The Causative Classification of Stroke system

Arsava, Ethem Murat; Ballabio, E.; Benner, Thomas; Cole, John W.; Delgado-Martinez, M. P.; Dichgans, Martin; Fazekas, Franz; Furie, Karen L.; Illoh, Kachi; Jood, Katarina; Kittner, Steven J.; Lindgren, Arne; Majersik, Jennifer J.; Macleod, Malcolm; Meurer, William J; Montaner, Joan; Olugbodi, Alkintomi A.; Pasdar, Alireza; Redfors, Petra; Schmidt, Reinhold; Sharma, Pankaj; Singhal, Aneesh B.; Sorensen, A. Gregory; Sudlow, Cathie; Thijs, Vincent; Worrall, Bradford B.; Rosand, Jonathan; Ay, Hakan

doi:10.1212/wnl.0b013e3181f612ce

Cited by 105 publications

(79 citation statements)

References 20 publications

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“…The inter-rater reliability of SPARKLE (κ = 0.76) was not substantially different from that for CCS (κ = 0.8) [24]. The greatest disagreement between the two raters occurred when information from the medical history was overlooked.…”

Section: Discussionmentioning

confidence: 99%

SPARKLE (Subtypes of Ischaemic Stroke Classification System), Incorporating Measurement of Carotid Plaque Burden: A New Validated Tool for the Classification of Ischemic Stroke Subtypes

et al. 2014

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Background: Previous classification systems of acute ischemic stroke (Causative Classification System, CCS, of acute ischemic stroke, Trial of Org 10172 in Acute Stroke Treatment, TOAST) established the diagnosis of large artery disease (LAD) based on the presence or absence of carotid stenosis. However, carotid plaque burden is a stronger predictor of cardiovascular risk than stenosis. Our objective was to update definitions of ischemic stroke subtypes to improve the detection of LAD and to assess the validity and reliability of a new classification system: SPARKLE (Subtypes of Ischaemic Stroke Classification System). Methods: In a retrospective review of clinical research data, we compared three stroke subtype classifications: CCS, TOAST and SPARKLE. We analyzed a random sample of 275 patients presenting with minor stroke or transient ischemic attack (TIA) in an Urgent TIA Clinic in London, Ont., Canada, between 2002 and 2012. Results: There was substantial overall agreement between SPARKLE and CCS (κ = 0.75), with significant differences in the rate of detection of LAD, cardioembolic and undetermined causes of stroke or TIA. The inter-rater reliability of SPARKLE was substantial (κ = 0.76) and the intra-rater reliability was excellent (κ = 0.91). Conclusion: SPARKLE is a valid and reliable classification system, providing advantages compared to CCS and TOAST. The incorporation of plaque burden into the classification of LAD increases the proportion of cases attributable to LAD and reduces the proportion classified as being of 'undetermined' etiology.

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Section: Discussionmentioning

confidence: 99%

SPARKLE (Subtypes of Ischaemic Stroke Classification System), Incorporating Measurement of Carotid Plaque Burden: A New Validated Tool for the Classification of Ischemic Stroke Subtypes

et al. 2014

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Section: Methodsmentioning

confidence: 99%

“…13,14 Phenotypic subtypes referred to abnormal test findings categorized in major etiologic groups without weighting towards the most likely cause in the presence of multiple causes. 14 There were 4 main phenotypic categories: large artery atherosclerosis (LAA), cardiac embolism (CE), lacunar infarction (LI), and other-uncommon causes. There were 4 possible states for LAA and CE (major, minor, absent, incomplete evaluation), 3 for LI (major, absent, incomplete evaluation), and 2 for other-uncommon causes (major and absent), giving rise to a total of 96 phenotypic categories.…”

