke were evaluated with the X2 and the Fisher exact test; a p value < 0.05 was considered significant. Significant variables were included in a "log-lineal regression analysis" where those with an odds ratio (OR) 95% confidence limits not including the unit were considered to construct an index using the odds ratio coefficient (C). The results indicated that of 197 records which were included, 22 cases of SAH and 175 of ICH or CI were demonstrated. Kappa coefficients for observer variation in clinical data retrieval was 0.91. After "log-lineal regression analysis" was carried out the following variables were significant: neck stiffness (C = 3, OR = 21); lack of focal neurologic signs (C = 2, OR = 6.88); and age < or = 60 years (C = 1.5, OR = 4.35). A fourth variable, seizures (C = 1, OR = 3.25), was marginally significant (p = 0.07), but added predictive value to the index. The positive predictive values of the sum of the coefficients were: 0 = 0%; 1-2 = 3%; 2.5-3.5 = 21%; 4-5 = 40%; 6.5 = 75%; 7.5 = 100%. In conclusion, when a stroke patient shows neck stiffness, or any combination of young age, lack of focal neurologic signs or seizures (a score > or = 2.5, the index has a 91% sensitivity and 82% specificity), he/she must be referred to a tertiary care center.

The objective of the study was to assess total cerebrospinal creatinine-kinase activity (CSF-CK) measurement in differential diagnosis of "metabolic" and organic causes of coma. The setting for the study was a tertiary care reference medical center and community general hospital. The design of the study was a series of consecutive patients with profound coma (Glasgow scale ratings between 3 and 6) as the presenting complaint to the emergency room and controls. Measurements and main results were as follows: CSF-CK was measured in 103 consecutive patients including 18 patients with metabolic causes of coma, 27 patients with organic causes of coma, 18 patients scheduled for elective orthopedic surgery with epidural anesthesia and 27 patients with compressive myelopathy and radiculopathy. CSF-CK activities were significantly different between groups (H = 29.48, p < 0.001, Kruskal-Wallis test), controls had a median of 0 mU/ml (range 0-16 mU/ml), patients with metabolic causes of coma had a median of 0 mU/ml (range 0-65 mU/ml), patients with compressive myelopathy or radiculopathy had a median of 19 mU/ml (range 0-80 mU/ml), and patients with organic causes of coma had a median of 20 mU/ml (range 0-400 mU/ml). The test sensitivity was 83% (95% confidence interval (CI 65-100%) specificity 62% (CI 43-80%) positive predictive value 60% (CI 49-79%) and negative predictive value 85% (CI 75-95%). The conclusion of the study was that the test is useful for ruling out metabolic causes of coma when CSF-CK activity is high (i.e., above 16 mU/ml).