Association of neonatal inflammatory markers and perinatal stroke subtypes.

OBJECTIVE: To examine the relationship between neonatal inflammatory cytokines and perinatal stroke using a systems biology approach analyzing serum and blood-spot cytokines from 47 patients. METHODS: This was a population-based, controlled cohort study with prospective and retrospective case ascertainment. Participants were recruited through the Alberta Perinatal Stroke Project. Stroke was classified as neonatal arterial ischemic stroke (NAIS), arterial presumed perinatal ischemic stroke (APPIS), or periventricular venous infarction (PVI). Biosamples were stored blood spots (retrospective) and acute serum (prospective). Controls had comparable gestational and maternal ages. Sixty-five cytokines were measured (Luminex). Hierarchical clustering analysis was performed to create heat maps. The Fisher linear discriminant analysis was used to create projection models to determine discriminatory boundaries between stroke types and controls. RESULTS: A total of 197 participants were analyzed (27 with NAIS, 8 with APPIS, 12 with PVI, 150 controls). Cytokines were quantifiable with quality control measures satisfied (standards testing, decay analysis). Linear discriminant analysis had high accuracy in using cytokine profiles to separate groups. Profiles in participants with PVI and controls were similar. NAIS separation was accurate (sensitivity 77%, specificity 97%). APPIS mapping was also distinguishable from NAIS (sensitivity 86%, specificity 99%). Classification tree analysis generated similar diagnostic accuracy. CONCLUSIONS: Unique inflammatory biomarker signatures are associated with specific perinatal stroke diseases. Findings support an acquired pathophysiology and suggest the possibility that at-risk pregnancies might be identified to develop prevention strategies. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that differences in acute neonatal serum cytokine profiles can discriminate between patients with specific perinatal stroke diseases and controls.

Clinical risk factors associated with recurrence of ischemic stroke within two years: A cohort study.

To identify the clinical risk factors and investigate the efficacy of a classification model based on the identified factors for predicting 2-year recurrence after ischemic stroke.From June 2017 to January 2019, 358 patients with first-ever ischemic stroke were enrolled and followed up in Shenzhen Traditional Chinese Medicine Hospital. Demographic and clinical characteristics were recorded by trained medical staff. The outcome was defined as recurrence within 2 years. A multivariate logistic regression model with risk factors and their interaction effects was established and evaluated.The mean (standard deviation) age of the participants was 61.6 (12.1) years, and 101 (28.2%) of the 358 patients were female. The common comorbidities included hypertension (286 patients, 79.9%), diabetes (148 patients, 41.3%), and hyperlipidemia (149 patients, 41.6%). The 2-year recurrence rate was 30.7%. Of the 23 potential risk factors, 10 were significantly different between recurrent and non-recurrent subjects in the univariate analysis. A multivariate logistic regression model was developed based on 10 risk factors. The significant variables include diabetes mellitus, smoking status, peripheral artery disease, hypercoagulable state, depression, 24 h minimum systolic blood pressure, 24 h maximum diastolic blood pressure, age, family history of stroke, NIHSS score status. The area under the receiver operating characteristic curve (ROC) was 0.78 (95% confidence interval: 0.726-0.829) with a sensitivity of 0.61 and a specificity of 0.81, indicating a potential predictive ability.Ten risk factors were identified, and an effective classification model was built. This may aid clinicians in identifying high-risk patients who would benefit most from intensive follow-up and aggressive risk factor reduction.The clinical trial registration number: ChiCTR1800019647.

Current advances in ischemic stroke research and therapies.

With more than 795,000 cases occurring every year, stroke has become a major problem in the United States across all demographics. Stroke is the leading cause of long-term disability and is the fifth leading cause of death in the US. Ischemic stroke represents 87% of total strokes in the US, and is currently the main focus of stroke research. This literature review examines the risk factors associated with ischemic stroke, changes in cell morphology and signaling in the brain after stroke, and the advantages and disadvantages of in vivo and in vitro ischemic stroke models. Classification systems for stroke etiology are also discussed briefly, as well as current ischemic stroke therapies and new therapeutic strategies that focus on the potential of stem cells to promote stroke recovery.

