Stroke, Vol 24, 35-41, Copyright © 1993 by American Heart Association
HP Adams Jr, BH Bendixen, LJ Kappelle, J Biller, BB Love, DL Gordon and EE Marsh 3d
BACKGROUND AND PURPOSE: The etiology of ischemic stroke affects prognosis,
outcome, and management. Trials of therapies for patients with acute stroke
should include measurements of responses as influenced by subtype of
ischemic stroke. A system for categorization of subtypes of ischemic stroke
mainly based on etiology has been developed for the Trial of Org 10172 in
Acute Stroke Treatment (TOAST). METHODS: A classification of subtypes was
prepared using clinical features and the results of ancillary diagnostic
studies. "Possible" and "probable" diagnoses can be made based on the
physician's certainty of diagnosis. The usefulness and interrater agreement
of the classification were tested by two neurologists who had not
participated in the writing of the criteria. The neurologists independently
used the TOAST classification system in their bedside evaluation of 20
patients, first based only on clinical features and then after reviewing
the results of diagnostic tests. RESULTS: The TOAST classification denotes
five subtypes of ischemic stroke: 1) large-artery atherosclerosis, 2)
cardioembolism, 3) small-vessel occlusion, 4) stroke of other determined
etiology, and 5) stroke of undetermined etiology. Using this rating system,
interphysician agreement was very high. The two physicians disagreed in
only one patient. They were both able to reach a specific etiologic
diagnosis in 11 patients, whereas the cause of stroke was not determined in
nine. CONCLUSIONS: The TOAST stroke subtype classification system is easy
to use and has good interobserver agreement. This system should allow
investigators to report responses to treatment among important subgroups of
patients with ischemic stroke. Clinical trials testing treatments for acute
ischemic stroke should include similar methods to diagnose subtypes of
stroke.
ARTICLES
Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment
Department of Neurology, University of Iowa, Iowa City 52242-1053.
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