(Stroke. 2001;32:e1091.)
© 2001 American Heart Association, Inc.
Original Contributions |
Appendix TOAST Abstraction Manual TOAST Medical Record Abstraction Manual
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Introduction |
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 Top Introduction |
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Section 1A. History/Emboli
- General precepts
All noted
historical information must occur prior to index stroke
admission. If a diagnosis is found within the discharge summary, it
must not have been diagnosed during the index admission. It
is often best to consult the admission history and physical for
complete past medical history rather than discharge
summary.
You may wish to circle (or otherwise denote)
presence of all applicable conditions. If both high risk and medium
risk sources occur, score the section as "[1]—high risk source for
emboli." If multiple medium risk sources are present (but no high
risk), the section is scored "[2]—medium risk source for
emboli." If no high or medium risk sources are present, score the
question "[3]—No source for emboli."
- Specific diagnoses
Mechanical
prosthetic heart valve: Record this if explicitly
stated in history. May be alternatively described as Starr-Edwards
valve (ball and cage device), Medtronic-Hall (single tilting disc
valve) or St. Jude Medical model (bi-leaflet valve).
Bioprosthetic valves (e.g. porcine) are not considered high
risk (see below) so it is important to distinguish between the types of
valve replacements when possible. If it is stated that the person has a
valve replacement (or prosthetic valve) but this is not further
described keep the following in mind: (1) All persons with a
mechanical valve of any sort should be anticoagulated before admission
(usually with coumadin). However, persons with bioprosthetic
valves sometimes require anticoagulation. (2) Persons
with mechanical valve may be described as having a ‘clink’ or
metallic heart sound on cardiac physical exam. (3) All
mechanical heart valves should be visible on chest x-ray (or echo) and
appropriately described. (4) If the type of valve
remains ambiguous after the following consideration, consider it a
bioprosthetic valve and score it under [2]—"Medium risk
source for emboli."
Atrial fibrillation: Score this response if
the patient has a documented history of any episode of atrial
fibrillation prior to admission. Score even if the patient is being
treated with anticoagulation (e.g. coumadin), antiarrhythmics (e.g.
digoxin, calcium channel blockers, beta-blockers), has a pacemaker, or
has been successfully undergone cardioversion in the past. Do not score
other forms of supraventricular tachycardia or
conduction abnormalities (e.g. multifocal atrial
tachycardia, Wolff-Parkinson-White syndrome)
Sick-sinus syndrome: Score this response if patient
has history of sick-sinus syndrome, even if being treated with
anticoagulation, antiarrhythmics (e.g. digoxin, calcium channel
blockers, beta-blockers), or pacemaker.
Myocardial Infarction (MI) within 4 weeks: as
stated.
Dilated cardiomyopathy: as
stated per history.
Atrial myxoma: as described by studies prior to
admission (usually echocardiogram)
Infective endocarditis: Score this item if at any
time in the patient’s history they were diagnosed with infective
endocarditis. Score even if adequately treated and even if valve
replacement surgery was subsequently performed.
Akinetic left ventricular segment:
Score if any prior echocardiogram described complete lack of wall
motion in any segment of the left ventricle.
Left ventricular thrombus: Score this
item if at any time in the patient’s history they were found to have a
thrombus in the left ventricle. Score even if the patient has completed
their recommended course of anticoagulation or if currently taking
anticoagulants. Score even if echocardiogram on current admission fails
to find thrombus.
MI >4 weeks ago but <6 months ago: as
stated.
Congestive heart failure: Score if recorded in
patient’s history at any time. Score regardless of patient’s current
medication regimen or echocardiographic findings on
present admission.
Left ventricular aneurysm: as
recorded in history.
Atrial flutter: Score if this rhythm recorded
at any time. Score even if the patient is being treated with
anticoagulation (e.g. coumadin), antiarrhythmics (e.g. digoxin, calcium
channel blockers, beta-blockers), has a pacemaker, or has been
successfully undergone cardioversion in the past.
Bioprosthetic heart valve: Score as
recorded in patient’s history. May be described as porcine graft,
xenograft, pericardial valve, Carpentier-Edwards (porcine xenograft),
Biocor, or Sorin Pericarbon. If the type of prosthetic valve is
not described, see "mechanical valve" above. Do NOT score if
patient has aortic allograft or pulmonary valve homograft (Ross
procedure).
Mitral stenosis without atrial
fibrillation: as recorded in history.
Mitral valve prolapse: as recorded in
history.
Mitral annular calcification: as recorded in
history or prior echocardiograms.
Atrial septal defect: as recorded in history.
Do NOT record if patient has undergone surgical closure of
defect.
Patent foramen ovale: as recorded in history or
prior echocardiograms.
Interatrial septal aneurysm: as
recorded in history or prior echocardiograms.
Nonbacterial endocarditis: as recorded in
history. This would include marantic or Libman-Sacks endocarditis.