Marine n-3 Polyunsaturated Fatty Acids and the Risk of Ischemic Stroke.

Background and Purpose- We hypothesized that total marine n-3 polyunsaturated fatty acids (PUFA), in particular eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in the diet and in adipose tissue (biomarkers of long-term intake and endogenous exposure) were inversely associated with the risk of ischemic stroke and its subtypes. Methods- The Diet, Cancer and Health cohort consisted of 57 053 participants aged 50 to 65 years at enrolment. All participants filled in a food frequency questionnaire and had an adipose tissue biopsy taken at baseline. Information on ischemic stroke during follow-up was obtained from The Danish National Patient Register, and all cases were validated. Cases and a random sample of 3203 subjects from the whole cohort had their fatty acid composition of adipose tissue determined by gas chromatography. Results- During 13.5 years of follow-up 1879 participants developed an ischemic stroke. Adipose tissue content of EPA was inversely associated with total ischemic stroke (hazard ratio [HR], 0.74; 95% CI, 0.62-0.88) when comparing the highest with the lowest quartile. Also, lower rates of large artery atherosclerosis were seen with higher intakes of total marine n-3 PUFA (HR, 0.69; 95% CI, 0.50-0.95), EPA (HR, 0.66; 95% CI, 0.48-0.91) and DHA (HR, 0.72; 95% CI, 0.53-0.99), and higher adipose tissue content of EPA (HR, 0.52; 95% CI, 0.36-0.76). Higher rates of cardioembolism were seen with higher intakes of total marine n-3 PUFA (HR, 2.50; 95% CI, 1.38-4.53) and DHA (HR, 2.12; 95% CI, 1.21-3.69) as well as with higher adipose tissue content of total marine n-3 PUFA (HR, 2.63; 95% CI, 1.33-5.19) and DHA (HR, 2.00; 95% CI, 1.04-3.84). The EPA content in adipose tissue was inversely associated with small-vessel occlusion (HR, 0.69; 95% CI, 0.55-0.88). Conclusions- EPA was associated with lower risks of most types of ischemic stroke, apart from cardioembolism, while inconsistent findings were observed for total marine n-3 PUFA and DHA.

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

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.

[A Study of Etiology Classification of Minor Stroke Based on TOAST and ASCO Systems].

OBJECTIVES: To investigate the differences in the etiology between minor stroke and non-minor stroke based on TOAST and ASCO systems, and to guide the early intervention for minor stroke. METHODS: We retrospectively analyzed the patients with acute ischemic stroke admitted to our department from July 2012 to July 2014. We sub-typed minor stroke patients and non-minor stroke patients in etiology using Trial of Org 10172 in Acute Stroke Treatment (TOAST) and ASCO (A for atherosclerosis, S for small vessel disease, C for Cardiac source, O for other cause) systems respectively to investigate the difference of etiology between the two groups. RESULTS: We included a total of 406 patients with minor stroke and 651 patients with non-minor stroke. The constituent ratio of TOAST was different (P<0.001) between the two groups. small-artery occlusion (SAO) was the highest cause (40.4%, 164 cases) in minor stroke group, while stroke undertermined etiology (SUE) was the most common (30.9%, 201 cases)in non-minor stroke group. The A1+2 ratio and C1+2 ratio in minor stroke group were lower than those in non-minor stroke group (22.8% vs. 35.4%, P<0.001; 19.3% vs. 32.1%, P<0.001), and the ratio of S1+2 was higher than that in non-minor stroke group (49.8% vs. 27.3%, P<0.001). CONCLUSIONS: The etiology of minor stroke is different to non-minor stroke SAO is the most common cause in minor stroke, while CE and LAA are more common in non-minor stroke.

Inflammatory and metabolic markers and short-time outcome in patients with acute ischemic stroke in relation to TOAST subtypes.

