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Updated: Oct 15, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
ASCOD Phenotyping of Stroke With Anterior Large Vessel Occlusion Treated by Mechanical Thrombectomy
Louis Fontaine1,2,3, Igor Sibon4, Nicolas Raposo1,2,3
1Acute Stroke Unit (L.F., N.R., J.-F.A., A.V., L.C., J.-M.O.), Toulouse University Hospital, France.
Insights
Cardio-embolism, particularly atrial fibrillation, is the leading cause of acute ischemic stroke from large vessel occlusion. Early detection of atrial fibrillation is crucial for effective secondary stroke prevention strategies.
Area of Science:
- Neurology
- Cardiology
- Stroke Medicine
Background:
- Determining the cause of large vessel occlusion (LVO) acute ischemic stroke is vital for secondary prevention.
- The ASCOD (atherosclerosis, small vessel disease, cardiac source, other cause, dissection) classification aids in etiological workup.
Purpose of the Study:
- To investigate the distribution of causes for LVO acute ischemic stroke using the ASCOD classification.
- To analyze stroke mechanisms in patients treated with mechanical thrombectomy.
Main Methods:
- A predefined substudy of the FRAME trial included 215 patients undergoing mechanical thrombectomy.
- Systematic etiological workup involved brain/vascular imaging and ECG monitoring.
- Stroke mechanisms were classified using the ASCOD system at 3 months.
Main Results:
- A single potential cause was identified in 69% of patients.
- Cardio-embolism (53%) was the most frequent cause, with atrial fibrillation accounting for 88% of cardiac causes.
- Possible causes were found in 83% of patients; 7% had no identified cause.
Conclusions:
- Cardio-embolism, especially atrial fibrillation, is the primary cause of LVO acute ischemic stroke.
- This highlights the importance of detecting paroxysmal atrial fibrillation for stroke management.
Background And Purpose:
Determining the mechanism of large vessel occlusion related acute ischemic stroke is of major importance to initiate a tailored secondary prevention strategy. We investigated using the atherosclerosis, small vessel disease, cardiac source, other cause, dissection (ASCOD) classification the distribution of the causes of large vessel occlusion related acute ischemic stroke treated by mechanical thrombectomy.
Methods:
This was a predefined substudy of the FRAME (French Acute Multimodal Imaging to Select Patient for Mechanical Thrombectomy). Each patient underwent a systematic etiological workup including brain and vascular imaging, electrocardiogram monitoring lasting at least 24 hours and routine blood tests. Stroke mechanisms were systematically evaluated using the atherosclerosis, small vessel disease, cardiac source, other cause, dissection grading system at 3 months. We defined single potential cause by one cause graded 1 in a single domain, possible cause as a cause graded 1 or 2 regardless of overlap, and no identified cause without grade 1 nor 2 causes.
Results:
A total of 215 patients (mean age 70±14; 50% male) were included. A single potential cause was identified in 148 (69%). Cardio-embolism (53%) was the most frequent, followed by atherosclerosis (9%), dissection (5%) and other causes (1%). Atrial fibrillation accounted for 88% of C1. Overlap between grade 1 causes was uncommon (3%). Possible causes were identified in 168 patients (83%) and 16 (7%) had no cause identified after the initial evaluation.
Conclusions:
Cardio-embolism, especially atrial fibrillation, was the major cause of large vessel occlusion related acute ischemic stroke. This finding emphasizes the yield of paroxysmal atrial fibrillation detection in those patients. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03045146.
