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Clinical evaluation of patients with stroke is still worthwhile
  1. Stroke Service, USL 2, Perugia, Italy
  2. email istitaly{at}

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    Do we still need clinical evaluation in the era of “high tech” functional neuroimaging, or should we just rely on machines? For those of us who care for patients with stroke where they are normally admitted—that is, peripheral hospitals with poor access to complex facilities—the answer is obviously yes, and the results shown in the paper by the Edinburgh group (this issue, pp 558-562)1 are an important confirmation of this view.

    After CT to rule out a haemorrhage, the clinical distinction between total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), posterior circulation infarct (POCI), and lacunar infarct (LACI), as defined in the Oxfordshire Community Stroke Project (OCSP) study,2 which is based on history and examination, gives important information to the clinician. In fact, not only the site and size of the future infarct on CT can be reasonably predicted (a fact which is scientifically important, but has no practical value for the actual management of the patient), but also solid hints on the pathogenesis of the ischaemia can be made, and therefore a diagnostic programme can be established more reliably, especially when the access to additional investigations is not easy. The authors1correctly point out that if the patient has been labelled as having had a LACI, the probability of finding important and surgically treatable lesions on carotid Doppler or transoesophageal echocardiography is low. However, these tools have a very important role in patients with PACI, where an embolic source is very likely, and a better and more rational use of resources can be made using this classification.

    Some clinicians involved in stroke research think that there is little or no value in the OCSP classification, in the very acute phase of the stroke; in fact, Mead and colleagues rightly point out that a formal validation of the OCSP classification in the hyperacute phase of the stroke, when symptoms and signs may change within a few hours, would be useful. However, some work in this direction has already been made, using data from the International stroke trial,3 and looking at the prediction of outcome (which is clinically meaningful) instead of the future presence of a lesion on a repeated scan; results show that even for patients evaluated within 6 hours the OCSP classification still correctly predicts the short term outcome of the patient,4 and can be used to stratify patients very early, when a CT is usually normal.

    Stroke doctors are not yet (and will probably never be) in the position of Dr Leonard “Bones” McCoy, the physician of the Enterprise starship in Star Trek movie, who could make any possible diagnosis by means of a very sophisticated machine, without talking to the patients or even touching them; we have still to rely on our clinical skills to direct the diagnostic itinerary and, possibly, the therapeutic decisions. Therefore, while waiting for further research on this topic, we can apply the OCSP classification in our clinical setting, and recommend its wide use in epidemiological research and in clinical trials, to make results really transferable to clinical practice.


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