The aim of this study was to evaluate the association between inflammatory and metabolic markers and short-time outcome with acute ischemic stroke subtypes. A total of 121 patients was classified according to TOAST criteria, such as large artery atherosclerosis (LAAS), lacunar infarct (LAC), cardioembolic infarct (CEI), other determined etiology (ODE), and undetermined etiology (UDE). The functional impairment was evaluated within the first eight hours of stroke and the outcome after three-month follow-up using the modified Rankin Scale. Blood samples were obtained up to 24 h of stroke. Compared with 96 controls, patients with LAAS, CEI, and LAC subtypes showed higher levels of white blood cells, high-sensitivity C-reactive protein (hsCRP), interleukin 6 (IL-6), metalloproteinase 9 (MMP-9), glucose, and iron (p < 0.05); and lower high-density lipoprotein cholesterol (HDL-C) (p < 0.0001); platelets, insulin, insulin resistance, and homocysteine were higher in LAC (p < 0.0001); ferritin was higher in LAAS (p < 0.0001); and total cholesterol (TC) was lower in LAAS and CEI (p < 0.01). When stroke subtypes were compared, insulin was higher in LAAS vs. LAC and in LAC vs. CEI (p < 0.05); and TC was lower in LAAS vs. LAC (p < 0.05). Outcome and rate of mortality after three-month were higher in LAAS vs. LAC (p < 0.001 and p = 0.0391 respectively). The results underscored the important role of the inflammatory response and metabolic changes in the pathogenesis of ischemic stroke subtypes that might be considered on the initial evaluation of stroke patients to identify those that could benefit with individualized therapeutic strategies that taken into account these markers after acute ischemic event.

Association of the ASCO classification with the executive function subscores of the Montreal cognitive assessment in patients with postischemic stroke.

BACKGROUND: The ASCO classification can evaluate the etiology and mechanisms of ischemic stroke more comprehensively and systematically than conventional stroke classification systems such as Trial of Org 10172 in Acute Stroke Treatment (TOAST). Simultaneously, risk factors for cognitive impairment such as arterial sclerosis, leukoaraiosis, and atrial fibrillation can also be gathered and graded using the ASCO classification. METHODS: Sixty patients with postischemic stroke underwent cognitive testing, including testing by the Japanese version of the Montreal cognitive assessment (MoCA-J) and the mini-mental state examination (MMSE). Ischemic strokes were categorized and graded by the ASCO classification. In this phenotype-based classification, every patient is characterized by the A-S-C-O system (A for Atherosclerosis, S for Small vessel disease, C for Cardiac source, and O for Other cause). Each of the 4 phenotypes is graded 0, 1, 2, or 3, according to severity. The conventional TOAST classification was also applied. Correlations between individual MoCA-J/MMSE scores and the ASCO scores were assessed. RESULTS: The total score of the ASCO classification significantly correlated with the total scores of MoCA-J and MMSE. This correlation was more apparent in MoCA-J than in MMSE, because MoCA-J scores were normally distributed, whereas MMSE scores were skewed toward the higher end of the range (ceiling effect). Results for individual subtests of MoCA-J and MMSE indicated that cognitive function for visuoexecutive, calculation, abstraction, and remote recall significantly correlated with ASCO score. CONCLUSIONS: These results suggest that the ASCO phenotypic classification of stroke is useful not only for assessing the etiology of ischemic stroke but also for predicting cognitive decline after ischemic stroke.

Cryptogenic subtype predicts reduced survival among cancer patients with ischemic stroke.

BACKGROUND AND PURPOSE: Cryptogenic stroke is common in patients with cancer. Autopsy studies suggest that many of these cases may be because of marantic endocarditis, which is closely linked to cancer activity. We, therefore, hypothesized that among patients with cancer and ischemic stroke, those with cryptogenic stroke would have shorter survival. METHODS: We retrospectively analyzed all adult patients with active systemic cancer diagnosed with acute ischemic stroke at a tertiary care cancer center from 2005 through 2009. Two neurologists determined stroke mechanisms by consensus. Patients were diagnosed with cryptogenic stroke if no specific mechanism could be determined. The diagnosis of marantic endocarditis was restricted to patients with cardiac vegetations on echocardiography or autopsy and negative blood cultures. Patients were followed until July 31, 2012, for the primary outcome of death. Kaplan-Meier statistics and the log-rank test were used to compare survival between patients with cryptogenic stroke and patients with known stroke mechanisms. Multivariate Cox proportional hazard analysis evaluated the association between cryptogenic stroke and death after adjusting for potential confounders. RESULTS: Among 263 patients with cancer and ischemic stroke, 133 (51%) were cryptogenic. Median survival in patients with cryptogenic stroke was 55 days (interquartile range, 21-240) versus 147 days (interquartile range, 33-735) in patients with known stroke mechanisms (P<0.01). Cryptogenic stroke was independently associated with death (hazard ratio, 1.64; 95% confidence interval, 1.25-2.14) after adjusting for age, systemic metastases, adenocarcinoma histology, and functional status. CONCLUSIONS: Cryptogenic stroke is independently associated with reduced survival in patients with active cancer and ischemic stroke.