Section 1B. History/Large Vessel Disease
- General precepts
All noted
historical information must occur prior to index stroke
admission. If a diagnosis is found within the discharge summary, it
must not have been diagnosed during the index admission. It
is often best to consult the admission history and physical for
complete past medical history rather than discharge summary.
This section refers only to diagnosis made by relevant
extracranial studies (e.g. Doppler/duplex, MRA, CT angiogram or
conventional angiogram). Data gleaned from physical exam (e.g. bruits)
are not relevant.
In order for the lesion to be
scored, it should be both extracranial and appropriate:
• carotid lesions should be greater than 50% stenosis and ipsilateral to symptoms
• vertebral lesions are relevant only in cases of brainstem infarction
Data are to primarily
obtained directly from radiological reports. If these are not
available, then review information from admission notes, progress
notes, or discharge summaries. If there is a conflict, use the data
from the official radiology report. If percent stenosis is not
given, translate keywords as follows: mild = 16–49%,
moderate=50–69%, severe=70–89%, critical=90–99%, and
occluded=100%.
Do not score a lesion as
present if the lesion was documented only prior to corrective
surgery (e.g. carotid
endarterectomy).
Studies
performed at an outside hospital prior to transfer are considered to
occur prior to admission and may be recorded in this section.
Section 1C. History/Prior Specialized Tests
- General precepts
This
section records any historical mention of conditions which are not
related to large vessel atherosclerosis, cardiogenic
embolism, or lipohyalinosis (small vessel disease) and, in view of a
negative evaluation for these causes, have been indicated as the likely
cause of the patient’s stroke. If any of the diagnoses listed below
are recorded in the past medical history, you can assume that the
appropriate lab test has been conducted and score "[1] Prior
specialized tests (hematological, CSF, or histology) demonstrating
evidence of underlying cause."
The response
"[2] Negative prior specialized tests" should be scored if any
one or more tests listed below were previously conducted and ALL were
found to be negative. If none of the specified diagnoses are carried or
no specialized tests were performed, record "[3] No prior
specialized tests completed." The test/condition should be
recorded on the form if present.
- Specific diagnoses
- Below follows a list of conditions known to be associated with stroke
and the appropriate methods of diagnosis:
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Section 2. Physical Exam
- General precepts
Only physical
exam findings obtained the day of admission are relevant. If there is
no exam recorded upon the day of admission, use the exam closest to
that date. Note that many discharge summaries are from rehabilitation
units and may contain physical exam findings obtained at
transfer—therefore, it is best as a general rule to use admit day
notes.
- Specific findings
Atrial
fibrillation: Under the cardiac exam, the phrase "irregularly
irregular" shall be taken to be indicative of atrial fibrillation.
This item may be scored if ANY examiner records the phrase
"irregularly irregular." Terms such as "frequent ectopy," and
descriptions of murmurs or extra heart sounds are not relevant.
Tachycardia need not be present. EKG findings are NOT
considered under this section.
Evidence of
systemic embolization: These would include visible clots on
funduscopic exam, splinter hemorrhages, Roth spots, Janeway
lesions, Osler’s nodes.
Classic lacunar
syndromes:
• Note: this section relies heavily on an experienced physician’s neurological examination. Therefore, in cases where physical exam findings differ, use the most experienced examiner. Neurologist’s exams should be used in preference to that of emergency department physicians or internists wherever possible. The impression or assessment of the examining physician need not be explicitly stated as "lacunar infarct" but often is. The term "small vessel distribution stroke" is also frequently used.
• Lacunar syndromes can immediately be ruled out if any of the following are new findings:
Alteration in consciousness
(somnolence, coma)
Aphasia
Visual
or visuospatial abnormalities
Oculomotor
abnormalities
Disorders of higher mental function,
including calculation, reading, writing recognition, attention,
praxis
• Pure motor (hemiparesis/hemiplegia): New onset weakness of the face, arm and leg. All should be involved on the same side of the body, usually but not always to the same degree. Dysarthria is frequently present. Sensory findings and poor coordination inappropriate for muscle weakness should not be present.
• Pure Sensory: New onset sensory findings occurring on one side of the body, involving at least two of our three body areas (face, arm, leg). Objective findings of sensory loss are not required—sensory symptoms (e.g. numbness) in the above noted distributions qualify. Motor and cerebellar findings should be absent.
• Mixed sensorimotor: Motor and sensory findings simultaneously located in at least 2 out of 3 body areas (face, arm and leg). Tongue deviation and dysarthria may be present.
• Ataxic Hemiparesis: Ipsilateral cerebellar ataxia and hemiparesis. Gait ataxia may be present, and the presence or absence of sensory findings on the same side of the body is variable. The face need not be involved, and arm and leg may be weak to varying extents.
