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Etiological Classification of Stroke in Patients with Chagas Disease Using TOAST, Causative Classification System
Rodrigo de Paiva Bezerra1, Maramélia Araújo de Miranda Alves1, Adriana Bastos Conforto1
1Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil.
Insights
Cardioembolism is a common cause of ischemic stroke (IS) in Chagas disease (CD) patients. However, other stroke causes like atherosclerosis and small vessel disease are also prevalent, as shown by CCS and ASCOD classifications.
Area of Science:
- Neurology
- Cardiology
- Infectious Diseases
Background:
- Cardioembolism is a primary cause of ischemic stroke (IS) in patients with Chagas disease (CD).
- Previous research indicated that over 40% of CD patients have stroke subtypes other than cardioembolism, based on TOAST classification.
- This study aimed to re-evaluate stroke etiology in CD patients using multiple classification systems.
Purpose of the Study:
- To compare the etiologic classification of stroke in Chagas disease patients using TOAST, Causative Classification System (CCS), and ASCOD.
- To investigate the prevalence of different stroke subtypes in a prospective cohort of IS and CD patients.
Main Methods:
- A prospective cohort of 32 patients with ischemic stroke and Chagas disease was evaluated between 2012 and 2015.
- Full etiological investigation for stroke was performed for all included patients.
- TOAST, CCS TOAST, and ASCOD classifications were applied and compared.
Main Results:
- Hypertension was the most frequent vascular risk factor (87.5%).
- TOAST classification identified 87.5% of strokes as cardioembolic.
- CCS TOAST and ASCOD phenotyping revealed a significant prevalence of other etiologies, including large-artery atherosclerosis (up to 50.1%) and small-vessel disease (up to 66%).
Conclusions:
- The Causative Classification System (CCS) and ASCOD phenotyping confirm a high incidence of cardioembolic ischemic stroke in Chagas disease patients.
- These advanced classification systems also highlight the significant prevalence of other stroke etiologies, such as large-artery atherosclerosis and small-vessel occlusion, in this population.
Background:
Cardioembolism is considered a major pathophysiological mechanism in patients with ischemic stroke (IS) and Chagas disease (CD). However, a previous study reported that other stroke subtypes are present in more than 40% of CD patients according to the TOAST classification. Therefore, the aim of our study was to evaluate the etiologic classification of stroke in patients with CD using the Causative Classification System (CCS), the ASCOD, and the TOAST classifications in a prospective cohort of patients.
Methods:
Patients evaluated in our outpatient clinic from 2012 to 2015 with IS and CD were included and underwent full investigation for stroke etiology. TOAST, CCS TOAST, and the ASCOD classifications were compared.
Findings:
We Included 32 patients (18 men; mean age 62.7 +/-10.1 years). A total of 93.8% had at least 1 vascular risk factor; the most frequent was hypertension (87.5%). According to TOAST, we defined 87.5% as having cardioembolic stroke, being 9.4% as large-artery atherosclerotic (LAA) and 3.1% as undetermined cause. Using the CCS TOAST, 62.5% were classified as cardioaortic embolism evident and 15.6% as possible, 6.3% as small artery occlusion evident and 3.1% as probable, and 12.5% as LAA evident. When ASCOD phenotyping was applied, atherosclerosis was present in 50.1% of patients (A1 = 6.3%, A3 = 43.8%), cardiac pathology in 84.4% (C1 = 62.5%, C2 = 15.6%, C3 = 6.3%), and small-vessel disease in 66% (S1 = 9.4%, S2 = 3.1%, S3 = 3.1%).
Findings:
In conclusion, the use of the CCS and the ASCOD phenotyping in patients with CD confirmed a high frequency of cardioembolic IS but also showed that other etiologies are prevalent, such as large-artery atherosclerosis and small-vessel occlusion.
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