Risk factor profile by etiological subtype of ischemic stroke in the young.

BACKGROUND AND PURPOSE: Studies of risk factors for ischemic stroke in the young have generally considered ischemic stroke as a whole. The purpose of the present study was to evaluate the association of traditional cardiovascular risk factors with etiological subtypes of ischemic stroke in young adults. METHODS: Retrospective review of data from patients aged 16-54 years consecutively treated for first-ever ischemic stroke in an academic stroke unit. Definite causes of stroke were classified using the ASCO (A for atherothrombosis, S for small vessel disease, C for cardiac source, O for other cause) classification system. We used multinomial logistic regression analysis to evaluate associations of age, gender, smoking, hypertension, diabetes and blood lipids with each etiological subtype. RESULTS: A total of 400 patients were included: 244 men (61.1%), 156 women (38.9%); mean age (SD) 44.5 (8.5) years. A definite cause of stroke could be identified in 202 (50.5%) patients. Definite causes of stroke included: atherothrombosis, 72 (18.0%) patients; cardioembolism, 37 (9.25%) patients; small vessel disease, 28 (7.0%) patients; other definite cause, 65 (16.25%) patients including 44 patients with carotid or vertebral artery dissection. Atherothrombosis was associated with age, smoking, diabetes, hypertension and low HDL-cholesterol. Small vessel disease was associated with age and hypertension. Cardioembolism was associated with age. CONCLUSION: The risk factor profile differs between etiological subtypes of ischemic stroke in young adults. Our findings emphasize the impact of smoking, diabetes, hypertension and low HDL-cholesterol as risk factors for atherothrombosis, and of hypertension as a risk factor for small vessel disease in young adults.

Risk factors and acute ischemic stroke subtypes.

BACKGROUND: Acute ischemic stroke (AIS) is influenced by gender, age, and the brain site affected. Better characterization of AIS is necessary for improving guidelines, prevention, and destination of resources. METHODS: Demographics, prestroke conditions, etiology, subtypes, specific hospital outcome, clinical and laboratory parameters, and mortality rates were prospectively registered in 105 southern Italian patients. RESULTS: AIS became more frequent in women than in men after age 65 years. Cryptogenic AIS decreased with age independently of sex and lesion site. Cerebellum-brainstem stroke was more prevalent in men, whereas anterior AIS was more frequent in women. There were no overall differences in 6- and 12-month survival rates based on site or sex; however, mortality rates were high after age 80 years. Chronic kidney disease was more frequent in patients with cerebellum-brainstem stroke, and its prevalence increased significantly with age independently of sex. Association of AIS with arterial hypertension, diabetes, and previous myocardial infarction increased with age, whereas that with active smoking decreased with age, independently of sex and site. CONCLUSION: Specific AIS etiology and blood characteristics associated independently to the youngest and oldest AIS patients, respectively. Chronic kidney disease was a specific predictor of cerebellum-brainstem AIS. AIS mortality showed peculiar association with the oldest patients.

Association between arterial calcifications and nonlacunar and lacunar ischemic strokes.