• Dysarthria-Clumsy hand: Severe dysarthria, clumsy ataxic hand (especially on writing); facial weakness; tongue deviation may or may not be present, as may ipsilateral hyper-reflexia and Babinski sign.
Section 3. Diagnostic Tests
(A) CT Scan
- General precepts
The TOAST
algorithm is for cerebral infarction only. Any patient whose CT is read
by radiology as having any of the following in absence of a clinically
appropriate new infarct should be excluded from analysis:
primary intracerebral hematoma (hemorrhage),
intraparenchymal hemorrhage,
intraventricular hemorrhage,
subarachnoid hemorrhage, subdural hematoma, epidural
hematoma, or any nonvascular lesion (e.g. neoplasm, intraparenchymal
infection (e.g. toxoplasmosis)). Hemorrhagic infarction is
not excluded from analysis (note: a hemorrhagic
infarction is a hemorrhage originating within and secondary to
infarction and has a characteristic radiographic appearance
that distinguishes it from primary hemorrhage—the distinction
should be made on the radiographic report).
Inasmuch as CT is relatively insensitive for ischemic
infarct in the hyperacute stage (6 hr post ictus), readings from the
acute stage (1–7 days post ictus) are preferred—record data from
scans done this period unless it is clinically evident that
the patient has had a second event since
admission.
Data are primarily obtained from official
radiology reports. Only in cases where these are not available should
information be used from progress notes or the discharge. If there is
conflict between the radiologist’s interpretation and that of any
other physician, the radiologist’s opinion is considered authoritative
for data collection purposes.
If a patient is a
transfer from an outside hospital and has imaging done only at the
outside institution, this data may be recorded for this section
(even if the scan is negative).
If more than
one CT scan is performed, use the results from the latest scan
performed during the admission unless there was an interval change
(i.e., clinically neurological significant change) in the patient’s
clinical status. If an interval change occurred, use the results from
the earlier scan.
For this section, only
a single response is appropriate. Responses [1]–[5] refer to acute
infarcts only. Only score responses [8], [9], and [10] if
responses [1]–[7] are not applicable.
- Specific findings
[1] Acute or
subacute bland or hemorrhagic infarction involving cortical and
possibly extending into subcortical structures, or infarct>1.5 cm in
subcortical structures in the cerebral hemisphere, appropriate for
symptoms, or multiple acute or subacute infarctions of same age in
same vascular territory: The lesion should be described as a
SINGLE bland (ischemic) or hemorrhagic infarct or as multiple
recent infarcts (acute/subacute) in the vascular distribution of a
single large extracranial artery. That is, multiple anterior
circulation lesions should all occur in the same hemisphere, and
brainstem lesions should not coexist with hemispheric lesions in the
distribution of the ACA or MCA. PCA distribution infarcts may coexist
with either anterior or posterior circulation infarcts or may involve
both hemispheres. ‘Cortical structures’ refers to the gray matter on
the exterior of the cerebral hemispheres. Subcortical refers to deeper
structures, including corona radiata, basal ganglia, internal capsule,
thalamus. Progress notes should verify the concordances of any
described lesions and the patient’s clinical picture. Do not
record any lesion here that is not clinically
appropriate.
[2] Acute or subacute
infarct in the distribution of a circumferential artery in the
brainstem and/or cerebellum: Typically>1.5 cm (non-lacunar)
infarcts in the distribution of any one of the circumferential arteries
of the brainstem/cerebellum. Long circumferential vessels include
posterior inferior cerebellar (PICA), anterior
inferior cerebellar (AICA), superior cerebellar (SCA), and
the proximal portion of the posterior cerebral artery. There are
numerous short circumferential vessels that arise from the basilar
artery also. Score this only if a SINGLE new lesion is
present.
[3] Multiple acute or
subacute infarctions of same age in different vascular
territories: Score this response if there are multiple non-lacunar
acute or subacute infarcts of the same age occurring in the
distribution of more than one large extracranial artery (carotid or
vertebral artery). This would include any anterior circulation (ACA,
MCA) infarct coexisting with a brainstem or contralateral hemisphere
infarct.
[4] Hyper-dense artery sign:
Score this response if a hyper-dense artery sign is specifically
described in the radiology report in the presumed distribution of the
infarct. Do not score if items [1], [2], [3], or [5] are
applicable—score them instead.
[5] <1.5 cm
in diameter infarct in a subcortical structure or brainstem in the
territory of a small penetrating artery: Infarct should be smaller
than 1.5 cm (or described as ‘small’ or ‘lacunar’). Typical
subcortical locations include corona radiata, internal capsule,
external capsule, basal ganglia, thalamus. Lesions may also be located
in the pons or medulla. You may score this response if ANY one of
multiple new lacunar infarcts is appropriate for symptoms. You may also
score this response if there is a clinically appropriate lesion of
undetermined age. Do not score if the patient is described as having
‘Binswanger’s disease (encephalopathy)’ unless there is a discrete
new lesion appropriate for
symptoms.
