Current Neurology and Neuroscience Reports

, Volume 10, Issue 1, pp 14–20 | Cite as

Advances in the Diagnosis of Etiologic Subtypes of Ischemic Stroke

Article

Abstract

A fundamental goal of etiologic stroke classification is to generate subgroups with discrete phenotypic, therapeutic, and prognostic features. Accurate stroke classification requires integration of multiple aspects of diagnostic stroke evaluation in a standardized manner. Diagnostic test findings can be simply organized into major etiologic groups to create a phenotypic subtype, or they can be reduced to a single causative subtype through a decision-making process. It is essential for a classification system to provide consistent results across different raters in different clinical settings. Comparability of subtype assignments is the key to valid communication of research results across the field. This article highlights important theoretical aspects of etiologic stroke classification and reviews major etiologic classification systems that have benefited from recent advances in etiologic stroke evaluation.

Keywords

Ischemic stroke Etiology Classification 

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Mohr JP, Caplan LR, Melski JW, et al.: The Harvard Cooperative Stroke Registry: a prospective registry. Neurology 1978, 28:754–762.PubMedGoogle Scholar
  2. 2.
    Sacco RL, Ellenberg JH, Mohr JP, et al.: Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Ann Neurol 1989, 25:382–390.CrossRefPubMedGoogle Scholar
  3. 3.
    Adams HP Jr, Bendixen BH, Kappelle LJ, et al.: 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 1993, 24:35–41.PubMedGoogle Scholar
  4. 4.
    Johnson CJ, Kittner SJ, McCarter RJ, et al.: Interrater reliability of an etiologic classification of ischemic stroke. Stroke 1995, 26:46–51.PubMedGoogle Scholar
  5. 5.
    Ay H, Furie KL, Singhal A, et al.: An evidence-based causative classification system for acute ischemic stroke. Ann Neurol 2005, 58:688–697.CrossRefPubMedGoogle Scholar
  6. 6.
    •• Ay H, Benner T, Arsava EM, et al.: A computerized algorithm for etiologic classification of ischemic stroke: the Causative Classification of Stroke System. Stroke 2007, 38:2979–2984. This article outlines important theoretical aspects of causative stroke classification and introduces a computerized algorithm that allows assignment of cases into specific classes with excellent interrater reliability.CrossRefPubMedGoogle Scholar
  7. 7.
    • Amarenco P, Bogousslavsky J, Caplan LR, et al.: New approach to stroke subtyping: the A-S-C-O (phenotypic) classification of stroke. Cerebrovasc Dis 2009, 27:502–508. This article describes a phenotypic classification system that takes into account the quality and completeness of the diagnostic stroke workup in assigning patients to subtypes.CrossRefPubMedGoogle Scholar
  8. 8.
    Chmura Kraemer H, Periyakoil VS, Noda A: Kappa coefficients in medical research. Stat Med 2002, 21:2109–2129.CrossRefPubMedGoogle Scholar
  9. 9.
    Choi SC, Clifton GL, Marmarou A, Miller ER: Misclassification and treatment effect on primary outcome measures in clinical trials of severe neurotrauma. J Neurotrauma 2002, 19:17–22.CrossRefPubMedGoogle Scholar
  10. 10.
    Muller MJ, Szegedi A: Effects of interrater reliability of psychopathologic assessment on power and sample size calculations in clinical trials. J Clin Psychopharmacol 2002, 22:318–325.CrossRefPubMedGoogle Scholar
  11. 11.
    Moroney JT, Bagiella E, Paik MC, et al.: Risk factors for early recurrence after ischemic stroke: the role of stroke syndrome and subtype. Stroke 1998, 29:2118–2124.PubMedGoogle Scholar
  12. 12.
    Murat Sumer M, Erturk O: Ischemic stroke subtypes: risk factors, functional outcome and recurrence. Neurol Sci 2002, 22:449–454.CrossRefPubMedGoogle Scholar
  13. 13.
    Grau AJ, Weimar C, Buggle F, et al.: Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German stroke data bank. Stroke 2001, 32:2559–2566.CrossRefPubMedGoogle Scholar
