Appendix. Appendix TOAST Abstraction Manual. TOAST Medical Record Abstraction Manual

Transcription

1 Appendix Appendix TOAST Abstraction Manual TOAST Medical Record Abstraction Manual Section 1A. History/Emboli All noted historical information must occur prior to index stroke admission. If a diagnosis is found within the discharge summary, it must not have been diagnosed during the index admission. It is often best to consult the admission history and physical for complete past medical history rather than discharge summary. You may wish to circle (or otherwise denote) presence of all applicable conditions. If both high risk and medium risk sources occur, score the section as [1] high risk source for emboli. If multiple medium risk sources are present (but no high risk), the section is scored [2] medium risk source for emboli. If no high or medium risk sources are present, score the question [3] No source for emboli. Mechanical prosthetic heart valve: Record this if explicitly stated in history. May be alternatively described as Starr- Edwards valve (ball and cage device), Medtronic-Hall (single tilting disc valve) or St. Jude Medical model (bi-leaflet valve). Bioprosthetic valves (e.g. porcine) are not considered high risk (see below) so it is important to distinguish between the types of valve replacements when possible. If it is stated that the person has a valve replacement (or prosthetic valve) but this is not further described keep the following in mind: (1) All persons with a mechanical valve of any sort should be anticoagulated before admission (usually with coumadin). However, persons with bioprosthetic valves sometimes require anticoagulation. (2) Persons with mechanical valve may be described as having a clink or metallic heart sound on cardiac physical exam. (3) All mechanical heart valves should be visible on chest x-ray (or echo) and appropriately described. (4) If the type of valve remains ambiguous after the following consideration, consider it a bioprosthetic valve and score it under [2] Medium risk source for emboli. Atrial fibrillation: Score this response if the patient has a documented history of any episode of atrial fibrillation prior to admission. Score even if the patient is being treated with anticoagulation (e.g. coumadin), antiarrhythmics (e.g. digoxin, calcium channel blockers, beta-blockers), has a pacemaker, or has been successfully undergone cardioversion in the past. Do not score other forms of supraventricular tachycardia or conduction abnormalities (e.g. multifocal atrial tachycardia, Wolff-Parkinson-White syndrome) Sick-sinus syndrome: Score this response if patient has history of sick-sinus syndrome, even if being treated with anticoagulation, antiarrhythmics (e.g. digoxin, calcium channel blockers, beta-blockers), or pacemaker. Myocardial Infarction (MI) within 4 weeks: as stated. Dilated cardiomyopathy: as stated per history. Atrial myxoma: as described by studies prior to admission (usually echocardiogram) Infective endocarditis: Score this item if at any time in the patient s history they were diagnosed with infective endocarditis. Score even if adequately treated and even if valve replacement surgery was subsequently performed. Akinetic left ventricular segment: Score if any prior echocardiogram described complete lack of wall motion in any segment of the left ventricle Left ventricular thrombus: Score this item if at any time in the patient s history they were found to have a thrombus in the left ventricle. Score even if the patient has completed their recommended course of anticoagulation or if currently taking anticoagulants. Score even if echocardiogram on current admission fails to find thrombus. MI >4 weeks ago but <6 months ago: as stated. Congestive heart failure: Score if recorded in patient s history at any time. Score regardless of patient s current medication regimen or echocardiographic findings on present admission. Left ventricular aneurysm: as recorded in history. Atrial flutter: Score if this rhythm recorded at any time. Score even if the patient is being treated with anticoagulation (e.g. coumadin), antiarrhythmics (e.g. digoxin, calcium channel blockers, beta-blockers), has a pacemaker, or has been successfully undergone cardioversion in the past. Bioprosthetic heart valve: Score as recorded in patient s history. May be described as porcine graft, xenograft, pericardial valve, Carpentier-Edwards (porcine xenograft), Biocor, or Sorin Pericarbon. If the type of prosthetic valve is not described, see mechanical valve above. Do NOT score if patient has aortic allograft or pulmonary valve homograft (Ross procedure). Mitral stenosis without atrial fibrillation: as recorded in history. Mitral valve prolapse: as recorded in history. Mitral annular calcification: as recorded in history or prior echocardiograms. Atrial septal defect: as recorded in history. Do NOT record if patient has undergone surgical closure of defect. Patent foramen ovale: as recorded in history or prior echocardiograms. Interatrial septal aneurysm: as recorded in history or prior echocardiograms. Nonbacterial endocarditis: as recorded in history. This would include marantic or Libman-Sacks endocarditis. Section 1B. History/Large Vessel Disease All noted historical information must occur prior to index stroke admission. If a diagnosis is found within the discharge summary, it must not have been diagnosed during the index admission. It is often best to consult the admission history and physical for complete past medical history rather than discharge summary. This section refers only to diagnosis made by relevant extracranial studies (e.g. Doppler/duplex, MRA, CT angiogram or conventional angiogram). Data gleaned from physical exam (e.g. bruits) are not relevant. In order for the lesion to be scored, it should be both extracranial and appropriate: carotid lesions should be greater than 50% stenosis and ipsilateral to symptoms vertebral lesions are relevant only in cases of brainstem infarction Data are to primarily obtained directly from radiological reports. If these are not available, then review information from admission notes, progress notes, or discharge summaries. If there is a conflict, use the data from the official radiology report. If percent stenosis is not given, translate keywords as follows: mild 16 49%, moderate 50 69%, severe 70 89%, critical 90 99%, and occluded 100%. Do not score a lesion as present if the lesion was documented only prior to corrective surgery (e.g. carotid endarterectomy). Studies performed at an outside hospital prior to transfer are considered to occur prior to admission and may be recorded in this section.

