TOAST Classification of Strokes Flashcards
(13 cards)
TOAST classification of ischemic stroke subtypes
*identifies stroke subtypes based on etiology
1. large-artery atherosclerosis (LAA)
2. cardioembolic stroke (CE)
3. small-vessel disease (SVD) / penetrating artery disease (PAD)
4. stroke of another determined cause
5. stroke of undetermined cause (cryptogenic stroke)
TOAST strokes: large artery disease
*large artery disease includes artery-to-artery embolism, hypoperfusion, and thrombosis of large arteries
*pts with large artery disease may benefit from interventions like carotid endarterectomy or stenting in cases of significant carotid stenosis
*antiplatelet therapy (aspirin, clopidogrel) is commonly used to prevent further thromboembolic events
*aggressive management of atherosclerotic risk factors such as HTN, HLD, and DM are crucial
TOAST strokes: cardioembolic stroke
*high-risk groups include: pts with mechanical prosthetic valves, mitral stenosis with A-fib, left atrial appendage thrombus, A-fib, sick sinus syndrome, and recent MI (<4 wks)
*medium-risk groups include: pts with mitral valve stenosis, patent foramen ovale (PFO), CHF, and MI (>4 wks)
*cardioembolic stroke tx typically involves anticoagulation (warfarin, DOACs) to prevent recurrent strokes
*diagnostic eval: echo (TTE, TEE) and ECG
*management of underlying cardiac conditions (A-fib, CHF) is necessary
TOAST strokes: small vessel disease
*small vessel disease often results in lacunar infarcts and is typically associated with DM & HTN
*controlling HTN and DM is key to preventing lacunar strokes
*antiplatelet therapy (aspirin, clopidogrel) is used for secondary prevention
*imaging (MRI) helps differentiate lacunar infarcts from other stroke subtypes
TOAST strokes: stroke of other determined etiology
*category includes rare causes such as nonatherosclerotic vasculopathies, hypercoagulable states, and hematologic disorders
*identification of the underlying etiology through appropriate tests (e.g. hypercoagulability workup, genetic testing) is critical, and treatment is tailored to the specific cause (e.g. anticoagulation for hypercoagulable states, immunosuppression for vasculopathies)
TOAST strokes: stroke of undetermined etiology
*includes cases with negative or incomplete evaluations
*further diagnostic workup may be necessary, including advanced imaging and prolonged cardiac monitoring
*empiric treatment with antiplatelets or anticoagulation may be considered based on clinical judgement
TOAST strokes: embolic stroke of undetermined source (ESUS)
*ESUS is defined as a non-lacunar brain infarct without proximal arterial stenosis or a major cardioembolic source
*extensive evaluation to rule out potential embolic sources is required
*antiplatelet therapy is often used, though anticoagulation may be considered in certain cases
large artery disease (overview)
*extracranial large vessel disease, such as carotid artery stenosis or occlusion, can lead to strokes in anterior circulation (frontal, parietal, temporal lobes; basal ganglia)
*vertebral artery stenosis or occlusion can lead to strokes in posterior circulation (brainstem, cerebellum, occipital lobe)
*intracranial large vessel disease includes conditions such as MCA stenosis or occlusion, which supplies lateral aspects of the frontal, parietal, and temporal lobes
*ACA stenosis or occlusion supplies medial aspects of the frontal and parietal lobes
*PCA stenosis or occlusion supplies the occipital lobe, inferior temporal lobe, and parts of the thalamus
*basilar artery stenosis or occlusion supplies the brainstem and cerebellum
lacunar syndrome: pure motor stroke
- lenticulostriate branches of MCA
- penetrating branches of the basilar artery
*affects the posterior limb of the internal capsule & basis pontis
lacunar syndrome: pure sensory stroke
- thalamoperforate branches of PCA
*affects the ventroposterolateral nucleus of the thalamus
POINT/CHANCE trials - clinical implications & MDM
*dual antiplatelet therapy (DAPT: clopidogrel plus aspirin) is recommended for 21 days following minor stroke or high-risk TIA
*careful consideration of bleeding risk is necessary when deciding on the duration of DAPT
DAWN/DEFUSE-2 trials - clinical implications & MDM
*thrombectomy is recommended for select patients up to 24 hours from symptom onset IF they meet specific imaging criteria (large vessel occlusion)
*advanced imaging (CT perfusion, MRI) is crucial for patient selection
SAMMPRIS trial - clinical implications & MDM
*aggressive medical management (antiplatelet therapy, statins, control of risk factors) is preferred over stenting for intracranial arterial stenosis
*regular follow-up and monitoring of risk factors are essential to prevent recurrent strokes