  14. 14.
    Pinto A, Tuttolomondo A, Di Raimondo D, et al.: Risk factors profile and clinical outcome of ischemic stroke patients admitted in a Department of Internal Medicine and classified by TOAST classification. Int Angiol 2006, 25:261–267.PubMedGoogle Scholar
  15. 15.
    Steger C, Pratter A, Martinek-Bregel M, et al.: Stroke patients with atrial fibrillation have a worse prognosis than patients without: data from the Austrian Stroke registry. Eur Heart J 2004, 25:1734–1740.CrossRefPubMedGoogle Scholar
  16. 16.
    Sacco SE, Whisnant JP, Broderick JP, et al.: Epidemiological characteristics of lacunar infarcts in a population. Stroke 1991, 22:1236–1241.PubMedGoogle Scholar
  17. 17.
    Liu X, Xu G, Wu W, et al.: Subtypes and one-year survival of first-ever stroke in Chinese patients: the Nanjing Stroke Registry. Cerebrovasc Dis 2006, 22:130–136.CrossRefPubMedGoogle Scholar
  18. 18.
    Sacco RL, Adams R, Albers G, et al.: Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke 2006, 37:577–617.CrossRefPubMedGoogle Scholar
  19. 19.
    Adams HP Jr, Bendixen BH, Leira E, et al.: Antithrombotic treatment of ischemic stroke among patients with occlusion or severe stenosis of the internal carotid artery: a report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 1999, 53:122–125.PubMedGoogle Scholar
  20. 20.
    Chimowitz MI, Poole RM, Starling MR, et al.: Frequency and severity of asymptomatic coronary disease in patients with different causes of stroke. Stroke 1997, 28:941–945.PubMedGoogle Scholar
  21. 21.
    A classification and outline of cerebrovascular diseases. Neurology 1958, 8:395–434.Google Scholar
  22. 22.
    Hajat C, Coshall C, Rudd AG, et al.: The inter- and intraobserver reliabilities of a new classification system for ischaemic stroke: the South London Stroke Register. J Neurol Sci 2001, 190:79–85.CrossRefPubMedGoogle Scholar
  23. 23.
    Comess KA, DeRook FA, Beach KW, et al. Transesophageal echocardiography and carotid ultrasound in patients with cerebral ischemia: prevalence of findings and recurrent stroke risk. J Am Coll Cardiol. 1994;23:1598–603.PubMedCrossRefGoogle Scholar
  24. 24.
    Tejada J, Diez-Tejedor E, Hernandez-Echebarria L, Balboa O: Does a relationship exist between carotid stenosis and lacunar infarction? Stroke 2003, 34:1404–1409.CrossRefPubMedGoogle Scholar
  25. 25.
    Gordon DL, Bendixen BH, Adams HP Jr, et al.: Interphysician agreement in the diagnosis of subtypes of acute ischemic stroke: implications for clinical trials. The TOAST Investigators. Neurology 1993, 43:1021–1027.Google Scholar
  26. 26.
    Goldstein LB, Jones MR, Matchar DB, et al.: Improving the reliability of stroke subgroup classification using the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria. Stroke 2001, 32:1091–1098.PubMedGoogle Scholar
  27. 27.
    Atiya M, Kurth T, Berger K, et al.: Interobserver agreement in the classification of stroke in the Women’s Health Study. Stroke 2003, 34:565–567.CrossRefPubMedGoogle Scholar
  28. 28.
    Meschia JF, Barrett KM, Chukwudelunzu F, et al.: Interobserver agreement in the trial of org 10172 in acute stroke treatment classification of stroke based on retrospective medical record review. J Stroke Cerebrovasc Dis 2006, 15:266–272.CrossRefPubMedGoogle Scholar
  29. 29.
    Selvarajah JR, Glaves M, Wainwright J, et al.: Classification of minor stroke: intra- and inter-observer reliability. Cerebrovasc Dis 2009, 27:209–214.CrossRefPubMedGoogle Scholar
  30. 30.
    Ay H, Sharma P, Dichgans M, et al.: International validation of a computerized algorithm for etiologic classification of ischemic stroke: the causative classification of stroke system. Stroke 2009, 4:e203.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Stroke Service and A. A. Martinos Center for Biomedical Imaging, Departments of Neurology and Radiology, Massachusetts General HospitalHarvard Medical SchoolCharlestownUSA

Personalised recommendations