2 1092 Stroke May 2001 Section 1C. History/Prior Specialized Tests This section records any historical mention of conditions which are not related to large vessel atherosclerosis, cardiogenic embolism, or lipohyalinosis (small vessel disease) and, in view of a negative evaluation for these causes, have been indicated as the likely cause of the patient s stroke. If any of the diagnoses listed below are recorded in the past medical history, you can assume that the appropriate lab test has been conducted and score [1] Prior specialized tests (hematological, CSF, or histology) demonstrating evidence of underlying cause. The response [2] Negative prior specialized tests should be scored if any one or more tests listed below were previously conducted and ALL were found to be negative. If none of the specified diagnoses are carried or no specialized tests were performed, record [3] No prior specialized tests completed. The test/condition should be recorded on the form if present. Below follows a list of conditions known to be associated with stroke and the appropriate methods of diagnosis: Infectious vasculopathy: Neurosyphilis Neurotuberculosis Typhus Schistosomiasis Trichinosis Mycoses Mucormycoses Rickettsioses (e.g. Rocky Mountain Spotted Fever) Neuroborreliosis (Lyme disease) Neurobrucellosis Malaria HIV Herpes encephalitis Inflammatory vasculopathy: Systemic lupus erythematosus Scleroderma Sjogen s syndrome Polyarteritis nodosa Rheumatoid arthritis Takayasu s disease Wegener s granulomatosus Granulomatous angiitis of the CNS Degos-Kohlmeier Disease Churg-Strauss syndrome Behcet s syndrome Hodgkin s lymphoma Neurosarcoidosis Eale s disease Relapsing polychondritis Drug induced vasculitis Vasospasm Drug induced (amphetamine, cocaine, heroin, LSD, PCP, ecstasy) Congenital connective tissue disorders Marfan s syndrome Ehler s-danlos syndrome CSF: pleocytosis, high protein; VDRL>1 16; PCR; serum VDRL, RPR, or FTA-ABS CSF: pleocytosis, high protein, low glucose, AFB; PCR; MRI; PPD, chest x-ray, serology, PCR Microscopic urinalysis, stool for O& P Muscle biopsy, serology Specimen isolated in tissue Specimen isolated in tissue, serology, serology (ELISA) CSF: culture for brucella, IgG agglutination>1/160 Peripheral blood smear demonstrating vasculitis; serology, Western blot, PCR or AIDS defining illness CSF:PCR, brain biopsy, fana test, histology Lip biopsy, anti SSA and SSB antibodies Angiography, histology features, rheumatoid factor, canca Angiography, histology, gastroduodenal endoscopy Eosinophilia, histology, histology (nonspecific lab tests, e.g. ESR, are often abnormal) Urine and serum drug screens (there are specific tests for certain subtypes, such as protein electrophoresis (I,II), urine lysyl hydroxylase (VI), skin biopsy (IV, VIIb, VIIc), histology (skin) Pseudoxanthoma elasticum Fabry s Disease Functional assay for alpha-galactosidase A. Osler Weber Rendu Syndrome

3 Goldstein et al Improving the Reliability of Stroke Subgroup Classification 1093 Other non-inflammatory vasculopathies Fibromuscular dysplasia Moya moya Homocysteinemia Post-irradiation vasculopathy Neoplastic angioendotheliosis Dolichoectasia Amyloid angiopathy Sneddon s syndrome Spontaneous arterial dissection Venous sinus thrombosis Hematologic Severe Anemia Thrombotic thrombocytopenic purpura (TTP) Lupus anticoagulant Anticardiolipin antibody Sickle cell disease Thalassemias Hemoglobin SC disease Polycythemia rubra vera Waldenstrom s macroglobulinemia Cryoglobulinemia Essential thrombocythemia Myeloproliferative disorders Coagulation factor deficiencies: antithrombin III, protein C, protein S, plasminogen, factor VIII (hemophilia), factor XII, C2, prekallikrein, heparin cofactor II) Activated protein C resistance (e.g. Factor V Leiden) Platelet hyperaggregability Disseminated intravascular coagulation Vitamin K therapy Paroxysmal nocturnal hemoglobinuria Paraneoplastic syndrome Oral contraceptive induced hypercoagulability MELAS CADASIL Angiography Angiography Urine and serum homocysteine History, CT/MRI/Angiography/ Angiography, CT, MRI Angiography CT, MRI, angiography Complete blood count, Hemoglobin>7 g/dl features, peripheral blood smear (schistocytes) Functional assay for lupus anticoagulant ELISA for anticardiolipin antibody Hemoglobin electrophoresis Peripheral blood smear Hemoglobin electrophoresis Complete blood count, Hemoglobin>20 g/dl or requiring phlebotomy Serum and urine protein electrophoresis (SPEP and UPEP) SPEP Complete blood count, >600,000 platelets/mm3 Complete blood count, blood smear, bone marrow biopsy Serum factor levels by functional assay PCR for Factor V or functional assay for APC-R Platelet aggregation studies DIC panel, PT Ham test, flow cytometry Neoplasm, laboratory evidence of coagulopathy History/, laboratory evidence of hypercoagulable state, mitochondrial DNA analysis PCR for CADASIL gene

