Editorial Comment— Time to Burn the TOAST

There will be a rediscovery of the worth of the now-almost-abandoned autopsy and clinical pathological conference and the realization that MRI, computed tomography, and ultrasonography cannot substitute for direct postmortem examination of the brain and blood vessels.1 — James F. Toole The observations of many 20th century stroke studies led their authors to question whether there were any significant special risk factors, like hypertension, for little strokes. By assuming the onerous and painstaking task of systematically reviewing all of the pertinent literature, Jackson and Sudlow have accomplished a unique task, the proof of a negative!2 There are no specific etiological diagnostic risk factors for small-vessel occlusion (lacune), the most common variety of stroke in the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) tabulation.3 TOAST was the standard classification system for clinical definition of ischemic strokes. Even BT (before TOAST), the common knowledge of most experienced clinicians was that family history, age, smoking, hypertension, cardiac or systemic atherosclerosis, previous stroke, diabetes, obesity, and cachexia of any cause are pertinent to general health and probably to the incidence of stroke. And they knew that big strokes are worse than little strokes, especially for debilitated older patients. In 1993, the TOAST stroke investigators recognizing “the etiology of ischemic stroke affects prognosis, outcome, and management,” proposed a “classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial.”3 Their premise was “determining the cause of stroke does influence choices for management.” Their Table 1 illustrates the range of their causal conclusions, 5 major categories, segregated with modest hedging. For large-artery atherosclerosis, there is an (embolus/thrombosis) choice, and for cardioembolism, a choice of (high-risk/medium-risk). These, along with small-vessel occlusion (lacune) and stroke of other determined etiology, are adorned with an asterisk whose footnote indicates the …