[6] Normal: Score this
response if the scan is read as ‘normal’ or ‘age appropriate
atrophy’ or if the radiology report is unavailable and progress notes
or discharge summary records indicate as ‘normal,’
‘unremarkable,’ ‘without change,’ et cetera.
[7] Not Done: Score if no CT was performed, if no
data regarding the CT can be found, or if the scan was
non-diagnostic (e.g. poor quality or
uninterpretable).
[8] Old stroke, same
vascular territory: Score this response only if: [1]–[7] are
not applicable and the scan shows an old infarct in the same vascular
distribution as the new lesion. If the location of the present
lesion is unclear and the CT shows only an old infarct, score [9]. If
there are multiple old strokes in more than one vascular territory
(e.g. bilateral infarcts) then score [9].
[9] Old stroke, different vascular territory:
Score this response only if: [1]–[7] are not applicable and the
scan shows an old infarct in a different vascular distribution as the
new lesion OR if the location of the present lesion is unclear and
the CT shows only an old infarct OR if there are multiple old strokes
in more than one vascular territory.
[10]
Old, nonspecific small vessel disease: Score this response only
if: [1]–[9] are not applicable and the scan shows patchy, white
matter periventricular disease. Lacunar infarct(s) may be
present. Score this also if the terms ‘Binswanger’s disease
(encephalopathy)’ or ‘leukoencephalopathy’ are used.
(B) MRI
- General precepts
The TOAST
algorithm is for cerebral infarction only. Any patient whose MRI is
read as having hemorrhage or nonvascular lesions (see CT
section for examples) in the absence of an infarct that accounts for
new clinical findings should be excluded.
MRI
findings for ischemic infarct in the hyper-acute stage (24 hr)
can be subtle—therefore if multiple scans are done, use readings from
the acute stage (1–7 days post ictus) unless it is
clinically evident that the patient has had a second event since
admission. In such a case, use the latest MRI scan occurring before the
event.
If a patient is a transfer from an outside
hospital and has imaging done only at the outside institution, this
data may be recorded for this section (even if the scan is
negative).
Data are primarily obtained from official
radiology reports. Only in cases where these are not available should
information found in progress notes or the discharge summary be used.
If there is conflict between the radiologist’s interpretation and that
of any other physician, the radiologist’s opinion is considered
authoritative for data collection purposes.
If
more than one MRI scan is performed, use the results from the latest
scan performed during the admission unless there was an interval change
(i.e., clinically neurologically significant change) in the patient’s
clinical status. If an interval change occurred, use the results from
the earlier scan.
For this section, only a
single response is appropriate. Responses [1]–[5] refer to acute
infarcts only. Only score responses [8], [9], and [10] if
responses [1]–[7] are not applicable.
- Specific findings
[1] Acute or
subacute bland or hemorrhagic infarction involving cortical
structures and possibly extending into subcortical structures, or
infarct>1.5 cm in subcortical structures in the cerebral hemisphere,
appropriate for symptoms, or multiple acute or subacute infarctions
of same age in same vascular territory: The lesion should be
described as a SINGLE bland (ischemic) or hemorrhagic infarct
or as multiple recent infarcts (acute/subacute) in the vascular
distribution of a single large extracranial artery. That is, multiple
anterior circulation lesions should all occur in the same hemisphere,
and brainstem lesions should not coexist with hemispheric lesions in
the distribution of the ACA or MCA. PCA distribution infarcts may
coexist with either anterior or posterior circulation infarcts or may
involve both hemispheres. ‘Cortical structures’ refers to the gray
matter on the exterior of the cerebral hemispheres. Subcortical refers
to deeper structures, including corona radiata, basal ganglia, internal
capsule, thalamus. Progress notes should verify the concordances of any
described lesions and the patient’s clinical picture. Do not
record any lesion here that is not clinically
appropriate.
[2] Acute or subacute
infarct in the distribution of a circumferential artery in the
brainstem and/or cerebellum: Typically>1.5 cm (non-lacunar)
infarcts in the distribution of any one of the circumferential arteries
of the brainstem/cerebellum. Long circumferential vessels include
posterior inferior cerebellar (PICA), anterior
inferior cerebellar (AICA), superior cerebellar (SCA), and
the proximal portion of the posterior cerebral artery. There are
numerous short circumferential vessels that arise from the basilar
artery also. Score this only if a SINGLE new lesion is
present.
[3] Multiple acute or
subacute infarctions of same age in different vascular
territories: Score this response if there are multiple non-lacunar
acute or subacute infarcts of the same age occurring in the
distribution of more than one large extracranial artery (carotids or
vertebral arteries). This would include any anterior circulation (ACA,
MCA) infarct coexisting with a brainstem or contralateral hemisphere
infarct.
