TOAST Subtypes of Ischemic Stroke and Its Risk Factors: A Hospital-Based Study at Cipto Mangunkusumo Hospital, Indonesia

Abstract

Background and Purpose Stroke is a leading cause of death and disability, with ischemic stroke as the highest prevalent cases in Indonesia. Ischemic stroke can be classified further into five subtypes according to TOAST classification. Numerous studies have revealed that stroke risk factor has variable correlation with different stroke subtype. Currently, there is no data regarding this phenomenon in Indonesia. The aim of study is to identify characteristic of ischemic stroke subtypes and the risk factors in TOAST classification. Methods A retrospective, cross-sectional study of patients diagnosed with ischemic stroke at Cipto Mangunkusumo Hospital from January till December 2016. Demographic data, ischemic stroke subtypes, risk factors, and other relevant data were documented. Bivariate and multivariate analysis was done using SPSS 23. Results 235 recorded data patients were included. Large artery atherosclerosis (LAA) was the most prevalent stroke subtypes at 59,6%, followed with small vessel disease (SVD) at 26,7%, undetermined etiology at 9,8%, cardioembolism (CE) at 2,1%, and other determined etiology at 0,9%. Hypertension was the most common vascular risk factor. However, it was only significant in SVD (p=0,023) and undetermined etiology subtypes (p<0,001). Significant risk factor in LAA was diabetes (55%; p=0,016) while in CE subtypes was atrial fibrillation (60%;p<0,001). In multivariate analyses, hypertension (OR 3; 95% CI 1,12-8,05) was the only variable that was related to SVD while in CE it was atrial fibrillation (OR 113,5; 95% CI 13,6-946,5). Conclusion LAA was the most common stroke ischemic subtypes. Associated risk factor in LAA was diabetes while in SVD and undetermined etiology subtypes it was hypertension. Atrial fibrillation was associated with cardioembolism.

TOAST classification and risk factors of ischemic stroke in Lebanon

“…The proportion of males in our cohort (58%) was one of the highest and was comparable to that of Indonesian and Chinese cohorts (59%) in contrast to that of French (45%) and Japanese (48%) cohorts where the proportion of females were more prevalent . The mean age in our cohort (72) was comparable to that of German (72.9), Auckland (71.8), French (74.2), North Dublin (72.2), and South London (71.4) cohorts, and was higher than that of Japanese (56.5), Indonesian (60.9), Iranian (64.1), and Pakistani (65.1) cohorts . Concerning the most common risk factors, the prevalence of HTN in our cohort was one of the highest across cohorts (77%) and only being outnumbered by the Indonesian cohort (83%), as compared to other cohorts where it did not cross 66%.…”

“…Our cohort had high rates of DM (42%) compared to other cohorts and was comparable to that of Pakistani cohort (38.6%) . Interestingly, rates of DL (62%) were higher than any of the cohorts where the rates varied between 15% and 51% . As for AF, its prevalence was significantly variable across cohorts with that of Dublin cohort being higher (35%) than that of our cohort (27%), while cohorts from Iran (9.7%), China (15.6%), and Indonesia (2.6%) had significantly lower rate .…”

“…13 Interestingly, rates of DL (62%) were higher than any of the cohorts where the rates varied between 15% and 51%. [4][5][6][7][8][9][10][11][12][13][14][15][16][17] As for AF, its prevalence was significantly variable across cohorts with that of Dublin cohort being higher (35%) than that of our cohort (27%), while cohorts from Iran (9.7%), China (15.6%), and Indonesia (2.6%) had significantly lower rate. 4,5,9,11 Taken together, the prevalence of the most common vascular risk factors (HTN, DM, DL, smoking) in our cohort was strikingly high compared to other cohorts from other countries.…”

“…Ischemic stroke can be preventable if the population modifiable risk factors can be addressed appropriately. Studies from different populations showed regional variabilities concerning the distribution of stroke subtypes and prevalence their risk factors . Various scores have been developed to help clinicians predict the risk of stroke occurrence in order to promote primary and secondary stroke prevention.…”

“…Studies from different populations showed regional variabilities concerning the distribution of stroke subtypes and prevalence their risk factors. [4][5][6][7][8][9][10][11][12][13][14][15][16][17] Various scores have been developed to help clinicians predict the risk of stroke occurrence in order to promote primary and secondary stroke prevention. CHA 2 DS 2 -VASc score is used to stratify the risk of developing ischemic stroke in atrial fibrillation.…”