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Original research
Inconsistent centralised versus non-centralised ischaemic stroke aetiology
  1. Yue Suo1,2,
  2. Jing Jing1,2,
  3. Xia Meng1,2,
  4. Zixiao Li1,2,
  5. Yuesong Pan1,2,
  6. Yong Jiang1,2,
  7. Xiaomeng Yang1,2,
  8. Huan Liu1,2,
  9. Hongyi Yan1,2,
  10. Liping Liu1,2,
  11. Xingquan Zhao1,2,
  12. Yilong Wang1,2,
  13. Hao Li1,2,
  14. Yongjun Wang1,2
  1. 1 Department of Neurology, Beijing Tiantan Hospital, Beijing, China
  2. 2 China National Clinical Research Center for Neurological Diseases, Beijing, China
  1. Correspondence to Dr Yongjun Wang; yongjunwang{at}ncrcnd.org.cn

Abstract

Background and purpose The Trial of Org 10 172 in Acute Stroke Treatment (TOAST) system is the most widely used aetiological categorisation system in clinical practice and research. Limited studies have validated the accuracy of routine aetiological diagnosis of patients with ischaemic stroke according to the TOAST criteria when the reported subtype is assumed to be correct. We investigated the agreement between centralised and non-centralised (site-reported, at discharge) stroke subtypes in the Third China National Stroke Registry (CNSR-III), and analysed the influence of classification consistency on evaluation during hospitalisation and for secondary prevention strategy.

Methods All patients with ischaemic stroke from the CNSR-III study with complete diffusion-weighted imaging data were included. We used multivariable Cox proportional-hazard regression models to evaluate the factors associated with consistency between centralised and non-centralised stroke subtypes. Sensitivity analyses were conducted of the subgroup of patients with complete information.

Results This study included 12 180 patients (mean age, 62.3 years; and women, 31.4%). Agreement between centralised and non-centralised subtype was the highest for the large-artery atherosclerosis subtype stroke (77.4% of centralised patients), followed by the small-vessel occlusion subtype (40.6% of centralised patients). Agreements for cardioembolism and stroke of other determined aetiology subtypes were 38.7% and 12.2%, respectively. Patient-level and hospital-level factors were associated with the inconsistency between centralised/non-centralised aetiological subtyping. This inconsistency was related to differences in secondary prevention strategies. Only 15.3% of the newly diagnosed patients with cardioembolism underwent centralised subtyping with indications to receive oral anticoagulants at discharge. In comparison, 51.3% of the consistent cardioembolism group and 42.0% of the centrally reassigned cardioembolism group with anticoagulation indications were prescribed oral anticoagulants.

Conclusions Substantial inconsistency exists between centralised and non-centralised subtyping in China. Inaccurate aetiological subtyping could lead to inadequate secondary prevention, especially in patients with cardioembolic stroke.

  • stroke
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/svn-2020-000576

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    • Contributors Y-JW had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Y-JW, JJ and YS designed the protocol and framework of this study. YS, JJ, XM, YJ and YP collected the data. Huan Liu and HY conducted statistical analysis. YS drafted the manuscript. ZL, YJ, XY, LL, XZ, Y-LW and Hao Li reviewed, edited and approved the final version.

    • Funding This study was funded by National Science and Technology Major Project National Key R&D Program of China Beijing Municipal Science & Technology Commission (D171100003017002).

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available on reasonable request.