BACKGROUND AND PURPOSE: Nonlacunar cerebral infarcts are presumed to be caused by thromboembolism from the heart or extracranial arteries, whereas lacunar infarcts are thought to be caused by small vessel disease. We investigated to what extent arterial calcifications differ between nonlacunar and lacunar ischemic strokes. METHODS: We studied 820 consecutive patients with transient ischemic attack or ischemic stroke in the anterior circulation who underwent multidetector computed tomography angiography and had no rare cause of stroke. The presence of likely cardioembolic pathogenesis was determined according to the Trial of Org 10172 in Acute Stroke Treatment criteria. The remaining 708 patients were categorized as nonlacunar or lacunar strokes, either transient ischemic attacks or strokes, based on clinical symptoms corrected by brain imaging results. We measured volume of calcifications in the aortic arch, symptomatic extracranial and intracranial carotid artery using multidetector computed tomography angiography. The difference in calcifications between nonlacunar and lacunar strokes was assessed with a multivariable logistic regression analysis. We adjusted for degree of symptomatic carotid artery stenosis and cardiovascular risk factors. RESULTS: We found an independent association between volume of aortic arch calcifications and nonlacunar ischemic strokes (adjusted odds ratio [95% confidence interval], 1.11 [1.02-1.21]). No independent associations between extracranial and intracranial carotid artery calcifications and nonlacunar strokes were present. CONCLUSIONS: The only difference we found between nonlacunar and lacunar strokes was a higher calcification volume in the aortic arch in nonlacunar strokes. Our findings only partially confirm the notion of distinct etiologies and suggest that the potential role of other plaque components, plaque morphology, and aortic arch calcifications in ischemic stroke subtypes awaits further evaluation.

Stroke subtypes and comorbidity among ischemic stroke patients in Brasilia and Cuenca: a Brazilian-Spanish cross-cultural study.

BACKGROUND: With the increase in life expectancy worldwide, changes in stroke subtypes and burden of stroke population are expected in both developing and developed countries. Prevalence of stroke subtypes and comorbidity in ischemic stroke patients was assessed in Brasilia, Brazil, and Cuenca, Spain. METHODS: This was an international (Brazilian-Spanish) cross-sectional study. Stroke subtypes were assessed by means of Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification. Modified Rankin scale was used to measure functional recovery and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) was used to assess comorbidity. RESULTS: A total of 500 patients (mean age 66.2 ± 16.4 years; 48% female; 48.2% Spanish) were included in the study. Spanish patients were significantly older than Brazilian ones (76.4 ± 11.2 versus 56.7 ± 14.6 years; P < .0001). Prevalence of ischemic cardiopathy (20.3% versus 6.2%) and atrial fibrillation (25.7% versus 6.6%) was significantly higher in Spanish stroke patients, whereas they less frequently used tobacco (28.3% versus 52.9%); P less than .0001. Prevalence of stroke subtypes in Spanish and Brazilian stroke patients was: stroke of undetermined etiology (58.1% versus 32.4%), cardioembolism (24.5% versus 11.6%), lacunar infarct (11.6% versus 25.5%), atherothrombotic (3.7% versus 19.7%), and other causes (2.1% versus 10.8%); P less than .0001. The Spanish sample had a significantly higher frequency of comorbidities. The CIRS-G total score and CIRS-G mean number of affected organs significantly increased with age, and correlated with the level of functional dependence as measured by Rankin scale (rS = 0.50; P = .0005). CONCLUSION: Spanish stroke people had a higher frequency of comorbid conditions, atrial fibrillation, and cardioembolism and these facts were associated with age. Atherothrombotic and lacunar strokes were more common in the younger Brazilian stroke population.

Types of stroke recurrence in patients with ischemic stroke: a substudy from the PRoFESS trial.

BACKGROUND: Risk profiles for stroke recurrence are poorly characterized. AIMS: We determined the variation in the risk and type of recurrent stroke among index ischemic stroke subtypes, and whether index stroke subtype and conventional stroke risk factors were predictors of stroke recurrence. METHODS: Patients enrolled in the Prevention Regimen for Effectively Avoiding Second Strokes trial were included in this study. RESULTS: In 1794 patients' recurrent stroke subtypes were the same as the index stroke in: 48·3% of patients with large artery atherothrombosis stroke; 50% of patients with cardioembolic stroke; 48·7% of patients with small artery occlusion stroke; 8·1% of patients with stroke of other etiology, and 45·3% of patients with undetermined etiology stroke. Patients with cardioembolic stroke, who were unwilling or unable to take oral anticoagulants, had the greatest risk of stroke recurrence. Predictors of stroke recurrence in multivariable analysis were: older age and previous stroke among large artery atherothrombosis strokes; older age, male sex, previous stroke, previous transient ischemic attack, hypertension, diabetes, and tobacco use among small artery occlusion strokes; older age among cardioembolic strokes; atrial fibrillation and anti-diabetic medications among other etiology strokes; older age, previous stroke and atrial fibrillation among undetermined etiology strokes. Predictors of brain hemorrhage as recurrent stroke were index small artery occlusion stroke, older age, previous stroke, and antiplatelet treatment with aspirin plus extended-release dipyridamole. CONCLUSIONS: Risk predictors for stroke recurrence and for brain hemorrhage differ by index ischemic stroke subtype, information that is important when initiating secondary prevention therapy.

