Interobserver Agreement for the Bedside Clinical Assessment of Suspected Stroke

Abstract

Background and Purpose-Stroke remains primarily a clinical diagnosis, with information obtained from history and examination determining further management. We aimed to measure inter-rater reliability for the clinical assessment of stroke, with emphasis on items of history, timing of symptom onset, and diagnosis of stroke or mimic. We explored reasons for poor reliability. Methods-The study was based in an urban hospital with an acute stroke unit. Pairs of observers independently assessed suspected stroke patients. Findings from history, neurological examination, and the diagnosis of stroke or mimic, were recorded on a standard form. Reliability was measured by the statistic. We assessed the impact of observer experience and confidence, time of assessment, and patient-related factors of age, confusion, and aphasia on inter-rater reliability. Results-Ninety-eight patients were recruited. Most items of the history and the diagnosis of stroke were found to have moderate to good inter-rater reliability. There was agreement for the hour and minute of symptom onset in only 45% of cases. Observer experience and confidence improved reliability; patient-related factors of confusion and aphasia made the assessment more difficult. There was a trend for worse inter-rater reliability among patients assessed very early and very late after symptom onset. Conclusions-Clinicians should be aware that inter-rater reliability of the clinical assessment is affected by a variety of factors and is improved by experience and confidence.

Atrial Fibrillation, Stroke, and Cognition

“…The inter-rater reliability of most items of neurological assessment and the clinical diagnosis of stroke have been shown to be moderate or better. 43,44 The neuropathological results in this study confirmed that the subjects classified in the clinical stroke group did have significant vascular pathology and there was a significant association between clinical stroke and the presence of macroscopic brain infarcts, particularly multiple large infarcts. Another limitation in our study is lack of comprehensive neuropsychological examination.…”

Global aphasia as a predictor of mortality in the acute phase of a first stroke

“…Interobserver agreement is usually lower among patients assessed very early and very late after symptom onset. Published data are available to support the fact that increasing experience and specific training may lead to a more accurate diagnosis in time 31 . Since most studies tend to evaluate vascular aphasia in the chronic phase, more data is needed for acute stroke patients with speech and language disturbances.…”

A topographic study on the evaluation of speech and language in the acute phase of a first stroke

“…Four of the eight patients who did not survive had a cardioembolic stroke, while cardioembolism was the most frequent etiology for patients with global (5) Spontaneous speech* -5 5 14 2 0.0001 (6) Counting from 1 to 20* -4 2 11 1 0.0120 (6) Mentioning the 7 weekdays* -3 3 10 0 0.0046 (6) Singing* -3 4 12 0 0.0001 (6) Phono-articulatory function* -0 4 4 7 0.0043 (6) Constructional praxis (4 matches)* -3 2 14 4 0.0021 (6) Constructional praxis (9 matches)* -2 4 14 6 0.0105 (6) Ideomotor praxis (mean±SD) 5 2.8±1.6 2.4±1.5 1.6±2.0 4.7±0.5 0.0012 (7) SD: standard deviation; MCA: middle cerebral artery. *Number of subjects with difficulties and/or errors; (1) ANOVA; (2) ANOVA followed by Tukey's test (differences between the following groups: capsule-nuclear and whole middle cerebral artery territory; capsule-nuclear and temporal-parietal; capsulenuclear and frontal); (3) ANOVA followed by Tukey's test (differences between the following groups: frontal and temporal-parietal; frontal and whole middle cerebral artery territory; capsule-nuclear and temporal-parietal; capsule-nuclear and whole middle cerebral artery territory); (4) ANOVA followed by Tukey's test (differences between the capsule-nuclear group and the whole middle cerebral artery territory group); (5) ANOVA followed by Tukey's test (differences between the following groups: capsule-nuclear and whole middle cerebral artery territory; capsule-nuclear and frontal); (6) Fisher's exact test; (7) ANOVA followed by Tukey's test (differences between the following groups: capsule-nuclear and temporal-parietal; capsule-nuclear and whole middle cerebral artery territory).…”

“…Other complicating factors for assessment of speech and language in the acute stroke phase are, for instance, patient cooperation, the required length for a complete evaluation, and time of stroke evolution. Increasing experience and specific training for examination of speech and language may lead to a more precise diagnosis in time 5 .…”