Positive Findings (Patient Has This)
| Risk Factors | Increased Disease Probability (Positive Likelihood Ratio) |
|---|---|
| Age <=60y | 1.7× (1.4-1.9) |
| Alcohol consumption | 1.6× (1-2.5) |
| Male | 1.2× (1.1-1.3) |
| Hypertension | 1.1× (1.0-1.2) |
| Cigarette smoking | 0.79× (0.45-1.4) |
| Diabetes mellitus | 0.64× (0.43-0.95) |
| Prior stroke | 0.59× (0.17-2.0) |
| Hyperlipidemia | 0.48× (0.2-1.1) |
| Coronary artery disease | 0.44× (0.31-0.61) |
| Atrial fibrillation | 0.44× (0.25-0.78) |
| Peripheral artery disease | 0.41× (0.2-0.83) |
| Prior TIA | 0.34× (0.18-0.65) |
| Symptoms | Increased Disease Probability (Positive Likelihood Ratio) |
|---|---|
| Seizures w/ neurological deficit | |
| Vomiting | |
| Headache | |
| Loss of consciousness | |
| Acute onset deficit | 0.65 (0.52-0.81) |
| Signs | Increased Disease Probability (Positive Likelihood Ratio) |
|---|---|
| Kernig's or Brudzinski's or both | |
| LOC: coma | |
| Neck stiffness | |
| Diastolic BP >110 mmHg | |
| LOC: drowsy | |
| Plantar response: both extensor | 1.8× (0.99-3.4) |
| Plantar response: single extensor | 1× (0.87-1.2) |
| Hemiparesis | 0.96× (0.9-1.0) |
| Plantar response: both flexor | 0.45× (0.25-0.81) |
| LOC: alert | 0.35× (0.24-0.5) |
| Cervical bruit | 0.12× (0.03-0.47) |
| Labs/Studies | Increased Disease Probability (Positive Likelihood Ratio) |
|---|---|
| Xanthochromia in CSF | |
| Atrial fibrillation on ECG | 0.19× (0.06-0.59) |
| Other | Increased Disease Probability (Positive Likelihood Ratio) |
|---|---|
| Clinician's Gestalt |
Negative Findings (Patient Doesn't Have This)
| Risk Factors | Decreased Disease Probability (Negative Likelihood Ratio) |
|---|---|
| Age <=60y | 0.71× (0.63-0.82) |
| Alcohol consumption | 0.75× (0.51-1.1) |
| Male | 0.85× (0.77-0.94) |
| Hypertension | 0.88× (0.77-1.01) |
| Diabetes mellitus | 1.1× (1.0-1.2) |
| Prior stroke | 1.1× (0.88-1.4) |
| Hyperlipidemia | 1.1× (1.1-1.1) |
| Coronary artery disease | 1.1× (1.0-1.3) |
| Atrial fibrillation | 1.1× (1.05-1.1) |
| Peripheral artery disease | 1.1× (1.0-1.1) |
| Prior TIA | 1.2× (1.1-1.3) |
| Cigarette smoking | 1.2× (0.79-1.8) |
| Symptoms | Decreased Disease Probability (Negative Likelihood Ratio) |
|---|---|
| Vomiting | 0.73× (0.59-0.91) |
| Headache | 0.66× (0.56-0.77) |
| Loss of consciousness | 0.65× (0.52-0.82) |
| Seizures w/ neurological deficit | 0.93× (0.9-0.96) |
| Acute onset deficit | 1.7× (1.4-2.1) |
| Signs | Decreased Disease Probability (Negative Likelihood Ratio) |
|---|---|
| Diastolic BP >110 mmHg | 0.59× (0.93-0.89) |
| Neck stiffness | 0.83× (0.75-0.92) |
| Kernig's or Brudzinski's or both | 0.87× (0.73-1.0) |
| Hemiparesis | 1.1× (1.0-1.2) |
| Cervical bruit | 1.1× (1.0-1.1) |
| Labs/Studies | Decreased Disease Probability (Negative Likelihood Ratio) |
|---|---|
| Xanthochromia in CSF | |
| Atrial fibrillation on ECG | 1.2× (1.0-1.5) |
| Other | Decreased Disease Probability (Negative Likelihood Ratio) |
|---|---|
| Clinician's Gestalt |
Narrative
Caveats
- Authors' RCE study selection criteria excluded those that enrolled patients with subarachnoid hemorrhage (which will present with some similar findings of hemorrhagic stroke).
- Diagnostic value of Xanthochromia was only reported by one study (Britton et al., Acta Med Scand 1983), which determined xanthochromia by both visual assessment and spectophotometry for comparison. LRs calculated by each technique were almost the same.
Published/Updated
What are Likelihood Ratios?
LR, pretest probability and posttest (or posterior) probability are daunting terms that describe simple concepts that we all intuitively understand.
Let's start with pretest probability: that's just a fancy term for my initial impression, before we perform whatever test it is that we're going to use.
For example, a patient with prior stents comes in sweating and clutching his chest in agony, I have a pretty high suspicion that he's having an MI – let's say, 60%. That is my pretest probability.
He immediately gets an ECG (known here as the "test") showing an obvious STEMI.
Now, I know there are some STEMI mimics, so I'm not quite 100%, but based on my experience I'm 99.5% sure that he's having an MI right now. This is my posttest probability - the new impression I have that the patient has the disease after we did our test.
And likelihood ration? That's just the name for the statistical tool that converted the pretest probability to the posttest probability - it's just a mathematical description of the strength of that test.
Using an online calculator, that means the LR+ that got me from 60% to 99.5% is 145, which is about as high an LR you can get (and the actual LR for an emergency physician who thinks an ECG shows an obvious STEMI).
(Thank you to Seth Trueger, MD for this explanation!)