4 1094 Stroke May 2001 Section 2. Physical Exam Only physical exam findings obtained the day of admission are relevant. If there is no exam recorded upon the day of admission, use the exam closest to that date. Note that many discharge summaries are from rehabilitation units and may contain physical exam findings obtained at transfer therefore, it is best as a general rule to use admit day notes. Specific findings Atrial fibrillation: Under the cardiac exam, the phrase irregularly irregular shall be taken to be indicative of atrial fibrillation. This item may be scored if ANY examiner records the phrase irregularly irregular. Terms such as frequent ectopy, and descriptions of murmurs or extra heart sounds are not relevant. Tachycardia need not be present. EKG findings are NOT considered under this section. Evidence of systemic embolization: These would include visible clots on funduscopic exam, splinter hemorrhages, Roth spots, Janeway lesions, Osler s nodes. Classic lacunar syndromes: Note: this section relies heavily on an experienced physician s neurological examination. Therefore, in cases where physical exam findings differ, use the most experienced examiner. Neurologist s exams should be used in preference to that of emergency department physicians or internists wherever possible. The impression or assessment of the examining physician need not be explicitly stated as lacunar infarct but often is. The term small vessel distribution stroke is also frequently used. Lacunar syndromes can immediately be ruled out if any of the following are new findings: Alteration in consciousness (somnolence, coma) Aphasia Visual or visuospatial abnormalities Oculomotor abnormalities Disorders of higher mental function, including calculation, reading, writing recognition, attention, praxis Pure motor (hemiparesis/hemiplegia): New onset weakness of the face, arm and leg. All should be involved on the same side of the body, usually but not always to the same degree. Dysarthria is frequently present. Sensory findings and poor coordination inappropriate for muscle weakness should not be present. Pure Sensory: New onset sensory findings occurring on one side of the body, involving at least two of our three body areas (face, arm, leg). Objective findings of sensory loss are not required sensory symptoms (e.g. numbness) in the above noted distributions qualify. Motor and cerebellar findings should be absent. Mixed sensorimotor: Motor and sensory findings simultaneously located in at least 2 out of 3 body areas (face, arm and leg). Tongue deviation and dysarthria may be present. Ataxic Hemiparesis: Ipsilateral cerebellar ataxia and hemiparesis. Gait ataxia may be present, and the presence or absence of sensory findings on the same side of the body is variable. The face need not be involved, and arm and leg may be weak to varying extents. Dysarthria-Clumsy hand: Severe dysarthria, clumsy ataxic hand (especially on writing); facial weakness; tongue deviation may or may not be present, as may ipsilateral hyper-reflexia and Babinski sign. Section 3. Diagnostic Tests (A) CT Scan The TOAST algorithm is for cerebral infarction only. Any patient whose CT is read by radiology as having any of the following in absence of a clinically appropriate new infarct should be excluded from analysis: primary intracerebral hematoma (hemorrhage), intraparenchymal hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, subdural hematoma, epidural hematoma, or any nonvascular lesion (e.g. neoplasm, intraparenchymal infection (e.g. toxoplasmosis)). Hemorrhagic infarction is not excluded from analysis (note: a hemorrhagic infarction is a hemorrhage originating within and secondary to infarction and has a characteristic radiographic appearance that distinguishes it from primary hemorrhage the distinction should be made on the radiographic report). Inasmuch as CT is relatively insensitive for ischemic infarct in the hyperacute stage (6 hr post ictus), readings from the acute stage (1 7 days post ictus) are preferred record data from scans done this period unless it is clinically evident that the patient has had a second event since admission. Data are primarily obtained from official radiology reports. Only in cases where these are not available should information be used from progress notes or the discharge. If there is conflict between the radiologist s interpretation and that of any other physician, the radiologist s opinion is considered authoritative for data collection purposes. If a patient is a transfer from an outside hospital and has imaging done only at the outside institution, this data may be recorded for this section (even if the scan is negative). If more than one CT scan is performed, use the results from the latest scan performed during the admission unless there was an interval change (i.e., clinically neurological significant change) in the patient s clinical status. If an interval change occurred, use the results from the earlier scan. For this section, only a single response is appropriate. Responses [1] [5] refer to acute infarcts only. Only score responses [8], [9], and [10] if responses [1] [7] are not applicable. Specific findings [1] Acute or subacute bland or hemorrhagic infarction involving cortical and possibly extending into subcortical