[4] Absence of a flow void in major
extracranial artery: Score this response if the radiology report
records an absence flow void in a clinically appropriate major
extracranial vessel (extracranial carotid or vertebral arteries). Do
not score if items [1], [2], [3], or [5] are applicable—score
them instead.
[5] <1.5 cm in diameter
infarct in a subcortical structure or brainstem in the territory of a
small penetrating artery: Infarct should be smaller than 1.5 cm
(or described as ‘small’ or ‘lacunar’). Typical subcortical
locations include corona radiata, internal capsule, external capsule,
basal ganglia, thalamus. Lesions may also be located in the pons or
medulla. You may score this response if ANY one of multiple new lacunar
infarcts is appropriate for symptoms. You may also score this response
if there is a clinically appropriate lesion of undetermined age. Do not
score if the patient is described as having ‘Binswanger’s disease
(encephalopathy)’ unless there is a discrete new lesion appropriate
for symptoms.
[6] Normal: Score this
response if the scan is read as ‘normal,’ or ‘age appropriate
atrophy’ or if the radiology report is unavailable and progress notes
or discharge summary records as ‘normal,’ ‘unremarkable,’
‘without change,’ et cetera.
[7] Not
Done: Score if no MRI was performed, if no data regarding the MRI
can be found, or if the scan was non-diagnostic (e.g. poor
quality or un-interpretable).
[8] Old
stroke, same vascular territory: Score this response only if:
[1]–[7] are not applicable and the scan shows an old infarct in
the same vascular distribution as the new lesion. If the location of
the present lesion is unclear and the MRI shows only an old
infarct, score [9]. If there are multiple old strokes in more than
one vascular territory (e.g. bilateral infarcts) then score
[9].
[9] Old stroke, different vascular
territory: Score this response only if: [1]–[7] are not
applicable and the scan shows an old infarct in a different vascular
distribution as the new lesion OR if the location of the present
lesion is unclear and the MRI shows only an old infarct OR if there are
multiple old strokes in more than one vascular territory.
[10] Old, nonspecific small vessel disease: Score
this response only if: [1]–[9] are not applicable and the scan
shows patchy, white matter periventricular disease. Lacunar
infarct(s) may be present. Score this also if the terms
‘Binswanger’s disease (encephalopathy)’ or ‘leukoencephalopathy’
are used.
(C) Non-invasive vascular studies
- General precepts
Official
radiology reports should be considered the primary source for data
collection—if the final report is not available, the preliminary
report may be used. Only in cases where these are not available should
information found in progress notes or the discharge summary be used.
If there is conflict between the radiologist’s interpretation and that
of any other physician, the radiologist’s opinion is considered
authoritative for data collection purposes.
Check
the appropriate box describing the study performed. If both studies
were performed and data is available, check [] MRA and evaluate MRA
results only. If both studies were done but interpretable data is
available for only one, check that box and evaluate the study below. If
neither study was performed or data are unavailable, check [3] Not
Done.
- Specific responses
[1] Greater than or
equal to 50% stenosis of an appropriate large extracranial
artery: Stenosis should be greater or equal to 50% or
described as mild-moderate, moderate, severe or critical. The lesion
should be in the extracranial carotid artery ipsilateral to the lesion
(for hemispheric lesions) or in either vertebral artery for posterior
circulation lesions. Do not score lesions in the MCA artery, carotid
siphon, basilar artery, or circle of Willis.
[2] Less than 50% stenosis of an appropriate
large extracranial artery: Stenosis should be less than
50% or described as absent, mild, or ‘not
hemodynamically significant.’ If there is a percentage
estimate of stenosis record data according to this rather
than key words/descriptors. Data should be collected on the appropriate
artery only (ipsilateral carotid artery for hemispheric disease,
vertebral arteries for posterior circulation disease).
[3] Not Done: Score this response if there is no
interpretable data from either study (either not done or poor quality).
(D) Cerebral arteriogram
- General precepts
Official
radiology reports should be considered the primary source for data
collection—if the final report is not available, the preliminary
report may be used. Only in cases where these are not available should
information found in progress notes or the discharge summary be used.
If there is conflict between the radiologist’s interpretation and that
of any other physician, the radiologist’s opinion is considered
authoritative for data collection purposes.
A single
response is expected for this question. If response [4] is
appropriate, score this instead of any other finding that
may be present.
- Specific responses
[1] Occlusion,
greater than or equal to 50% stenosis or greater than or equal
to 2 mm ulceration of an appropriate large extracranial or
intracranial artery: Stenosis should be greater or equal
to 50% or described as mild-moderate, moderate, severe, critical or
completely occluded. Alternatively, an ulcerated plaque greater than or
equal to 2 mm can be present. For hemispheric lesions, the
ipsilateral common carotid, internal carotid, middle cerebral, anterior
cerebral, circle of Willis, or posterior cerebral may be scored. For
brainstem lesions, consider lesions in the vertebral arteries, basilar
artery, or any long circumferential artery (PICA, AICA, SCA). Do not
consider lesions in smaller arteries or lesions in the aortic arch or
subclavian arteries.
