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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

-mechanical pros valve


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

Medium Risk Source

-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

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