Journal of Neurology

, Volume 259, Issue 7, pp 1284–1289 | Cite as

Comparison of the new ASCO classification with the TOAST classification in a population with acute ischemic stroke

  • M. E. WolfEmail author
  • T. Sauer
  • A. Alonso
  • M. G. Hennerici
Original Communication


Precise analysis of stroke subtypes is important for clinical treatment decisions, the prognostic evaluation of patients, as well as defining stroke populations in clinical studies. The TOAST classification is the most widely used and approved form for etiologic subtyping. Increasing knowledge about stroke mechanisms and the introduction of new diagnostic techniques have supported the promotion of the new ASCO phenotypic classification, which aims to characterize patients using different grades of evidence for stroke subtypes. We prospectively assigned 103 consecutive patients from our stroke center for subtype classification using ASCO and TOAST. Clinical features and complementary investigations were recorded according to our standardized acute stroke care protocol. Evidence grade 1 with ASCO was assessed in 12.62% for large artery disease (A), 23.30% small-vessel disease (S), 36.89% cardiac source (C) and 1.94% another cause (O). Evidence grades 1–3 were identified in 60.19% A, 75.73% S, 49.51% C, and 3.88% O. A total of 68.93% of the patients were classified in more than one category, and only 3.88% remained completely undetermined. The κ value for inter-rater agreement was 0.92–1. Using TOAST, the distribution was 9.71% A, 23.30% S, 34.95% C, 1.94% O, and 30.10% undetermined. The ASCO classification showed a good concordance with TOAST. The inter-rater agreement was high. The comprehensive character of ASCO allows the recording of important additional information. This may be helpful for a specific treatment adaptation in each individual patient and creation of different etiological profiles in view of adapted clinical trials.


Stroke Subtype Classification systems Etiology 


Conflict of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24:35–41PubMedCrossRefGoogle Scholar
  2. 2.
    Amarenco P, Bogousslavsky J, Caplan LR, Donnan GA, Hennerici MG (2009) Classification of stroke subtypes. Cerebrovasc Dis 27:493–501PubMedCrossRefGoogle Scholar
  3. 3.
    Amarenco P, Bogousslavsky J, Caplan LR, Donnan GA, Hennerici MG (2009) New approach to stroke subtyping: the A-S-C-O (phenotypic) classification of stroke. Cerebrovasc Dis 27:502–508PubMedCrossRefGoogle Scholar
  4. 4.
    Ay H, Benner T, Arsava EM, Furie KL, Singhal AB, Jensen MB, Ayata C, Towfighi A, Smith EE, Chong JY, Koroshetz WJ, Sorensen AG (2007) A computerized algorithm for etiologic classification of ischemic stroke: the Causative Classification of Stroke System. Stroke 38:2979–2984PubMedCrossRefGoogle Scholar
  5. 5.
    Bamford J, Sandercock P, Dennis M, Burn J, Warlow C (1991) Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 337:1521–1526PubMedCrossRefGoogle Scholar
  6. 6.
    Bejot Y, Caillier M, Salem DB, Couvreur G, Rouaud O, Osseby GV, Durier J, Marie C, Moreau T, Giroud M (2008) Ischaemic stroke subtypes and associated risk factors: a French population based study. J Neurol Neurosurg Psychiatry 79:1344–1348PubMedCrossRefGoogle Scholar
  7. 7.
    Bogousslavsky J, Van Melle G, Regli F (1988) The Lausanne Stroke Registry: analysis of 1,000 consecutive patients with first stroke. Stroke 19:1083–1092PubMedCrossRefGoogle Scholar
  8. 8.
    Bousser MG, Amarenco P, Chamorro A, Fisher M, Ford I, Fox K, Hennerici MG, Mattle HP, Rothwell PM (2009) Rationale and design of a randomized, double-blind, parallel-group study of terutroban 30 mg/day versus aspirin 100 mg/day in stroke patients: the prevention of cerebrovascular and cardiovascular events of ischemic origin with terutroban in patients with a history of ischemic stroke or transient ischemic attack (PERFORM) study. Cerebrovasc Dis 27:509–518PubMedCrossRefGoogle Scholar
  9. 9.
    Lindley RI, Warlow CP, Wardlaw JM, Dennis MS, Slattery J, Sandercock PA (1993) Interobserver reliability of a clinical classification of acute cerebral infarction. Stroke 24:1801–1804PubMedCrossRefGoogle Scholar
  10. 10.
    Marnane M, Duggan CA, Sheehan OC, Merwick A, Hannon N, Curtin D, Harris D, Williams EB, Horgan G, Kyne L, McCormack PM, Duggan J, Moore A, Crispino-O’Connell G, Kelly PJ (2010) Stroke subtype classification to mechanism-specific and undetermined categories by TOAST, A-S-C-O, and causative classification system: direct comparison in the North Dublin population stroke study. Stroke 41:1579–1586PubMedCrossRefGoogle Scholar
  11. 11.
    Mohr JP, Caplan LR, Melski JW, Goldstein RJ, Duncan GW, Kistler JP, Pessin MS, Bleich HL (1978) The Harvard Cooperative Stroke Registry: a prospective registry. Neurology 28:754–762PubMedCrossRefGoogle Scholar
  12. 12.
    Montaner J, Perea-Gainza M, Delgado P, Ribo M, Chacon P, Rosell A, Quintana M, Palacios ME, Molina CA, Alvarez-Sabin J (2008) Etiologic diagnosis of ischemic stroke subtypes with plasma biomarkers. Stroke 39:2280–2287PubMedCrossRefGoogle Scholar
  13. 13.
    Pinto A, Tuttolomondo A, Di Raimondo D, Fernandez P, Licata G (2004) Cerebrovascular risk factors and clinical classification of strokes. Semin Vasc Med 4:287–303PubMedCrossRefGoogle Scholar
  14. 14.
    Rovira A, Grive E, Alvarez-Sabin J (2005) Distribution territories and causative mechanisms of ischemic stroke. Eur Radiol 15:416–426PubMedCrossRefGoogle Scholar
  15. 15.
    Touboul PJ, Elbaz A, Koller C, Lucas C, Adrai V, Chedru F, Amarenco P (2000) Common carotid artery intima-media thickness and brain infarction: the Etude du Profil Genetique de l’Infarctus Cerebral (GENIC) case-control study. The GENIC Investigators. Circulation 102:313–318PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • M. E. Wolf
    • 1
    Email author
  • T. Sauer
    • 1
  • A. Alonso
    • 1
  • M. G. Hennerici
    • 1
  1. 1.Department of NeurologyUniversitaetsmedizin Mannheim, University of HeidelbergMannheimGermany

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