[2] Less than 50%
stenosis or less than 2 mm ulceration of an appropriate
large extracranial or intracranial artery, with no
occlusion of appropriate stem, division, or branch artery:
Stenosis in all appropriate arteries should be less than 50%
or described as absent, mild, or ‘not hemodynamically
significant.’ If there is a percentage estimate of stenosis
record data according to this rather than key
words/descriptors.
[3] Less than 50%
stenosis or less than 2 mm ulceration of an appropriate
large extracranial or intracranial artery, with occlusion
of appropriate stem, division, or branch artery: Stenosis
in the appropriate arteries should be less than 50% or described as
absent, mild, or ‘not hemodynamically significant.’
There should be reported occlusion of a stem, division, or branch
artery (any artery derived from the larger ones mentioned in
[1]).
[4] Specific, non-atherosclerotic,
intra- or extra-cranial vascular pathology: Score this if findings
are present indicating a specific form of vascular pathology not
related to atherosclerosis (such as is mentioned in
section 1C). The lesions do not necessarily have to be in the
distribution of the infarct. Do not score this section to indicate
small vessel disease or non-significant atherosclerotic
disease.
[5] Normal: Score this if no
pathology is found on the arteriogram.
[6]
Not done: Score this if the study was not performed, if data is
not available, or if the study was uninterpretable.
(E) Cardiovascular Evaluation
- General precepts
This section
is scored by compiling data from individual
cardiovascular system tests, specifically (a)
echocardiogram, (b) EKG, and (c) Holter monitor/telemetry.
[1] High-risk source for emboli: should be scored
if ANY of the three cardiovascular subsections has a
‘[1] high risk source for emboli.’
[2]
Medium risk source for emboli: should be scored if ANY section has
a ‘[2] medium risk source for emboli’ and NO section has a ‘[1]
high risk source for emboli.’
[3] No high
or medium risk source for emboli: should be scored if ‘[3]
(Nonspecific abnormalities or) Normal’ is scored for the
echocardiogram section and the EKG section and the Holter monitor is
either ‘[3] Normal’ or ‘[4] Not done.’ This section should also
be scored if the echocardiogram is normal, Holter monitor is normal,
and EKG is normal or not done.
[4]
Incomplete evaluation or evaluation not done: Score if
echocardiogram is ‘[4] Not done’ and EKG and Holter monitor are
either ‘[3] normal’ or ‘[4] not done.’
- Specific cardiovascular
tests
Echocardiogram
• General precepts
Mark the
appropriate box describing the test done. If both
transesophageal (TEE) and transthoracic
echocardiograms (TTE) are performed, mark [] TEE and evaluate data
ONLY from the TEE. If it is not specified which type of study was
performed, mark [] TTE. If no echocardiogram was performed (or the
study was completely uninterpretable) mark ‘[4] Not
done.’
Use data from the official report when
present. If it is not present, use data from progress notes or
discharge summary.
You may wish to circle arrows (or
otherwise denote) presence of all applicable conditions. However, if
both high risk and medium risk sources occur, score the section as
"[1]—high risk source for emboli." If multiple medium risk
sources are present (but no high risk), the section is scored
"[2]—medium risk source for emboli." If no high or medium risk
sources are present, score the section as "[3]—Normal."
- Specific diagnoses
Left
ventricular thrombus: Circle this response if notation
of a thrombus (or thrombi) anywhere within the left ventricle is
described (e.g. mural, apical), regardless of whether the patient is or
was taking anticoagulants.
Dilated
Cardiomyopathy: As stated per report, or if
there is the combination of impaired systolic function
(EF<45%), dilation of one or both ventricles, and symptoms of
congestive heart failure.
Akinetic left
ventricular segment: As stated per report. Do NOT
consider hypokinetic or dyskinetic segments to be
akinetic.
Left atrial thrombus:
Circle this response if notation of a thrombus (or thrombi) anywhere
within the left atrium is described regardless of whether the patient
is or was taking anticoagulants.
Atrial
myxoma: As stated per report.
Infective
endocarditis: As stated per report, or if valvular
vegetations occur in the setting of febrile illness.
Congestive heart failure (CHF): As stated, or
impaired systolic function (EF<45%) accompanied by classic
physical findings (pedal edema, pulmonary edema, orthopnea,
paroxysmal nocturnal dyspnea, hepatolmegaly, S3, S4) WITHOUT dilation
of ventricles. If the ventricles are dilated, circle ‘Dilated
cardiomyopathy,’ and score the section as ‘[1]
High risk source for emboli’ even if discharge diagnosis is
‘congestive heart failure.’