Manejo agudo do acidente vascular cerebral / Acute management of vascular cerebral accident

A doença vascular cerebral é importante causa de mortalidade e morbidade no mundo, e sua prevalência vem crescendo com o aumento da expectativa de vida. O objetivo deste trabalho é revisar os principais fatores de risco, classificar os principais tipos de acidente vascular cerebral e revisar as mais atuais recomendações no manejo agudo desta patologia.

Cerebrovascular disease is an important cause of death and morbidity worldwide, and its prevalence is increasing with the increase in life expectancy. The objective of this paper is to review the major risk factors, classify the major types of stroke, and review the most current recommendations for acute management of this pathology.

The ASCOD phenotyping of ischemic stroke (Updated ASCO Phenotyping).

ASCO phenotyping (A: atherosclerosis; S: small-vessel disease; C: cardiac pathology; O: other causes) assigns a degree of likelihood of causal relationship to every potential disease (1 for potentially causal, 2 for causality is uncertain, 3 for unlikely causal but the disease is present, 0 for absence of disease, and 9 for insufficient workup to rule out the disease) commonly encountered in ischemic stroke describing all underlying diseases in every patient. In this new evolution of ASCO called ASCOD, we have added a 'D' for dissection, recognizing that dissection is a very frequent disease in young stroke patients. We have also simplified the system by leaving out the 'levels of diagnostic evidence', which has been integrated into grades 9 and 0. Moreover, we have also changed the cutoff for significant carotid or intracranial stenosis from 70% to more commonly used 50% luminal stenosis, and added a cardiogenic stroke pattern using neuroimaging. ASCOD captures and weights the overlap between all underlying diseases present in ischemic stroke patients.

Risk factors for and incidence of subtypes of ischemic stroke.

The TOAST classification divides patients with ischemic stroke into five subgroups according to the presumed etiological mechanism. The aims of the present study were to evaluate the distribution of the different etiological stroke subtypes in a hospital-based sample of stroke patients, and to investigate the association between important risk factors and stroke subtypes. A total of 210 patients with a first-ever ischemic stroke admitted to the stroke unit of Asker and Bærum Hospital in Norway between February 2007 and July 2008 were enrolled in the study. Information on vascular risk factors was collected at admittance, examination of neurological deficits was carried out during their stay, and classification was made according to the TOAST criteria. According to the TOAST classification, 24 (11.4%) of the patients suffered from large vessel disease, 66 (31.4%) from cardioembolic disease, 66 (31.4%) from small vessel disease and 54 (25.7%) from a stroke of undetermined etiology. The presence of hyperlipidemia and atrial fibrillation varied significantly between the different subtypes. In multivariate analyses, hyperlipidemia [odds ratio (OR) 2.46, 95% confidence interval (CI) 1.32-4.60] and current smoking (OR 2.06, 95% CI 1.04-4.08) were the only variables that were related to small vessel disease. Small vessel disease was observed more frequently and large vessel disease less frequently than previously reported. Small vessel disease was significantly associated with hyperlipidemia and current smoking. Our study supports the view that the etiology of lacunar strokes is multifactorial.

Stroke subtype classification: a comparative study of ASCO and modified TOAST.

