Skip to main content
SpringerLink
Log in

Etiological classification of ischemic stroke in young patients: a comparative study of TOAST, CCS, and ASCO

  • Original Article
  • Published:
Acta Neurologica Belgica Aims and scope Submit manuscript

Abstract

Analysis of stroke subtypes is important for making treatment decisions and prognostic evaluations. The TOAST classification system is most commonly used, but the CCS and ASCO classification systems might be more useful to identify stroke etiologies in young patients whose strokes have a wide range of different causes. In this manuscript, we aim to compare the differences in subtype classification between TOAST, CCS, and ASCO in young stroke patients. The TOAST, CCS, and ASCO classification schemes were applied to 151 patients with ischemic stroke aged 18–49 years old and the proportion of subtypes classified by each scheme was compared. For comparison, determined etiologies were defined as cases with evident and probable subtypes when using the CCS scheme and cases with grade 1 and 2 subtypes but no other grade 1 subtype when using the ASCO scheme. The McNemar test with Bonferroni correction was used to assess significance. By TOAST, 41.1% of patients’ stroke etiology was classified as undetermined etiology, 19.2% as cardioembolic, 13.2% as large artery atherosclerosis, 11.3% as small vessel occlusion, and 15.2% as other causes. Compared with TOAST, both CCS and ASCO assigned fewer patients to the undetermined etiology group (30.5% p < 0.001 and 26.5% p < 0.001, respectively) and assigned more patients to the small vessel occlusion category (19.9%, p < 0.001, and 21.9%, p < 0.001, respectively). Additionally, both schemes assigned more patients to the large artery atherosclerosis group (15.9 and 16.6%, respectively). The proportion of patients assigned to either the cardioembolic or the other causes etiology did not differ significantly between the three schemes. Application of the CCS and ASCO classification schemes in young stroke patients seems feasible, and using both schemes may result in fewer patients being classified as undetermined etiology. New studies with more patients and a prospective design are needed to explore this topic further.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Adams HP Jr et al (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(1):35–41

    Article  PubMed  Google Scholar 

  2. Lee LJ et al (2000) Impact on stroke subtype diagnosis of early diffusion-weighted magnetic resonance imaging and magnetic resonance angiography. Stroke 31(5):1081–1089

    Article  CAS  PubMed  Google Scholar 

  3. Ferro JM, Massaro AR, Mas JL (2010) Aetiological diagnosis of ischaemic stroke in young adults. Lancet Neurol 9(11):1085–1096

    Article  PubMed  Google Scholar 

  4. Wolf ME et al (2015) Phenotypic ASCO Characterisation of Young Patients with Ischemic Stroke in the Prospective Multicentre Observational sifap1 Study. Cerebrovasc Dis 40(3–4):129–135

    Article  PubMed  Google Scholar 

  5. Spengos K, Vemmos K (2010) Risk factors, etiology, and outcome of first-ever ischemic stroke in young adults aged 15 to 45—the Athens young stroke registry. Eur J Neurol 17(11):1358–1364

    Article  CAS  PubMed  Google Scholar 

  6. Ay H et al (2007) A computerized algorithm for etiologic classification of ischemic stroke: the causative classification of stroke system. Stroke 38(11):2979–2984

    Article  PubMed  Google Scholar 

  7. Amarenco P et al (2009) New approach to stroke subtyping: the A-S-C-O (phenotypic) classification of stroke. Cerebrovasc Dis 27(5):502–508

    Article  CAS  PubMed  Google Scholar 

  8. Putaala J et al (2009) Analysis of 1008 consecutive patients aged 15 to 49 with first-ever ischemic stroke: the Helsinki young stroke registry. Stroke 40(4):1195–1203

    Article  PubMed  Google Scholar 

  9. Varona JF et al (2007) Causes of ischemic stroke in young adults, and evolution of the etiological diagnosis over the long term. Eur Neurol 57(4):212–218

    Article  CAS  PubMed  Google Scholar 

  10. Cerrato P et al (2004) Stroke in young patients: etiopathogenesis and risk factors in different age classes. Cerebrovasc Dis 18(2):154–159

    Article  CAS  PubMed  Google Scholar 

  11. Musolino R et al (2003) Ischaemic stroke in young people: a prospective and long-term follow-up study. Cerebrovasc Dis 15(1–2):121–128

    Article  PubMed  Google Scholar 

  12. Chen PH et al (2012) Classifying Ischemic Stroke, from TOAST to CISS. CNS Neurosci Ther 18(6):452–456

    Article  PubMed  Google Scholar 

  13. Amarenco P et al (2009) Classification of stroke subtypes. Cerebrovasc Dis 27(5):493–501

    Article  CAS  PubMed  Google Scholar 

  14. Wolf ME et al (2012) Comparison of the new ASCO classification with the TOAST classification in a population with acute ischemic stroke. J Neurol 259(7):1284–1289

    Article  CAS  PubMed  Google Scholar 

  15. Arsava EM et al (2010) The causative classification of stroke system: an international reliability and optimization study. Neurology 75(14):1277–1284

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Marnane M et al (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(8):1579–1586

    Article  PubMed  Google Scholar 

  17. Desai JA et al (2014) Etiologic classification of TIA and minor stroke by A-S-C-O and causative classification system as compared to TOAST reduces the proportion of patients categorized as cause undetermined. Cerebrovasc Dis 38(2):121–126

    Article  PubMed  Google Scholar 

  18. Chatzikonstantinou A, Wolf ME, Hennerici MG (2012) Ischemic stroke in young adults: classification and risk factors. J Neurol 259(4):653–659

    Article  PubMed  Google Scholar 

  19. Suwanwela NC, Poungvarin N, Asian P (2016) Stroke advisory, stroke burden and stroke care system in Asia. Neurol India 64(Suppl):S46–S51

    Article  PubMed  Google Scholar 

  20. Wu CY et al (2010) Stroke risk factors and subtypes in different age groups: a hospital-based study. Neurol India 58(6):863–868

    Article  PubMed  Google Scholar 

  21. Yesilot Barlas N et al (2013) Etiology of first-ever ischaemic stroke in European young adults: the 15 cities young stroke study. Eur J Neurol 20(11):1431–1439

    CAS  PubMed  Google Scholar 

  22. Prasad K, Singhal KK (2010) Stroke in young: an Indian perspective. Neurol India 58(3):343–350

    Article  PubMed  Google Scholar 

  23. Balci K et al (2011) Ischemic stroke in young adults: risk factors, subtypes, and prognosis. Neurologist 17(1):16–20

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Bezmialem Vakif Universitesi Tip Fakultesi Hastanesi, Istanbul, Turkey

    Elif Gökçal, Elvin Niftaliyev & Talip Asil

Authors
  1. Elif Gökçal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Elvin Niftaliyev
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Talip Asil
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Elif Gökçal.

Ethics declarations

Funding

There was no funding for this study.

Conflict of interest

Author Elif Gökçal declares that she has no conflict of interest. Author Elvin Niftaliyev declares that he has no conflict of interest. Author Talip Asil declares that he has no conflict of interest.

Human and animal participants rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The data was obtained from our hospital records retrospectively for the study.

Informed consent

No informed consent was neccessary for the study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gökçal, E., Niftaliyev, E. & Asil, T. Etiological classification of ischemic stroke in young patients: a comparative study of TOAST, CCS, and ASCO. Acta Neurol Belg 117, 643–648 (2017). https://doi.org/10.1007/s13760-017-0813-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13760-017-0813-8

Keywords

Search

Navigation