Assessment of the Predictive Validity of Etiologic Stroke Classification
Assessment of the Predictive Validity of Etiologic Stroke Classification
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DOI：
10.1001/jamaneurol.2016.5815
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发表时间：
2017-04-01
期刊：
影响因子：
29
通讯作者：
Ay, Hakan
中科院分区：
文献类型：
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作者：
Arsava, E. Murat;Helenius, Johanna;Ay, Hakan
目的为了检验病因卒中亚型可以通过不同的临床病程识别不同疾病过程的假设。设计、背景和参与者我们对卒中病因分类(CCS)、急性卒中治疗组织试验(TOAST)和ASCO(动脉粥样硬化A、小血管疾病S、心源性C和其他病因O)分类系统生成具有不同临床、影像和预后特征的病因亚型的能力进行了正面评估。这项研究包括在不同时期招募的两个队列；第一个队列是在2003年4月至2006年6月之间招募的，第二个是在2009年6月至2011年12月之间招募的。数据分析在2014年6月至2016年5月期间进行。接受过卒中培训的不同神经科医生团队根据出院时可用的信息进行了CCS、TOAST和ASCO分类。我们通过计算二元变量(90天卒中复发和90天死亡率)的受试者操作特征曲线，以及通过对连续变量(美国国立卫生研究院卒中评分和急性脑梗塞体积)进行方差分析，计算类别间和类别内变异性的比率，来评估病因亚型和卒中特征之间的相关性。结果在1816名患者中，中位年龄为70岁(四分位数范围，58-80岁)(830名女性[46%])。分类系统在将卒中病因归入已知亚型的能力上有所不同；未确定类别的大小按CCS为33%，按Toast为53%，按ASCO为42%(对于所有二元比较，P<；.001)。所有系统都对测试的验证变量提供了显著的区分。对于主要验证变量(90天重复性)，CCS的受试者工作特征曲线下面积为0.71(95%CI，0.66-0.75)，TOAST为0.61(95%CI，0.56-0.67)，ASCO为0.66(95%CI，0.60-0.71)(CCS与ASCO的P=.01；CCS与TOAST的P<；.001；ASCO与TOAST的P=.13)。分类系统对90天的死亡率表现出类似的区分。对于入院的美国国立卫生研究院卒中评分和急性脑梗塞体积，CCS产生了更多不同的亚型，类别间到类别内的变异性高于TOAST和ASCO。结论我们的研究结果表明，主要的病因卒中亚型是具有不同卒中特征的不同类别，无论用于识别它们的分类系统如何。我们进一步表明，与TOAST或ASCO相比，CCS可产生不同的病因学类别，具有更多样的临床、影像和预后特征。
IMPORTANCE The ability of present-day etiologic stroke classification systems to generate subtypes with discrete stroke characteristics is not known.OBJECTIVE To test the hypothesis that etiologic stroke subtyping identifies different disease processes that can be recognized through their different clinical courses.DESIGN, SETTING, AND PARTICIPANTS We performed a head-to-head evaluation of the ability of the Causative Classification of Stroke (CCS), Trial of Org 10172 in Acute Stroke Treatment (TOAST), and ASCO (A for atherosclerosis, S for small-vessel disease, C for cardiac source, and O for other cause) classification systems to generate etiologic subtypes with different clinical, imaging, and prognostic characteristics in 1816 patients with ischemic stroke. This study included 2 cohorts recruited at separate periods; the first cohort was recruited between April 2003 and June 2006 and the second between June 2009 and December 2011. Data analysis was performed between June 2014 and May 2016.MAIN OUTCOMES AND MEASURES Separate teams of stroke-trained neurologists performed CCS, TOAST, and ASCO classifications based on information available at the time of hospital discharge. We assessed the association between etiologic subtypes and stroke characteristics by computing receiver operating characteristic curves for binary variables (90-day stroke recurrence and 90-day mortality) and by calculating the ratio of between-category to within-category variability from the analysis of variance for continuous variables (admission National Institutes of Health Stroke Scale score and acute infarct volume).RESULTS Among the 1816 patients included, the median age was 70 years (interquartile range, 58-80 years) (830 women [46%]). The classification systems differed in their ability to assign stroke etiologies into known subtypes; the size of the undetermined category was 33% by CCS, 53% by TOAST, and 42% by ASCO (P < .001 for all binary comparisons). All systems provided significant discrimination for the validation variables tested. For the primary validation variable (90-day recurrence), the area under the receiver operating characteristic curve was 0.71 (95% CI, 0.66-0.75) for CCS, 0.61 (95% CI, 0.56-0.67) for TOAST, and 0.66 (95% CI, 0.60-0.71) for ASCO (P = .01 for CCS vs ASCO; P < .001 for CCS vs TOAST; P = .13 for ASCO vs TOAST). The classification systems exhibited similar discrimination for 90-day mortality. For admission National Institutes of Health Stroke Scale score and acute infarct volume, CCS generated more distinct subtypes with higher between-category to within-category variability than TOAST and ASCO.CONCLUSIONS AND RELEVANCE Our findings suggest that the major etiologic stroke subtypes are distinct categories with different stroke characteristics irrespective of the classification system used to identify them. We further show that CCS generates discrete etiologic categories with more diverse clinical, imaging, and prognostic characteristics than either TOAST or ASCO.