structures, or infarct>1.5 cm in subcortical structures in the cerebral hemisphere, appropriate for symptoms, or multiple acute or subacute infarctions of same age in same vascular territory: The lesion should be described as a SINGLE bland (ischemic) or hemorrhagic infarct or as multiple recent infarcts (acute/subacute) in the vascular distribution of a single large extracranial artery. That is, multiple anterior circulation lesions should all occur in the same hemisphere, and brainstem lesions should not coexist with hemispheric lesions in the distribution of the ACA or MCA. PCA distribution infarcts may coexist with either anterior or posterior circulation infarcts or may involve both hemispheres. Cortical structures refers to the gray matter on the exterior of the cerebral hemispheres. Subcortical refers to deeper structures, including corona radiata, basal ganglia, internal capsule, thalamus. Progress notes should verify the concordances of any described lesions and the patient s clinical picture. Do not record any lesion here that is not clinically appropriate. [2] Acute or subacute infarct in the distribution of a circumferential artery in the brainstem and/or cerebellum: Typically 1.5 cm (non-lacunar) infarcts in the distribution of any one of the circumferential arteries of the brainstem/ cerebellum. Long circumferential vessels include posterior inferior cerebellar (PICA), anterior inferior cerebellar (AICA), superior cerebellar (SCA), and the proximal portion of the posterior cerebral artery. There are numerous short circumferential vessels that arise from the basilar artery also. Score this only if a SINGLE new lesion is present. [3] Multiple acute or subacute infarctions of same age in different vascular territories: Score this response if there are multiple non-lacunar acute or subacute infarcts of the same age occurring in the distribution of more than one large extracranial artery (carotid or vertebral artery). This would include any anterior circulation (ACA, MCA) infarct coexisting with a brainstem or contralateral hemisphere infarct. [4] Hyper-dense artery sign: Score this response if a hyperdense artery sign is specifically described in the radiology report in the presumed distribution of the infarct. Do not score

5 Goldstein et al Improving the Reliability of Stroke Subgroup Classification 1095 if items [1], [2], [3], or [5] are applicable score them instead. [5] <1.5 cm in diameter infarct in a subcortical structure or brainstem in the territory of a small penetrating artery: Infarct should be smaller than 1.5 cm (or described as small or lacunar ). Typical subcortical locations include corona radiata, internal capsule, external capsule, basal ganglia, thalamus. Lesions may also be located in the pons or medulla. You may score this response if ANY one of multiple new lacunar infarcts is appropriate for symptoms. You may also score this response if there is a clinically appropriate lesion of undetermined age. Do not score if the patient is described as having Binswanger s disease (encephalopathy) unless there is a discrete new lesion appropriate for symptoms. [6] Normal: Score this response if the scan is read as normal or age appropriate atrophy or if the radiology report is unavailable and progress notes or discharge summary records indicate as normal, unremarkable, without change, et cetera. [7] Not Done: Score if no CT was performed, if no data regarding the CT can be found, or if the scan was non-diagnostic (e.g. poor quality or uninterpretable). [8] Old stroke, same vascular territory: Score this response only if: [1] [7] are not applicable and the scan shows an old infarct in the same vascular distribution as the new lesion. If the location of the present lesion is unclear and the CT shows only an old infarct, score [9]. If there are multiple old strokes in more than one vascular territory (e.g. bilateral infarcts) then score [9]. [9] Old stroke, different vascular territory: Score this response only if: [1] [7] are not applicable and the scan shows an old infarct in a different vascular distribution as the new lesion OR if the location of the present lesion is unclear and the CT shows only an old infarct OR if there are multiple old strokes in more than one vascular territory. [10] Old, nonspecific small vessel disease: Score this response only if: [1] [9] are not applicable and the scan shows patchy, white matter periventricular disease. Lacunar infarct(s) may be present. Score this also if the terms Binswanger s disease (encephalopathy) or leukoencephalopathy are used. (B) MRI The TOAST algorithm is for cerebral infarction only. Any patient whose MRI is read as having hemorrhage or nonvascular lesions (see CT section for examples) in the absence of an infarct that accounts for new clinical findings should be excluded. MRI findings for ischemic infarct in the hyper-acute stage (24 hr) can be subtle therefore if multiple scans are done, use readings from the acute stage (1 7 days post ictus) unless it is clinically evident that the patient has had a second event since admission. In