Left
ventricular aneurysm: As stated, or if any
wall of the left ventricle is stated to be dyskinetic.
Aortic stenosis without atrial
fibrillation: As stated. Do NOT score aortic sclerosis
or calcific aortic sclerosis.
Mitral valve
prolapse: Score only if specifically diagnosed by echocardiogram.
Mitral regurgitation need not be present.
Mitral annular calcification: As stated.
Atrial septal defect: As stated, or if any of the
following terms are used: ostium primum defect, foramen primum defect,
ostium secundum defect, or foramen primum defect. Do not circle for
"patent foramen ovale" or "atrioventricular
canal." If there is an inter-atrial shunt as described by bubble
study and no lesion is specified, you may score this
response.
Patent foramen ovale: As
stated, regardless or presence, direction, or magnitude of inter-atrial
shunt.
Interatrial septal
aneurysm: As stated.
Nonbacterial endocarditis: As stated,
regardless of location or size of vegetations. The terms "marantic
endocarditis" or "Libman-Sacks endocarditis" may also be used and
should be scored.
Electrocardiogram (EKG)/Long rhythm strip
- General precepts
Obtain information from
original EKGs whenever possible. If more than one EKG is present in
the chart, all should be evaluated and findings that occur on ANY EKG
should be recorded. If no original EKG’s are available, then
interpretation found in the admission notes, progress notes or
discharge summary may be used.
If ANY EKG
demonstrates a high-risk source for emboli, score the section ‘[1]
High risk source for emboli.’ If ANY EKG shows a medium risk source
for emboli and NO EKG shows a high-risk source, the item should be
scored ‘[2] Medium risk source for emboli.’ If no high or medium
risk sources for emboli are found on ANY EKG, then score ‘[3]
Nonspecific abnormalities or normal.’ If no EKG or report of EKG
findings is found (or if all present studies are uninterpretable),
then score the item ‘[4] Not done.’
- Specific diagnoses
Atrial
fibrillation demonstrated at any time during the hospitalization:
As stated per interpretation, or all of the following: Absence of
discrete P waves, fibrillating baseline, irregularly irregular narrow
QRS complexes. Ventricular rate may be fast or slow. Score
regardless of patient’s current or past medication regimen.
Acute myocardial infarction: As stated per report,
or: an evolving pattern of EKG findings, culminating with the
appearance of new Q waves in the appropriate leads. First T wave
peaking occurs, then T wave inversion, then ST elevation, and finally
new Q waves. New Q waves are diagnostic of infarction—the
other findings are merely suggestive and should not be scored without
clinical correlation. Do NOT score "infarct of indeterminate
age."
Atrial flutter demonstrated at any
time during the hospitalization: As stated per interpretation, or
all of the following: P wave at 250–350 bpm, baseline with sawtooth
pattern (flutter waves), regularly occurring QRS complexes in a given
ratio with P waves.
Holter monitor/Telemetry
- General precepts
Findings from
either a Holter monitor or telemetry are appropriate for this section.
If multiple tests were performed, then all should be evaluated and the
highest risk source of emboli should be recorded.
Obtain information from original tracings (or Holter monitor
report) whenever possible. For telemetry, all tracings should be
evaluated and findings that occur on tracing should be recorded. If
no original tracings are available, then interpretation found in the
progress notes or discharge summary may be used.
If
ANY tracing (or the Holter monitor report) demonstrates a high-risk
source for emboli, score the section ‘[1] High risk source for
emboli.’ If ANY tracing shows a medium risk source for emboli and NO
tracing shows a high risk source, the item should be scored ‘[2]
Medium risk source for emboli.’ If no high or medium risk sources for
emboli are found on ANY tracing, then score ‘[3] Nonspecific
abnormalities or normal.’ If no tracing (or Holter monitor report) or
report of tracing (or monitor) findings is found (or if all present
studies are uninterpretable), then score the item ‘[4] Not
Done.’
- Specific diagnoses
Atrial fibrillation
demonstrated at any time during hospitalization: As stated per
interpretation, or all of the following: Absence of discrete P waves,
fibrillating baseline, irregularly irregular narrow QRS complexes.
Ventricular rate may be fast or slow. Score regardless of
patient’s current or past medication regimen.
Sick sinus syndrome: As stated per report,
or: the term "tachy-brady syndrome" is used, or if there are
alternating bouts of supraventricular
tachycardia (e.g. atrial flutter) and bradycardia. You
should score this if it is present regardless of medication regimen
or pacemaker placement.
Atrial flutter
demonstrated at any time during hospitalization: As stated per
interpretation, or all of the following: P wave at 250–350 bpm,
baseline with sawtooth pattern (flutter waves), regularly occurring QRS
complexes in a fixed ratio with P waves.
