Joint Symposium

2010 Stockholm

European Society of Cardiology and European Stroke Conference

NEW ASPECTS IN DIAGNOSIS AND TREATMENT OF AF
PROBLEMS IN CLASSIFICATION OF CARDIOGENIC STROKE

MG Hennerici

Joint Symposium

2010 Stockholm

European Society of Cardiology and European Stroke Conference

DISCLOSURE OF CONFLICT OF INTEREST: NONE

A variety of stroke subtyping systems have been proposed

They were developed for particular interests
They all have advantages and disadvantages
Their main shortcomings are:
they have not been modified since first description
they focus on the most likely cause but
the level of diagnostic evidence is unknown
recent technological advances are not included (MR)
they all disregard overlap of different sources of stroke

Traditional classifications
Harvard Stroke Data Bank HSDB
Trial of Org 10172 in Acute Stroke Treatment TOAST
Lausanne Registry LR
Genic Classification GC
Oxfordshire Classification
Recent classification
PERFORM classification
SSS-TOAST/Martinos Platform
A-S-C-O

60 yr m

NVAF on admission Territorial MCA stroke

a)

c)

b)

d)

Occlusion ICA l

Stroke subtype classification: TOAST

5 aetiologic subtypes:

Large-artery atherosclerosis
Cardioembolism
Small-vessel occlusion
Stroke of other determined etiology
Stroke of undetermined etiology
Adams HP, Bendixen BH, Kapelle LJ, Biller J, Love BB, Gordon DL, Marsh EE. Classification of
subtype of acute ischmemic stroke. Definitions for use in a multicenter clinical trial. Stroke
1993;24:1801-4

58 yr m
MCA territory stroke PWI>DWI ICA occlusion
acute stroke with global aphasia and right hemiplegia NIH 15
onset 1 h ago
NVAF treated INR 1.6

2 hrs after thrombolysis

full recovery NIH 1

24 hrs later: repeat TIAs similar symptoms

Extracranial US: 80% carotid stenosis
Increased platelet count

Stroke subtype classification: TOAST

5 aetiologic subtypes:

Large-artery atherosclerosis
Cardioembolism
Small-vessel occlusion
Stroke of other determined etiology
Stroke of undetermined etiology
Adams HP, Bendixen BH, Kapelle LJ, Biller J, Love BB, Gordon DL, Marsh EE. Classification of
subtype of acute ischmemic stroke. Definitions for use in a multicenter clinical trial. Stroke
1993;24:1801-4

39 yr m MCA territory ischemia DWI

mild dysarthria and facial paresis
Migraine with aura
PFO III + ASA
right ICA dissection

A0 S0 C3 O1

Stroke subtype classification: TOAST

5 aetiologic subtypes:

Large-artery atherosclerosis
Cardioembolism
Small-vessel occlusion
Stroke of other determined etiology
Stroke of undetermined etiology
Adams HP, Bendixen BH, Kapelle LJ, Biller J, Love BB, Gordon DL, Marsh EE. Classification of
subtype of acute ischmemic stroke. Definitions for use in a multicenter clinical trial. Stroke
1993;24:1801-4

 THERE

IS A NEED
FOR A BETTER CLASSIFICATION
OF STROKE SUBTYPES
WITH REGARD TO
PHENOMENOLOGY
ETIOLOGY
DEGREE OF CAUSALITY

Stroke subtype classification: A-S-C-O

A-S-C-O: acronym for
A = Atherosclerosis
S = Small vessel disease
C = Cardiac source
O = Other cause
additional grading
1 definitely a potential cause of the index stroke
2 causality uncertain
3 unlikely a direct cause of the index stroke (but disease is present)
0 disease is completely absent
9 grading not possible because of insufficient work-up
Every patient gets a phenotypic (descriptive) score: e.g. A0 S3 C1 O0

Amarenco P, Bogousslavsky J, Caplan LR, Donnan GA, Hennerici MG. Classification of Stroke
Subtypes. Cerebrovasc Dis 2009. 27(5):493-501
Amarenco P, Bogousslavsky J, Caplan LR, Donnan GA, Hennerici MG. New approach to Stroke
Subtyping: The A-S-C-O (Phenotypic) Classification of Stroke. Cerebrovasc Dis 2009. 27(5):502-508

Classification is of therapeutic relevance

Anticoagulation recommended A2 S0 C1 O0

Anticoagulation + Carotid endarterectomy recommended

A1 S0 C1 O3

Possibly antithrombotic treatment

No CEA, possibly PFO closure
A0 S0 C2 O1

More areas of interest and take home messages.

