TOAST Classification

16/05/03 Craig Douglas

Need For Subclassification

Prognosis, recurrence, aetiology and management differ between the subtypes The classification of ischaemic stroke according to the aetiological mechanism is considered logical, since it is only with understanding of the underlying mechanisms of stroke that rational acute and secondary therapies can be deployed (Bamford 2000)

Classification Systems

There are 2 systems which use aetiology as their basis: -Stroke Data Bank (Gross, 1986) -TOAST (Adams, 1993) The main difficulty with this system is performing the necessary technical examinations on all patients

Other Options?
(Bamford et al)

Oxfordshire Community Stroke Project

Bamford et al. 1991 Uses clinical localisation of the infarct topography Provides info. More relevant to the prognosis than to the underlying vascular pathology TACI, PACI, LACI, POCI

TOAST Classification
There are 5 diagnostic sub-types of ischaemic stroke: 1.Large artery atherosclerosis 2.Cardioembolism 3.Small vessel occlusion (lacunar) 4.Other determined aetiology 5.Undetermined aetiology Multiple possible aetiologies (No.6)

Determining TOAST Sub-type

(VTACS)

Section 1a History/Emboli

High Risk Source

Medium Risk Source

-mechanical pros valve -AF -sick sinus syndrome -MI (prev 4 weeks) -dilated cardiomyopathy -atrial myxoema -IE -akinetic LV Scores 1

-MI (>4 weeks, <6mon) -CCF -LV aneurysm -atrial flutter -bioprosthetic valve -mitral valve prolapse -mitral stenosis -ASD -patent foramen ovale Scores 2

Section 1b History/Large Vessel Disease

Known extracranial large vessel disease. Scores 1 Negative prior carotid study Scores 2 No previous carotid study Scores 3

Section 1c History/Prior Specialised Tests

Used for determining causes of stroke outwith LVA, cardioembolism or small vessel disease Positive past specialised tests (haematologic, CSF, histology) Scores 1 Negative past specialised tests Scores 2 None previously, scores 3

Section 2 Physical Exam

Findings obtained on the day of admission are used Atrial Fibrillation (1=yes, 2=no) Evidence of systemic emboli, such as clots on fundoscopy, splinter haemorrhages, RS, JL, ON Evidence of classical lacunar syndromes. Rule out LS if somnolence, aphasia, visual abnormalities, oculomotor abnormalities or disorders of higher motor function are new findings.

Lacunar Syndromes

Pure motor defecit Pure sensory defecit Mixed sensorimotor defecit Ataxic hemiparesis Dysarthria Clumsy hand!

Section 3a Diagnostic Signs (CT Scan)

Evidence of haemorrhage with no sign of recent infarction excludes the patient from typing Acute bland or haemorrhagic infarct involving cortical structures +/- subcortical structures, scores 1 Changes in the distribution of a circumferential artery in the brain stem or cerebellum, scores 2 Multiple lesions of same age widely distributed = large vessel disease, scores 3

Section 3b Diagnostic Tests (MRI)

Similar to section 3a, not many patients in Dundee will have had an MRI Also, look for absence of flow in major extracranial arteries, scored as 4 and indicative of large vessel atherosclerosis A scan not performed is scored as 7

Section 3c Non Invasive Vascular Studies

More than 50% stenosis of appropriate extracranial arteries Scores 1 Less than 50% stenosis of same vessels described above Scores 2 Investigations not done, scores 3

Section 3d Cerebral Arteriogram

Occlusion, >50% stenosis or >2mm ulceration of appropriate vessels, score 1 Non-atherosclerotic pathology is scored 4 and may indicate stroke of other determined aetiology Normal is a score of 5

Section 3e Cardiovascular Examination

This section is scored by compiling data from echocardiography, an ECG and Holter monitoring High risk of emboli detected at any of the three subsections should be scored 1 (see section 1a for findings) Medium risk, scores 2 Normal, scores 3

Section 3f Specialised Tests

Complete set of studies indicating the underlying cause, scores 1 and indicates stroke of other determined aetiology Incomplete set of studies suggestive of underlying cause, scores 2, think of other determined and multiple aetiologies Normal, score of 3

Postmortem Examination

This is a possible section for helping to subtype the stroke Use only in patients who had a primary infarct leading to fatality Look for large vessel narrowing Look for emboli and underlying heart disease Look for lacunar infarction

Conclusions

Using these criteria allows an experienced physician to sub-type ischaemic stroke By sub-typing according to aetiology, this allows better management of the patient and understanding of the condition It would take considerable time to use the described strategies for the sub-typing of stroke, and would demand huge resources