such a case, use the latest MRI scan occurring before the event. If a patient is a transfer from an outside hospital and has imaging done only at the outside institution, this data may be recorded for this section (even if the scan is negative). Data are primarily obtained from official radiology reports. Only in cases where these are not available should information found in progress notes or the discharge summary be used. If there is conflict between the radiologist s interpretation and that of any other physician, the radiologist s opinion is considered authoritative for data collection purposes. If more than one MRI scan is performed, use the results from the latest scan performed during the admission unless there was an interval change (i.e., clinically neurologically significant change) in the patient s clinical status. If an interval change occurred, use the results from the earlier scan. For this section, only a single response is appropriate. Responses [1] [5] refer to acute infarcts only. Only score responses [8], [9], and [10] if responses [1] [7] are not applicable. Specific findings [1] Acute or subacute bland or hemorrhagic infarction involving cortical structures and possibly extending into subcortical structures, or infarct>1.5 cm in subcortical structures in the cerebral hemisphere, appropriate for symptoms, or multiple acute or subacute infarctions of same age in same vascular territory: The lesion should be described as a SINGLE bland (ischemic) or hemorrhagic infarct or as multiple recent infarcts (acute/subacute) in the vascular distribution of a single large extracranial artery. That is, multiple anterior circulation lesions should all occur in the same hemisphere, and brainstem lesions should not coexist with hemispheric lesions in the distribution of the ACA or MCA. PCA distribution infarcts may coexist with either anterior or posterior circulation infarcts or may involve both hemispheres. Cortical structures refers to the gray matter on the exterior of the cerebral hemispheres. Subcortical refers to deeper structures, including corona radiata, basal ganglia, internal capsule, thalamus. Progress notes should verify the concordances of any described lesions and the patient s clinical picture. Do not record any lesion here that is not clinically appropriate. [2] Acute or subacute infarct in the distribution of a circumferential artery in the brainstem and/or cerebellum: Typically 1.5 cm (non-lacunar) infarcts in the distribution of any one of the circumferential arteries of the brainstem/ cerebellum. Long circumferential vessels include posterior inferior cerebellar (PICA), anterior inferior cerebellar (AICA), superior cerebellar (SCA), and the proximal portion of the posterior cerebral artery. There are numerous short circumferential vessels that arise from the basilar artery also. Score this only if a SINGLE new lesion is present. [3] Multiple acute or subacute infarctions of same age in different vascular territories: Score this response if there are multiple non-lacunar acute or subacute infarcts of the same age occurring in the distribution of more than one large extracranial artery (carotids or vertebral arteries). This would include any anterior circulation (ACA, MCA) infarct coexisting with a brainstem or contralateral hemisphere infarct. [4] Absence of a flow void in major extracranial artery: Score this response if the radiology report records an absence flow void in a clinically appropriate major extracranial vessel (extracranial carotid or vertebral arteries). Do not score if items [1], [2], [3], or [5] are applicable score them instead. [5] <1.5 cm in diameter infarct in a subcortical structure or brainstem in the territory of a small penetrating artery: Infarct should be smaller than 1.5 cm (or described as small or lacunar ). Typical subcortical locations include corona radiata, internal capsule, external capsule, basal ganglia, thalamus. Lesions may also be located in the pons or medulla. You may score this response if ANY one of multiple new lacunar infarcts is appropriate for symptoms. You may also score this response if there is a clinically appropriate lesion of undetermined age. Do not score if the patient is described as having Binswanger s disease (encephalopathy) unless there is a discrete new lesion appropriate for symptoms. [6] Normal: Score this response if the scan is read as normal, or age appropriate atrophy or if the radiology report is unavailable and progress notes or discharge summary records as normal, unremarkable, without change, et cetera. [7] Not Done: Score if no MRI was performed, if no data regarding the MRI can be found, or if the scan was non-diagnostic (e.g. poor quality or un-interpretable). [8] Old stroke, same vascular territory: Score this response only if: [1] [7] are not applicable and the scan shows an old infarct in the same vascular distribution as the new lesion. If the location of the present lesion is unclear and the MRI shows only an old infarct, score [9]. If there are multiple old strokes in more than one vascular territory (e.g.