BACKGROUND AND PURPOSE: The ASCO stroke classification may be an improvement over the modified TOAST for etiological diagnoses. We aimed to compare the differences in stroke subtype classification between these two classification system. METHODS: Selected for this study were 425 first-time acute ischemic stroke patients. For each, the cause of ischemic stroke was classified according to both the ASCO and modified TOAST criteria. The κ statistic and McNemar test were used to compare the similarities and differences, respectively, between the two approaches. RESULTS: More patients were classified as having an atherosclerotic etiology under the ASCO 1 category than the modified TOAST system (60.2% vs. 57.9%; P=0.132). There was no significant difference between the proportion of patients with undetermined etiology as defined by the ASCO 1 and the modified TOAST (15.5% vs. 16.2%; P=0.795). Both the modified TOAST and ASCO-1 correctly identified all patients with etiology "other cause". Agreement between the two classification systems was high in every subtype category except 'undetermined' (κ>0.81 for atherosclerosis, κ=0.61 to κ=0.8 for cardiac disease, and κ=0.480 for undetermined). When ASCO-1 to ASCO 3 were applied, atherosclerosis was identified as the cause in 76.0% of patients, small artery disease in 46.4%, and cardiac disease in 11.3%. CONCLUSION: There is a moderately high agreement between the ASCO and modified TOAST classification schemes in all subtypes except that of "undetermined" etiology. Application of ASCO-1 did not reduce the proportion of patients 'undetermined' etiology compared to modified TOAST.

Comparison of the new ASCO classification with the TOAST classification in a population with acute ischemic stroke.

Precise analysis of stroke subtypes is important for clinical treatment decisions, the prognostic evaluation of patients, as well as defining stroke populations in clinical studies. The TOAST classification is the most widely used and approved form for etiologic subtyping. Increasing knowledge about stroke mechanisms and the introduction of new diagnostic techniques have supported the promotion of the new ASCO phenotypic classification, which aims to characterize patients using different grades of evidence for stroke subtypes. We prospectively assigned 103 consecutive patients from our stroke center for subtype classification using ASCO and TOAST. Clinical features and complementary investigations were recorded according to our standardized acute stroke care protocol. Evidence grade 1 with ASCO was assessed in 12.62% for large artery disease (A), 23.30% small-vessel disease (S), 36.89% cardiac source (C) and 1.94% another cause (O). Evidence grades 1-3 were identified in 60.19% A, 75.73% S, 49.51% C, and 3.88% O. A total of 68.93% of the patients were classified in more than one category, and only 3.88% remained completely undetermined. The κ value for inter-rater agreement was 0.92-1. Using TOAST, the distribution was 9.71% A, 23.30% S, 34.95% C, 1.94% O, and 30.10% undetermined. The ASCO classification showed a good concordance with TOAST. The inter-rater agreement was high. The comprehensive character of ASCO allows the recording of important additional information. This may be helpful for a specific treatment adaptation in each individual patient and creation of different etiological profiles in view of adapted clinical trials.

Towards understanding the cause of stroke in young adults utilising a new stroke classification system (A-S-C-O).

BACKGROUND: Stroke in younger people is relatively common and frequently unexplained. While understanding of the causes of young stroke has improved, there remains uncertainty over the role of low-risk lesions such as a patent foramen ovale (PFO). The TOAST criteria are often used to describe stroke aetiology, but in younger people in whom PFOs are frequent, there is a very high proportion of cases attributed to cardiac embolism. The impact of using the newer A-S-C-O criteria on stroke aetiology was investigated. METHODS: Consecutive patients with ischaemic stroke were investigated and categorised by the TOAST and ASCO1 criteria. Stroke aetiology was presented and compared by the different classification systems. RESULTS: Of the 106 ischaemic stroke cases, by TOAST 6% were 'large artery atheroma', 11% 'small vessel occlusion', 28% 'cardioembolic', 22% 'other determined cause' and 33% 'undetermined cause'. The vascular territory and associated causes are presented. With the ASCO1 criteria, there were more cases of unclassified stroke (51.9 vs. 34.0%; p < 0.001) and fewer cases of cardiac embolism. Kappa ranged from 0.5 for 'undetermined aetiology' to 1.0 for both 'large artery atheroma' and 'other determined aetiology'. Younger cases (<45 years) were less likely to be either 'large artery atheroma' or 'small vessel occlusion'. CONCLUSION: Using the ASCO criteria, more patients fall into the undetermined group which more accurately reflects our current uncertainty regarding the pathogenic relevance of PFOs in this age group.