(F) Specialized tests (hematological, CSF, or histology)
- General precepts
This section
records data derived from any specific tests performed to evaluate
for presence of diseases which increase the likelihood of stroke by
means of a mechanism which is not related to large vessel
atherosclerosis, cardiogenic embolism, or
lipohyalinosis. A comprehensive list of such diagnoses and the
appropriate tests or diagnostic criteria are listed in
section 1C (History, prior specialized tests).
If
any of the tests mentioned in section 1C were performed and found to
demonstrate evidence of the accepted ‘other etiologies’ of cerebral
infarct, score:
‘[1] Complete set of studies
demonstrating evidence of underlying cause if one or more of the
bold faced tests was performed and found to be positive
or
‘[2] Incomplete set of studies
demonstrating evidence of underlying cause if only non-bold faced
tests were performed and found to be positive or
‘[3] Normal if non-bold tests were positive but
any boldfaced test was negative. The
response "[3] Normal" should be scored if any one or more tests
listed was conducted for the purposes of evaluating for ‘other
etiologies’ and ALL were found to be negative. If no specialized tests
were performed, record "[4] Incomplete or not done."
Section 4. Postmortem Examination
- General precepts
Any postmortem
examination is valid for evaluation, regardless of the recorded
cause of death or time discrepancy between infarct and postmortem
examination. The only exception would be any person who has had a
second event (of any nature, including surgical) involving the brain
tissue or vasculature which was implicated in the index
infarct.
Pathological findings should only be
recorded as they are relevant to tissue and vasculature involved in
the index infarct. If no infarct was detected by imaging, the infarct
found during autopsy should correspond to the clinical findings.
- Specific diagnoses
[1] Bland or hemorrhagic
infarct, an atheromatous lesion (possibly with adherent
thrombus) of an appropriate, large extracranial artery or possibly
occlusion of superficial or cortical arteries: A bland or
hemorrhagic infarct, involving cortical or subcortical structures,
appropriate for clinical presentation and corresponding to
radiographic findings (if present) should be described.
Furthermore, significant atherosclerosis (greater than
or equal to 50% stenosis) should be present in the
appropriate large arteries supplying the territory of the infarct.
There may or may not be atherosclerotic disease in the branch, stem, or
division arteries supplying the territory of the infarct. Do not
consider atherosclerosis in cerebral vessels not
involved with the infarct or in any other systemic vessels.
[2] Bland or hemorrhagic infarct(s),
arterial occlusion by an embolus and underlying heart
disease: Bland or hemorrhagic infarct(s) as mentioned above, with
embolic arterial occlusion in a vessel supplying at least
one of the lesions identified clinically or
radiographically during the index admission. Do not
consider any other embolic events. Underlying heart disease must
also be present. The pathology report may describe any
of the following: left ventricular thrombus, myocardial
infarction less than 4 weeks old, dilated ventricles, atrial thrombus,
atrial myxoma, infective endocarditis, aortic stenosis (not
aortic sclerosis or bicuspid aortic valve), mitral stenosis,
mitral annular calcification, myxomatous degeneration of the mitral
valve, atrial septal defect (ostium primum or ostium secundum), patent
foramen ovale (including ‘probe patent’), nonbacterial endocarditis
(marantic, Libman-Sacks), mechanical or bioprosthetic heart
valve (not homograft).
[3] Small deep
infarct in the territory of a penetrating artery: Infarct less
than 1.5 cm in diameter in a deep structure (corona radiata, internal
capsule, external capsule, basal ganglia, thalamus, pons, or medulla).
Score even if an embolus is present within the small artery
supplying the region of infarct. Do not score if there is evidence of
arterial occlusion of other etiology (e.g. vasculitis,
hematological abnormality, etc).
[4]
Bland or hemorrhagic infarct, without significant
atherosclerosis, normal cardiac pathology, and
arterial occlusion of specific etiology: Infarct of
ANY size or location corresponding clinically and radiologically to the
infarct described in the index admission accompanied by: (1) lack of
significant atherosclerosis involving vessels supplying
the infarct, (2) lack of embolic occlusion of the relevant vessel(s),
(3) lack of cardiac pathology suggestive of embolism (see [2]), and
(4) evidence of a specific disease state predisposing to cerebral
infarction. Specific disease states, which meet criterion (4), are
listed in section 1C ‘History/Prior Specialized Tests.’
[5] Infarction but no specific vascular
pathology: Score this response if the pathology report documents:
(1) lack of significant atherosclerosis
involving vessels supplying the infarct, (2) lack of embolic
occlusion of the relevant vessel(s), (3) lack of cardiac
pathology suggestive of embolism (see [2]), and (4) no
evidence of a specific disease state predisposing to cerebral
infarction. Subclinical atherosclerosis would fall into
this category.
[6] Not done: Score this
response if (1) no postmortem examination was performed, (2) an
incomplete postmortem examination was performed (e.g., no brain or
heart pathological examination), or (3) data from the autopsy is
unavailable. \.
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