6 1096 Stroke May 2001 bilateral infarcts) then score [9]. [9] Old stroke, different vascular territory: Score this response only if: [1] [7] are not applicable and the scan shows an old infarct in a different vascular distribution as the new lesion OR if the location of the present lesion is unclear and the MRI shows only an old infarct OR if there are multiple old strokes in more than one vascular territory. [10] Old, nonspecific small vessel disease: Score this response only if: [1] [9] are not applicable and the scan shows patchy, white matter periventricular disease. Lacunar infarct(s) may be present. Score this also if the terms Binswanger s disease (encephalopathy) or leukoencephalopathy are used. (C) Non-invasive vascular studies Official radiology reports should be considered the primary source for data collection if the final report is not available, the preliminary report may be used. Only in cases where these are not available should information found in progress notes or the discharge summary be used. If there is conflict between the radiologist s interpretation and that of any other physician, the radiologist s opinion is considered authoritative for data collection purposes. Check the appropriate box describing the study performed. If both studies were performed and data is available, check [] MRA and evaluate MRA results only. If both studies were done but interpretable data is available for only one, check that box and evaluate the study below. If neither study was performed or data are unavailable, check [3] Not Done. Specific responses [1] Greater than or equal to 50% stenosis of an appropriate large extracranial artery: Stenosis should be greater or equal to 50% or described as mild-moderate, moderate, severe or critical. The lesion should be in the extracranial carotid artery ipsilateral to the lesion (for hemispheric lesions) or in either vertebral artery for posterior circulation lesions. Do not score lesions in the MCA artery, carotid siphon, basilar artery, or circle of Willis. [2] Less than 50% stenosis of an appropriate large extracranial artery: Stenosis should be less than 50% or described as absent, mild, or not hemodynamically significant. If there is a percentage estimate of stenosis record data according to this rather than key words/descriptors. Data should be collected on the appropriate artery only (ipsilateral carotid artery for hemispheric disease, vertebral arteries for posterior circulation disease). [3] Not Done: Score this response if there is no interpretable data from either study (either not done or poor quality). (D) Cerebral arteriogram Official radiology reports should be considered the primary source for data collection if the final report is not available, the preliminary report may be used. Only in cases where these are not available should information found in progress notes or the discharge summary be used. If there is conflict between the radiologist s interpretation and that of any other physician, the radiologist s opinion is considered authoritative for data collection purposes. A single response is expected for this question. If response [4] is appropriate, score this instead of any other finding that may be present. Specific responses [1] Occlusion, greater than or equal to 50% stenosis or greater than or equal to 2 mm ulceration of an appropriate large extracranial or intracranial artery: Stenosis should be greater or equal to 50% or described as mild-moderate, moderate, severe, critical or completely occluded. Alternatively, an ulcerated plaque greater than or equal to 2 mm can be present. For hemispheric lesions, the ipsilateral common carotid, internal carotid, middle cerebral, anterior cerebral, circle of Willis, or posterior cerebral may be scored. For brainstem lesions, consider lesions in the vertebral arteries, basilar artery, or any long circumferential artery (PICA, AICA, SCA). Do not consider lesions in smaller arteries or lesions in the aortic arch or subclavian arteries. [2] Less than 50% stenosis or less than 2 mm ulceration of an appropriate large extracranial or intracranial artery, with no occlusion of appropriate stem, division, or branch artery: Stenosis in all appropriate arteries should be less than 50% or described as absent, mild, or not hemodynamically significant. If there is a percentage estimate of stenosis record data according to this rather than key words/descriptors. [3] Less than 50% stenosis or less than 2 mm ulceration of an appropriate large extracranial or intracranial artery, with occlusion of appropriate stem, division, or branch artery: Stenosis in the appropriate arteries should be less than 50% or described as absent, mild, or not hemodynamically significant. There should be reported occlusion of a stem, division, or branch artery (any artery derived from the larger ones mentioned in [1]). [4] Specific, non-atherosclerotic, intra- or extra-cranial vascular pathology: Score this if findings are present indicating a specific form of vascular pathology not related to atherosclerosis (such as is mentioned in section 1C). The lesions do not necessarily have to be in the distribution of the infarct. Do not score this section to indicate small vessel disease or non-significant atherosclerotic disease. [5] Normal: Score this if no pathology is found on the arteriogram. [6] Not done: Score this if the study was not performed, if data is not available, or if the study was uninterpretable. (E) Cardiovascular Evaluation This section is scored by compiling data from individual cardiovascular system tests, specifically (a) echocardiogram, (b) EKG, and (c) Holter monitor/telemetry. [1] High-risk source for emboli: should be scored if ANY of the three cardiovascular subsections has a [1] high risk source for emboli. [2] Medium risk source for emboli: should be scored if ANY section has a [2] medium risk source for emboli and NO section has a [1] high risk source for emboli. [3] No high or medium risk source for emboli: should be scored if [3] (Nonspecific abnormalities or) Normal is scored for the echocardiogram section and the EKG section and the Holter monitor is either [3] Normal or [4] Not done. This section should also be scored if the echocardiogram is normal, Holter monitor is normal, and EKG is normal or not done. [4] Incomplete evaluation or evaluation not done: Score if echocardiogram is [4] Not done and EKG and Holter monitor are either [3] normal or [4] not done. Specific cardiovascular tests Echocardiogram Mark the appropriate box describing the test done. If both transesophageal (TEE) and transthoracic echocardiograms (TTE) are performed, mark [] TEE and evaluate data ONLY from the TEE. If it is not specified which type of study was performed, mark [] TTE. If no echocardiogram was performed (or the study was completely uninterpretable) mark [4] Not done. Use data from the official report when present. If it is not present, use data from progress notes or discharge summary. You may wish to circle arrows (or otherwise denote) presence of all applicable conditions. However, if both high risk and medium risk sources occur, score the section as [1] high risk source for emboli. If multiple medium risk sources are present (but no high risk), the section is scored [2] medium risk source for emboli. If no high or medium risk sources are present, score the section as [3] Normal.

