Mustafa Kürşad KUTLUK, Vesile ÖZTÜRK, Nazire AFŞAR, Ali Kemal ERDEMOĞLU, Refik KUNT, Bedile İrem TİFTİKÇİOĞLU, Muhteşem GEDİZLİOĞLU

Comparison of conventional and modern methods in determining ischemic stroke etiology by general and stroke neurologists

Background/aim: This study aimed to investigate the consistency between stroke and general neurologists in subtype assignment usingthe Trial of ORG-10172 in Acute Stroke Treatment (TOAST) and Causative Classification of Stroke (CCS) systems.Materials and methods: Fifty consecutive acute ischemic stroke patients admitted to the stroke unit were recruited. Patients wereclassified by two stroke and two general neurologists, each from different medical centers, according to TOAST followed by the CCS.Each neurologist was assessed for consistency and compliance in pairs. Concordance among all four neurologists was investigated andevaluated using the kappa (ĸ) value.Results: The kappa (ĸ) value of diagnostic compliance between stroke neurologists was 0.61 (95% CI: 0.45–0.77) for TOAST and 0.78(95% CI: 0.62–0.94) for CSS-5. The kappa (ĸ) value was 0.64 (95% CI: 0.48–0.80) for TOAST and 0.75 (95% CI: 0.60–0.91) for CCS-5 forgeneral neurologists. Compliance was moderate [ĸ: 0.59 (95% CI: 0.52–0.65)] for TOAST and was strong [ĸ: 0.75 (95% CI: 0.68–0.81)]for CCS-5 for all 4 neurologists. ‘Cardioembolism’ (91.04%) had the highest compliance in both systems. The frequency of the groupwith ‘undetermined etiologies’ was less in the CCS (26%) compared to TOAST.Conclusion: The CCS system improved compliance in both stroke and general neurologists compared with TOAST. This suggests thatthe automatic, evidence-based, easily reproducible CCS system was superior to the TOAST system.

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1. Chen PH, Gao S, Wang YJ, Xu AD, Li YS, Wang D. Classifying ischemic stroke, from TOAST to CISS. CNS Neuroscience & Therapeutics 2012; 18: 452-456.
2. Ay H. Etiologic classification in ischemic stroke. Turkish Journal of Neurology 2011; 17: 1-6.
3. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE. 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.
4. Ay H, Furie KL, Singhal A, Smith WS, Sorensen AG, Koroshetz WJ. An evidence-based causative classification system for acute ischemic stroke. Ann Neurol 2005; 58: 688-697.
5. Ay H, Benner T, Arsava EM, Furie KL, Singhal AB, Jensen MB, Ayata C, Towfighi A, Smith EE, Chong JY et al. A computerized algorithm for etiologic classification of ischemic stroke: the causative classification of stroke system. Stroke 2007; 38: 2979- 2984.
6. Arsava EM, Ballabio E, Benner T, Cole JW, Delgado-Martinez MP, Dichgans M, Fazekas F, Furie KL, Illoh K, Jood K et al. The causative classification of stroke system: an international reliability and optimization study. Neurology 2010; 75: 1277- 1284.
7. McArdle PF, Kittner SJ, Ay H, Brown RD, Meschia JF, Rundek T, Wassertheil-Smoller S, Woo D, Andsberg G, Biffi A et al. Agreement between TOAST and CCS ischemic stroke classification: the NINDS SiGN study. Neurology 2014; 83: 1653-1660.
8. de Paiva Bezerra R, de Miranda Alves MA, Conforto AB, Rodrigues DLG, Silva GS. Etiological classification of stroke in patients with Chagas Disease using TOAST, Causative Classification System TOAST, and ASCOD Phenotyping. J Stroke Cerebrovasc Dis 2017; 26: 2864-2869.
9. Bogiatzi C, Wannarong T, McLeod AI, Heisel M, Hackam D, Spence JD. SPARKLE (subtypes of ischaemic stroke classification system), incorporating measurement of carotid plaque burden: a new validated tool for the classification of ischemic stroke subtypes. Neuroepidemiology 2014; 42: 243- 251.
10. Marnane M, Duggan CA, Sheehan OC, Merwick A, Hannon N, Curtin D, Harris D, Williams EB, Horgan G, Kyne L et al. 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 2010; 41: 1579-1586.
11. Desai JA, Abuzinadah AR, Imoukhuede O, Bernbaum ML, Modi J, Demchuk AM, Coutts SB. 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 2014; 38: 121-126.
12. Brott T, Adams HP, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989; 20: 864-870.
13. Rankin J. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 1957; 2: 200-215.
14. Lanfranconi S, Markus HS. Stroke subtyping for genetic association studies? A comparison of the CCS and TOAST classifications. Int J Stroke 2013; 8: 626-631.
15. 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 2017; 117: 643- 648.
16. Arsava EM, Helenius J, Avery R, Sorgun MH, Kim GM, PontesNeto OM, Park KY, Rosand J, Vangel M, Ay H. Assessment of the predictive validity of etiologic stroke classification. JAMA Neurol 2017; 74: 419-426.