How TOAST was Created-Classifying Strokes | News | Loyola Medicine
Tuesday, April 7, 2015

How a simple system for classifying strokes, called TOAST, was created

MAYWOOD, IL – In 1993, neurologists Harold P. Adams Jr., MD, and Jose Biller, MD, and colleagues proposed a new way to classify strokes.

It became known as the TOAST classification.

Twenty-two years later, TOAST remains an effective and easy-to-use system that is routinely employed in stroke studies around the world, Drs. Adams and Biller write in an article in the journal Stroke, published online ahead of print.

Dr. Adams is a professor of neurology and director of Cerebrovascular Disease at the University of Iowa Carver College of Medicine. Dr. Biller is chair of the Department of Neurology of Loyola University Chicago Stritch School of Medicine.

The original article that Drs. Adams, Biller and colleagues wrote describing the TOAST classification has been cited more than 4,600 times, making it one of the most cited articles ever published in Stroke. Stroke is published by the American Heart Association/American Stroke Association, the leading medical journal on stroke care.

TOAST is used to classify ischemic strokes, which are caused by blood clots and account for about 85 percent of all strokes. A wide range of diseases can cause blood clots in the brain. Establishing the most likely cause influences both short-term and long-term prognoses. It also affects treatment decisions, especially treatments to prevent recurrent strokes.

In the late 1980s, Drs. Adams and Biller were colleagues at the University of Iowa. They needed to classify strokes for their multi-center clinical trial of a promising clot-busting drug known as Org 10172. The name of the trial, which also became the name of the stroke classification system, was TOAST (Trial of Org 10172 in Acute Stroke Treatment).

Drs. Adams and Biller aggregated groups of ischemic stroke patients into five broad categories representing the most common causes of ischemic stroke: atherosclerosis (hardening) of a large artery; blockage of a small artery; cardioembolism (blood clot that develops in the heart and travels to the brain); other demonstrated causes; and undetermined causes. These broad categories have subcategories.

The system is most useful for real-world stroke research, but it may not be as helpful when determining treatment for an individual patient, Drs. Adams and Biller write. Also, TOAST is not intended for classifying pediatric strokes, and it may not work well in emergency settings because vascular and cardiac imaging studies may not be readily available.

Despite its limitations and age, TOAST “remains a useful tool for clinicians and researchers,” Drs. Adams and Biller write. “It should not be considered as a static instrument. The system has been and can continue to be modified as advances in the diagnosis of the causes of stroke continue.”

The article is titled “Classification of Subtypes of Ischemic Stroke: History of the Trial of Org 10172 in Acute Stroke Treatment Classification.”

About Loyola Medicine and Trinity Health

Loyola Medicine, a member of Trinity Health, is a quaternary care system based in the western suburbs of Chicago that includes Loyola University Medical Center (LUMC), Gottlieb Memorial Hospital, MacNeal Hospital and convenient locations offering primary and specialty care services from 1,877 physicians throughout Cook, Will and DuPage counties. LUMC is a 547-licensed-bed hospital in Maywood that includes the William G. and Mary A. Ryan Center for Heart & Vascular Medicine, the Cardinal Bernardin Cancer Center, a Level 1 trauma center, Illinois's largest burn center, a certified comprehensive stroke center and a children’s hospital. Having delivered compassionate care for over 50 years, Loyola also trains the next generation of caregivers through its teaching affiliation with Loyola University Chicago’s Stritch School of Medicine and Marcella Niehoff School of Nursing. Gottlieb is a 247-licensed-bed community hospital in Melrose Park with 150 physician offices, an adult day care program, the Gottlieb Center for Fitness, the Loyola Center for Metabolic Surgery and Bariatric Care and the Loyola Cancer Care & Research at the Marjorie G. Weinberg Cancer Center at Melrose Park. MacNeal Hospital is a 374-bed teaching hospital in Berwyn with advanced inpatient and outpatient medical, surgical and psychiatric services, advanced diagnostics and treatments. MacNeal has a 12-bed acute rehabilitation unit, a 25-bed inpatient skilled nursing facility, and a 68-bed behavioral health program and community clinics. MacNeal has provided quality, patient-centered care to the near west suburbs since 1919.

Trinity Health is one of the largest multi-institutional Catholic healthcare systems in the nation, serving diverse communities that include more than 30 million people across 22 states. Trinity Health includes 92 hospitals, as well as 109 continuing care locations that include PACE programs, senior living facilities and home care and hospice services. Its continuing care programs provide nearly 2.5 million visits annually. Based in Livonia, Mich., and with annual operating revenues of $18.3 billion and assets of $26.2 billion, the organization returns $1.1 billion to its communities annually in the form of charity care and other community benefit programs. Trinity employs about 129,000 colleagues, including 7,800 employed physicians and clinicians. Committed to those who are poor and underserved in its communities, Trinity is known for its focus on the country's aging population. As a single, unified ministry, the organization is the innovator of Senior Emergency Departments, the largest not-for-profit provider of home health care services—ranked by number of visits—in the nation, as well as the nation’s leading provider of PACE (Program of All Inclusive Care for the Elderly) based on the number of available programs.