7 Goldstein et al Improving the Reliability of Stroke Subgroup Classification 1097 Left ventricular thrombus: Circle this response if notation of a thrombus (or thrombi) anywhere within the left ventricle is described (e.g. mural, apical), regardless of whether the patient is or was taking anticoagulants. Dilated Cardiomyopathy: As stated per report, or if there is the combination of impaired systolic function (EF 45%), dilation of one or both ventricles, and symptoms of congestive heart failure. Akinetic left ventricular segment: As stated per report. Do NOT consider hypokinetic or dyskinetic segments to be akinetic. Left atrial thrombus: Circle this response if notation of a thrombus (or thrombi) anywhere within the left atrium is described regardless of whether the patient is or was taking anticoagulants. Atrial myxoma: As stated per report. Infective endocarditis: As stated per report, or if valvular vegetations occur in the setting of febrile illness. Congestive heart failure (CHF): As stated, or impaired systolic function (EF 45%) accompanied by classic physical findings (pedal edema, pulmonary edema, orthopnea, paroxysmal nocturnal dyspnea, hepatolmegaly, S3, S4) WITHOUT dilation of ventricles. If the ventricles are dilated, circle Dilated cardiomyopathy, and score the section as [1] High risk source for emboli even if discharge diagnosis is congestive heart failure. Left ventricular aneurysm: As stated, or if any wall of the left ventricle is stated to be dyskinetic. Aortic stenosis without atrial fibrillation: As stated. Do NOT score aortic sclerosis or calcific aortic sclerosis. Mitral valve prolapse: Score only if specifically diagnosed by echocardiogram. Mitral regurgitation need not be present. Mitral annular calcification: As stated. Atrial septal defect: As stated, or if any of the following terms are used: ostium primum defect, foramen primum defect, ostium secundum defect, or foramen primum defect. Do not circle for patent foramen ovale or atrioventricular canal. If there is an inter-atrial shunt as described by bubble study and no lesion is specified, you may score this response. Patent foramen ovale: As stated, regardless or presence, direction, or magnitude of inter-atrial shunt. Interatrial septal aneurysm: As stated. Nonbacterial endocarditis: As stated, regardless of location or size of vegetations. The terms marantic endocarditis or Libman-Sacks endocarditis may also be used and should be scored. Electrocardiogram (EKG)/Long rhythm strip Obtain information from original EKGs whenever possible. If more than one EKG is present in the chart, all should be evaluated and findings that occur on ANY EKG should be recorded. If no original EKG s are available, then interpretation found in the admission notes, progress notes or discharge summary may be used. If ANY EKG demonstrates a high-risk source for emboli, score the section [1] High risk source for emboli. If ANY EKG shows a medium risk source for emboli and NO EKG shows a high-risk source, the item should be scored [2] Medium risk source for emboli. If no high or medium risk sources for emboli are found on ANY EKG, then score [3] Nonspecific abnormalities or normal. If no EKG or report of EKG findings is found (or if all present studies are uninterpretable), then score the item [4] Not done. Atrial fibrillation demonstrated at any time during the hospitalization: As stated per interpretation, or all of the following: Absence of discrete P waves, fibrillating baseline, irregularly irregular narrow QRS complexes. Ventricular rate may be fast or slow. Score regardless of patient s current or past medication regimen. Acute myocardial infarction: As stated per report, or: an evolving pattern of EKG findings, culminating with the appearance of new Q waves in the appropriate leads. First T wave peaking occurs, then T wave inversion, then ST elevation, and finally new Q waves. New Q waves are diagnostic of infarction the other findings are merely suggestive and should not be scored without clinical correlation. Do NOT score infarct of indeterminate age. Atrial flutter demonstrated at any time during the hospitalization: As stated per interpretation, or all of the following: P wave at bpm, baseline with sawtooth pattern (flutter waves), regularly occurring QRS complexes in a given ratio with P waves. Holter monitor/telemetry Findings from either a Holter monitor or telemetry are appropriate for this section. If multiple tests were performed, then all should be evaluated and the highest risk source of emboli should be recorded. Obtain information from original tracings (or Holter monitor report) whenever possible. For telemetry, all tracings should be evaluated and findings that occur on tracing should be recorded. If no original tracings are available, then interpretation found in the progress notes or discharge summary may be used. If ANY tracing (or the Holter monitor report) demonstrates a high-risk source for emboli, score the section [1] High risk source for emboli. If ANY tracing shows a medium risk source for emboli and NO tracing shows a high risk source, the item should be scored [2] Medium risk source for emboli. If no high or medium risk sources for emboli are found on ANY tracing, then score [3] Nonspecific abnormalities or normal. If no tracing (or Holter monitor report) or report of tracing (or monitor) findings is found (or if all present studies are uninterpretable), then score the item [4] Not Done. Atrial fibrillation demonstrated at any time during hospitalization: As stated per interpretation, or all of the following: Absence of discrete P waves, fibrillating baseline, irregularly irregular narrow QRS complexes. Ventricular rate may be fast or slow. Score regardless of patient s current or past medication regimen. Sick sinus syndrome: As stated per report, or: the term tachy-brady syndrome is used, or if there are alternating bouts of supraventricular tachycardia (e.g. atrial flutter) and bradycardia. You should score this if it is present regardless of medication regimen or pacemaker placement. Atrial flutter demonstrated at any time during hospitalization: As stated per interpretation, or all of the following: P wave at bpm, baseline with sawtooth pattern (flutter waves), regularly occurring QRS complexes in a fixed ratio with P waves. (F) Specialized tests (hematological, CSF, or histology) This section records data derived from any specific tests performed to evaluate for presence of diseases which increase the likelihood of stroke by means of a mechanism which is not related to large vessel atherosclerosis, cardiogenic embolism, or lipohyalinosis. A comprehensive list of such diagnoses and the appropriate tests or diagnostic criteria are listed in section 1C (History, prior specialized tests). If any of the tests mentioned in section 1C were performed and found to demonstrate evidence of the accepted other etiologies of cerebral infarct, score: [1] Complete set of studies demonstrating evidence of underlying cause if one or more of the bold faced tests was performed and found to be positive or [2] Incomplete set of studies demonstrating evidence of underlying cause if only non-bold faced tests were performed and found to be positive or [3] Normal if non-bold tests were positive but any boldfaced test was negative. The response [3] Normal should be scored if any one or more tests listed was conducted for the purposes of evaluating for other etiologies and ALL were found to be negative. If no specialized tests were performed, record [4] Incomplete or not done.

