Interphysician agreement in the diagnosis of subtypes of acute ischemic stroke

Abstract

To test interphysician agreement on the diagnosis of subtype of ischemic stroke, we sent subtype definitions and 18 case summaries (clinical features and pertinent laboratory data) to 24 neurologists who have a special interest in stroke, and asked them to determine the most likely subtype diagnosis. The overall agreement was 0.64 (Kappa [K] = 0.54). Interphysician agreement was highest for the diagnoses of stroke secondary to cardioembolism (K = 0.75) or to large-artery atherosclerosis (K = 0.69). Individual physicians varied widely; four agreed with the consensus diagnosis in all 18 cases, while six others disagreed with the consensus diagnosis in three to five cases. Our level of interphysician agreement is greater than that reported in other studies and was substantial. However, despite using subtype definitions and being given extensive information often not available in the acute setting, physicians still disagree about the etiology of stroke, particularly in regard to stroke due to small-artery occlusion or of undetermined etiology. Physicians seem reluctant not to attribute stroke to a specific etiology. The uncertainty about subtype diagnosis will affect interpretation of the results of clinical trials in patients selected by the subtype of ischemic stroke and also suggests that results of treatment as affected by subtype should be cautiously interpreted unless efforts to assure uniformity are included in the trial's operations. Refinement of algorithms for determining subtype of ischemic stroke do improve interphysician agreement. Such criteria should be applied strictly, and trials should include measures to assure the most uniform diagnosis of stroke subtype possible.

Thrombolysis for Acute Ischemic Stroke: Experience in Dubai, and Comparison of Arab with Non-Arab Population

“…Atrial fibrillation was diagnosed based on ECG tracing in the hospital or if a patient was known with the condition. Strokes were sub typed using the Trial of Org 10172 in Acute Stroke Treatment criteria (TOAST) [9].…”

Gene Expression in Peripheral Blood Differs after Cardioembolic Compared with Large-Vessel Atherosclerotic Stroke: Biomarkers for the Etiology of Ischemic Stroke

“…The etiologies of the strokes were assessed using the TOAST (The Trial of ORG 10172 in Acute Stroke Treatment) criteria (Adams et al, 1993) and classified as large-vessel atherosclerotic stroke, cardioembolic stroke, and stroke with undetermined etiology. Patients with small artery lacunar stroke or other special etiologies were excluded from this study.…”

“…Ischemic stroke can be classified as cardioembolic, large-vessel atherosclerotic, lacunar, other, or undetermined cause (Adams et al, 1993). The differentiation of these types of stroke currently depends on clinical judgment inferred from patient history, symptoms, and laboratory evidence of potential sources of thromboembolism.…”

Apolipoprotein E and First-ever Ischaemic Stroke in Greek Hospitalized Patients

“…15,16 The criteria for atherothrombotic stroke were: CT or MRI without evidence of lacunar small-vessel infarction; neck vessel atheromatosis compatible with the clinical manifestation; and absence of a cardiac cause of stroke. 15,16 The criteria for lacunar small-vessel infarction were: clinical evidence of lacunar syndrome (pure motor hemiplegia, pure sensory stroke, dysarthria with weakness and clumsy hand, ipsilateral ataxia with leg weakness, dysarthria with facial weakness); CT or MRI characteristics of lacunar small-vessel infarction (< 0.5 cm in diameter); absence of neck vessel atheromatosis; and absence of a cardiac cause of stroke. 15,16 Patients in whom intracardiac thrombus was identified without neck vessel atheromatosis were considered to have had a cardioembolic stroke.…”