Section: Methodsmentioning

confidence: 99%

Pathogenic Ischemic Stroke Phenotypes in the NINDS-Stroke Genetics Network

Arsava

Andsberg

et al. 2014

Stroke

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Background and Purpose NINDS Stroke Genetics Network (SiGN) is an international consortium of ischemic stroke studies that aims to generate high quality phenotype data to identify the genetic basis of etiologic stroke subtypes. This analysis characterizes the etiopathogenetic basis of ischemic stroke and reliability of stroke classification in the consortium. Methods Fifty-two trained and certified adjudicators determined both phenotypic (abnormal test findings categorized in major etiologic groups without weighting towards the most likely cause) and causative ischemic stroke subtypes in 16,954 subjects with imaging-confirmed ischemic stroke from 12 US studies and 11 studies from 8 European countries using the web-based Causative Classification of Stroke System. Classification reliability was assessed with blinded re-adjudication of 1509 randomly selected cases. Results The distribution of etiologic categories varied by study, age, sex, and race (p<0.001 for each). Overall, only 40% to 54% of cases with a given major ischemic stroke etiology (phenotypic subtype) were classified into the same final causative category with high confidence. There was good agreement for both causative (kappa 0.72, 95%CI:0.69-0.75) and phenotypic classifications (kappa 0.73, 95%CI:0.70-0.75). Conclusions This study demonstrates that etiologic subtypes can be determined with good reliability in studies that include investigators with different expertise and background, institutions with different stroke evaluation protocols and geographic location, and patient populations with different epidemiological characteristics. The discordance between phenotypic and causative stroke subtypes highlights the fact that the presence of an abnormality in a stroke patient does not necessarily mean that it is the cause of stroke.

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“…One of the limitations of our analysis is lack of a gold standard for etiologic assignment and inter-rater agreement analysis for the three systems as in previous studies of this nature [6,12]. However, high inter-rater reliability of ASCO and CCS has previously been demonstrated in ischemic stroke patients [7,14]. …”

Section: Discussionmentioning

confidence: 98%

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

Desai¹,

Abuzinadah²,

Imoukhuede³

et al. 2014

Cerebrovasc Dis

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Background: The assortment of patients based on the underlying pathophysiology is central to preventing recurrent stroke after a transient ischemic attack and minor stroke (TIA-MS). The causative classification of stroke (CCS) and the A-S-C-O (A for atherosclerosis, S for small vessel disease, C for Cardiac source, O for other cause) classification schemes have recently been developed. These systems have not been specifically applied to the TIA-MS population. We hypothesized that both CCS and A-S-C-O would increase the proportion of patients with a definitive etiologic mechanism for TIA-MS as compared with TOAST. Methods: Patients were analyzed from the CATCH study. A single-stroke physician assigned all patients to an etiologic subtype using published algorithms for TOAST, CCS and ASCO. We compared the proportions in the various categories for each classification scheme and then the association with stroke progression or recurrence was assessed. Results: TOAST, CCS and A-S-C-O classification schemes were applied in 469 TIA-MS patients. When compared to TOAST both CCS (58.0 vs. 65.3%; p < 0.0001) and ASCO grade 1 or 2 (37.5 vs. 65.3%; p < 0.0001) assigned fewer patients as cause undetermined. CCS had increased assignment of cardioembolism (+3.8%, p = 0.0001) as compared with TOAST. ASCO grade 1 or 2 had increased assignment of cardioembolism (+8.5%, p < 0.0001), large artery atherosclerosis (+14.9%, p < 0.0001) and small artery occlusion (+4.3%, p < 0.0001) as compared with TOAST. Compared with CCS, using ASCO resulted in a 20.5% absolute reduction in patients assigned to the ‘cause undetermined' category (p < 0.0001). Patients who had multiple high-risk etiologies either by CCS or ASCO classification or an ASCO undetermined classification had a higher chance of having a recurrent event. Conclusion: Both CCS and ASCO schemes reduce the proportion of TIA and minor stroke patients classified as ‘cause undetermined.' ASCO resulted in the fewest patients classified as cause undetermined. Stroke recurrence after TIA-MS is highest in patients with multiple high-risk etiologies or cryptogenic stroke classified by ASCO.

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The Causative Classification of Stroke system

Abstract: Background: Valid and reliable ischemic stroke subtype determination is crucial for well-powered

Cited by 105 publications

References 20 publications

SPARKLE (Subtypes of Ischaemic Stroke Classification System), Incorporating Measurement of Carotid Plaque Burden: A New Validated Tool for the Classification of Ischemic Stroke Subtypes

SPARKLE (Subtypes of Ischaemic Stroke Classification System), Incorporating Measurement of Carotid Plaque Burden: A New Validated Tool for the Classification of Ischemic Stroke Subtypes

Pathogenic Ischemic Stroke Phenotypes in the NINDS-Stroke Genetics Network

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

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