Background: The Oxfordshire Community Stroke Project (OCSP) and Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classifications are widely used for the assessment of major ischaemic stroke. We explored their intra- and inter-observer reliability in the classification of outpatient minor stroke. Methods: Four physicians of differing seniority and training backgrounds classified minor stroke using clinical data from 90 patients. Results: For both the OCSP and TOAST classifications, the intra-observer reliability varied from moderate to excellent (κ = 0.48–0.83). The inter-observer reliability was good (κ = 0.64) for the OCSP and moderate (κ = 0.42) for the TOAST. Thus, neither classification was consistently reliable. Conclusions: Our results may reflect the limited validity of these classifications in a typical minor stroke outpatient population and variable observer expertise.

1.
Bamford J, Sandercock P, Dennis M, Burn J, Warlow C: Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1991;337:1521–1526.
2.
Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd: Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993;24:35–41.
3.
Madden KP, Karanjia PN, Adams HP Jr, Clarke WR: Accuracy of initial stroke subtype diagnosis in the TOAST study. Trial of ORG 10172 in Acute Stroke Treatment. Neurology 1995;45:1975–1979.
4.
Gordon DL, Bendixen BH, Adams HP Jr, Clarke W, Kappelle LJ, Woolson RF: Interphysician agreement in the diagnosis of subtypes of acute ischemic stroke: implications for clinical trials. Neurology 1993;43:1021–1027.
5.
Lindley RI, Warlow CP, Wardlaw JM, Dennis MS, Slattery J, Sandercock PA: Interobserver reliability of a clinical classification of acute cerebral infarction. Stroke 1993;24:1801–1804.
6.
Goldstein LB, Jones MR, Matchar DB, Edwards LJ, Hoff J, Chilukuri V, Armstrong SB, Horner RD: Improving the reliability of stroke subgroup classification using the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria. Stroke 2001;32:1091–1098.
7.
Atiya M, Kurth T, Berger K, Buring JE, Kase CS: Interobserver agreement in the classification of stroke in the Women’s Health Study. Stroke 2003;34:565–567.
8.
Fure B, Wyller TB, Thommessen B: TOAST criteria applied in acute ischemic stroke. Acta Neurol Scand 2005;112:254–258.
9.
Hand PJ, Haisma JA, Kwan J, Lindley RI, Lamont B, Dennis MS, Wardlaw JM: Interobserver agreement for the bedside clinical assessment of suspected stroke. Stroke 2006;37:776–780.
10.
Selvarajah JR, Smith CJ, Hulme S, Georgiou RF, Vail A, Tyrrell PJ: Prognosis in patients with transient ischaemic attack (TIA) and minor stroke attending TIA services in the North West of England: The NORTHSTAR Study. J Neurol Neurosurg Psychiatry 2008;79:38–43.
11.
Hatano S: Experience from a multicentre stroke register: a preliminary report. Bull World Health Organ 1976;54:541–553.
12.
Dennis MS, Bamford JM, Sandercock PA, Warlow CP: A comparison of risk factors and prognosis for transient ischaemic attacks and minor ischaemic strokes. The Oxfordshire Community Stroke Project. Stroke 1989;20:1494–1499.
13.
Brennan P, Silman A: Statistical methods for assessing observer variability in clinical measures. BMJ 1992;304:1491–1494.
14.
Lovett JK, Coull AJ, Rothwell PM: Early risk of recurrence by subtype of ischemic stroke in population-based incidence studies. Neurology 2004;62:569–573.
15.
Zhou H, Li JJ, Wang YJ: The reliability of ischemic stroke subtype classification using the TOAST criteria. Zhonghua Nei Ke Za Zhi 2005;44:825–827.
16.
Conti A, Innocenti R, Cagliarelli G, Sica ML, Olivotto I, Falcini F, Nozzoli C, Morettini A, Grifoni S, Berni G: Aetiologic diagnosis of ischaemic stroke in the emergency department: relevance for triage and clinical management. Eur J Emerg Med 2000;7:9–14.
17.
Publications Committee for the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators: Low molecular weight heparinoid, ORG 10172 (Danaparoid), and outcome after acute ischemic stroke. JAMA 1998;279:1265–1272.
18.
Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B, Heuschmann PU: Epidemiology of ischemic stroke subtypes according to TOAST criteria. Stroke 2001;32:2735–2740.
19.
Kang DW, Chalela JA, Ezzeddine MA, Warach S: Association of ischemic lesion patterns on early diffusion-weighted imaging with TOAST subtypes. Arch Neurol 2003;60:1730–1734.
20.
Paradowski B, Maciejak A: TOAST classification of subtypes of ischaemic stroke: diagnostic and therapeutic procedures in stroke. Cerebrovasc Dis 2005;20:319–324.
21.
Koran LM: The reliability of clinical methods, data and judgments. N Engl J Med 1975;293:642–646.
22.
Bamford JM: The role of the clinical examination in the subclassification of stroke. Cerebrovasc Dis 2000;10(suppl 4):2–4.
23.
Sempere AP, Duarte J, Cabezas C, Claveria LE: Etiopathogenesis of transient ischemic attacks and minor ischemic strokes: a community-based study in Segovia, Spain. Stroke 1998;29:40–45.
24.
Schulz UG, Flossman E, Francis JM, Redgrave JN, Rothwell PM: Evolution of the diffusion-weighted signal and the apparent diffusion coefficient in the late phase after minor stroke. J Neurol 2007;254:375–383.
25.
Prencipe M, Culasso F, Rasura M, Anzini A, Beccia M, Cao M, Giubilei F, Fieschi C: Long-term prognosis after a minor stroke. Stroke 1998;29:126–132.
26.
Lindgren A, Norrving B, Rudling O, Johansson BB: Comparison of clinical and neuroradiological findings in first-ever stroke: a population-based study. Stroke 1994;25:1371–1377.
27.
Lee LJ, Kidwell CS, Alger J, Starkman S, Saver JL: Impact on stroke subtype diagnosis of early diffusion-weighted magnetic resonance imaging and magnetic resonance angiography. Stroke 2000;31:1081–1089.
28.
Hoffmann M, Chichkova R, Ziyad M, Malek A: Too much lumping in ischemic stroke – a new classification. Med Sci Monit 2004;10:CR285–CR287.
29.
Ay H, Furie KL, Singhal A, Smith WS, Sorensen AG, Koroshetz WJ: An evidence-based causative classification system for acute ischemic stroke. Ann Neurol 2005;58:688–697.
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