8 1098 Stroke May 2001 Section 4. Postmortem Examination Any postmortem examination is valid for evaluation, regardless of the recorded cause of death or time discrepancy between infarct and postmortem examination. The only exception would be any person who has had a second event (of any nature, including surgical) involving the brain tissue or vasculature which was implicated in the index infarct. Pathological findings should only be recorded as they are relevant to tissue and vasculature involved in the index infarct. If no infarct was detected by imaging, the infarct found during autopsy should correspond to the clinical findings. [1] Bland or hemorrhagic infarct, an atheromatous lesion (possibly with adherent thrombus) of an appropriate, large extracranial artery or possibly occlusion of superficial or cortical arteries: A bland or hemorrhagic infarct, involving cortical or subcortical structures, appropriate for clinical presentation and corresponding to radiographic findings (if present) should be described. Furthermore, significant atherosclerosis (greater than or equal to 50% stenosis) should be present in the appropriate large arteries supplying the territory of the infarct. There may or may not be atherosclerotic disease in the branch, stem, or division arteries supplying the territory of the infarct. Do not consider atherosclerosis in cerebral vessels not involved with the infarct or in any other systemic vessels. [2] Bland or hemorrhagic infarct(s), arterial occlusion by an embolus and underlying heart disease: Bland or hemorrhagic infarct(s) as mentioned above, with embolic arterial occlusion in a vessel supplying at least one of the lesions identified clinically or radiographically during the index admission. Do not consider any other embolic events. Underlying heart disease must also be present. The pathology report may describe any of the following: left ventricular thrombus, myocardial infarction less than 4 weeks old, dilated ventricles, atrial thrombus, atrial myxoma, infective endocarditis, aortic stenosis (not aortic sclerosis or bicuspid aortic valve), mitral stenosis, mitral annular calcification, myxomatous degeneration of the mitral valve, atrial septal defect (ostium primum or ostium secundum), patent foramen ovale (including probe patent ), nonbacterial endocarditis (marantic, Libman-Sacks), mechanical or bioprosthetic heart valve (not homograft). [3] Small deep infarct in the territory of a penetrating artery: Infarct less than 1.5 cm in diameter in a deep structure (corona radiata, internal capsule, external capsule, basal ganglia, thalamus, pons, or medulla). Score even if an embolus is present within the small artery supplying the region of infarct. Do not score if there is evidence of arterial occlusion of other etiology (e.g. vasculitis, hematological abnormality, etc). [4] Bland or hemorrhagic infarct, without significant atherosclerosis, normal cardiac pathology, and arterial occlusion of specific etiology: Infarct of ANY size or location corresponding clinically and radiologically to the infarct described in the index admission accompanied by: (1) lack of significant atherosclerosis involving vessels supplying the infarct, (2) lack of embolic occlusion of the relevant vessel(s), (3) lack of cardiac pathology suggestive of embolism (see [2]), and (4) evidence of a specific disease state predisposing to cerebral infarction. Specific disease states, which meet criterion (4), are listed in section 1C History/ Prior Specialized Tests. [5] Infarction but no specific vascular pathology: Score this response if the pathology report documents: (1) lack of significant atherosclerosis involving vessels supplying the infarct, (2) lack of embolic occlusion of the relevant vessel(s), (3) lack of cardiac pathology suggestive of embolism (see [2]), and (4) no evidence of a specific disease state predisposing to cerebral infarction. Subclinical atherosclerosis would fall into this category. [6] Not done: Score this response if (1) no postmortem examination was performed, (2) an incomplete postmortem examination was performed (e.g., no brain or heart pathological examination), or (3) data from the autopsy is unavailable.