1) Classification of stroke subtypes relies on

best medical diagnosis and full workup

More areas of interest and take home messages.

1) Classification of stroke subtypes relies on

best medical diagnosis and full workup
2) Diagnosis of first ever strokes should
consider multiple sources in about 1/3 of
patients. The likelihood of activity should be
documented using an appropriate score.

More areas of interest and take home messages.

3) Cardiogenic strokes mainly affect the

elderly, often with territorial infarcts in
multiple vascular territories including the
posterior circulation. Secondary bleeding is
not rare and worsens the prognosis.

More areas of interest and take home messages.

4) Coincidence vs. Causality of cardiogenic

stroke mechanisms can be differentiated
using neuroimaging

More areas of interest and take home messages.

5) ASCO is the best available system for

stroke subtyping based on evidence based
grading criteria.

More areas of interest and take home messages.

Multiple lesions should not always be considered cardiogenic

A0 S3 C1 O0

Different territories (MCA/PCA)

Both hemispheres
AF

Cortical vs subcortical lesions

A0 S1 C3 O0

90 years old female patient:

- Paroxysmal AF ?

- 80% stenosis the right ICA

- Severe Small vessel disease
TOAST:
Cardiac cause (AF) +
Large vessel disease
(symptomatic carotid stenosis)

Watershed
infarction?

lacunar
infarction?

= undetermined
ASCO: A1 S1 C3 O0

DWI

FLAIR

SCORES to identify high-risk patients are unspecific

CHADS2
ABCD2
Stroke risk in AF
Stoke risk in TIA
------------------------------------------------------------------Congestive hearts failure
Age > 60yrs
Hypertension
Blood Pressure
Age >75 yrs
Clinical features (2)
Diabetes mellitus
Duration of symptoms
Prior stroke/TIA (2)
Diabetes mellitus
6 points

6 points

Both are unable to predict the individual stroke risk and may
only be used as rough estimates for recommendations

Future areas of interest .

Association with dementia

Among 37.025 patients (60.6 + 17.9 yrs)

10.161 (27%) AF and 1.535 (4.1%) dementia

TJ Bunch et al. Hearth Rhythm 2010; 433-437

New questions

Ablation of AF reduces risk of AD and dementia

Intermountain Medical Center Registry 37.908 pts

4212 underwent ablations, 16.848 best medical
treatment with AF, 16.848 controls without AF

293 developed dementia during 3 yrs follow-up

JD Day et al. Heart Rhythm Society May 13,2010

New questions

Ablation of AF reduces risk of AD and dementia

Endpoint

AF no abl.

No AF

AF abl.

AD

0.9%

0.5%

0.2% p<0.001

Other D

1.7%

0.7%

0.4% p<0.001

Mortality

23.5%

8.7%

6.0% p<0.001

Stroke

4.7%

2.4%

2.2% p<0.001

Mechanisms to be discussed: inflammation,

perfusion related WMLs and microembolism (=SVD)

JD Day et al. Heart Rhythm Society May 13, 2010

Two thirds of stroke have >1 source

28.16% among all strokes are C1

90% of C stroke have concomitant etiologies

4.85%
29.13%
25.73%
C1+

66.02%

26.70%

40.29%

Among C patients with

concomitant etiologies
22.65% have additional LA

2.43%
C1

4.85%
C+L+S

30.20% have additional SVD

C+S

45.28% have additional LA +

SVD

C+L

26.70%
C
40.29%

Thank you