<International Circulation>： When it comes to classifying these patients， what are some of the classifications systems you use in your practice and are there any new classification systems that you were particularly interested in?

　　《国际循环网》：:谈到目前给卒中患者分类，您在医疗实践中使用的分类系统是什么？另外，有没有一些新的您特别感兴趣的分类系统呢？
Dr. Koroshetz:To deal with the heterogeneity of stroke， the classification system that became quite popular in 1990s was called TOAST (Trial of Org 10 172 in Acute Stroke Treatment). It was named after a study of a drug. It classifies strokes into: large-artery atherosclerosis， small-vessel disease， cardioembolism， and undetermined or cryptogenic stroke. The groupⅠworked with at Massachusetts General Hospital had planned a study that was to use the TOAST criteria as we had in the past. However， this study required us to sit down with data and come to a consensus about a stroke subtype. We found that we could not arrive at consensus. There were many cases that were difficult to classify. A colleague of ours， Hakan Ay， decided to develop an algorithm that would allow arriving at the same classification. That is the CCS (Causes and Classifications of Stroke) scale and it improved the integrative reliability substantially and brought attention to all the details， ambiguities， data and evidence behind the classification of stroke. Prior to that， it was almost a gestalt. Regularizing the classification helped our study. Hakan went beyond that develop a computer system whereby physicians can input data for the patient workup and that computer itself would generate the classification. That takes some of the subjectively out of the diagnosis.

　　Dr. Koroshetz:为了对多种多样的卒中进行分类，上世纪90年代，TOAST（Trial of Org 10 172 in Acute Stroke Treatment）分类系统在临床应用中较广泛。这个分类系统是以药物研究命名，把卒中分为：大动脉粥样硬化性、小血管疾病性、心源性栓塞性、病因未明或隐源性卒中。我在麻省总医院工作的团队设计了一项研究，应用了TOAST分类标准。但是，这项研究需要我们处理很多数据并达成关于卒中亚型分类的共识。我们很难达成共识，因为有许多难以归类的病例。我的同事Hakan Ay决定开发一种新的能够使各种病例包括在同一分类系统的标准，这就是CCS（Causes and Classifications of Stroke）量表，很大程度上改善了整体信任度，并且注重收纳所有细节，有关卒中模糊的事情，及隐藏在卒中分类后的数据和证据。在此之前的分类系统几乎就是个完形的整体。调整后的分类系统有助于我们的研究。除此之外，Hakan还开发了一种电脑系统，通过这个系统医生可以输入患者详细数据，计算机就会对此数据处理并分类，可以排除卒中诊断中的主观因素。

<International Circulation>：What are some of the main ambiguities that you encountered when you developed this system?

　　《国际循环网》：在开发新的分类系统过程中，你们遇到的不明确的事情都有哪些？
Dr. Koroshetz:The ambiguities fell in a couple of areas. One of which should appear simple. There is some much data in a patient chart， that it was not uncommon for a classifier to latch onto one piece of data and ignore another piece. The TOAST classification system， approximately 40% of the strokes would be called cryptogenic， not because they could not identify a potential risk factor， but because there were multiple factors， with no way of determining which was the most likely cause. Now， there are ways to get around that. For instance， if you suspect a carotid stroke and you have AF， if the stroke you see on the MRI scan is a watershed distribution of the carotid artery， and then it will not be AF， it will be due to the carotid. There are ways to use the imaging pattern of the stroke to push you one way or the other. That is the algorithm would do: take all of the data and classify strokes in much better way in the presence of multiple risk factors. After all， most patients， namely the elderly， will have multiple risk factors.  That is where the system is most valuable.

　　Dr. Koroshetz: 在卒中分类中不明确的事情是方方面面的。其中一个看似简单，患者病历中常有许多数据，这些数据可能在分类系统中符合多种类型。分类者不能仅仅因为患者某个特点符合分类系统中的某类卒中而忽略其他特点。在TOAST分类系统中有40%的卒中归到原因不明卒中类型中。不是因为不能找出潜在危险因素，而是由于有多种影响因素，但是我们还无法确定哪一个是主要危险因素。现在我们有方法来避开这一困境。例如，患者被怀疑患颈动脉型卒中，同时又是房颤（AF）患者，如果核磁扫描显示卒中范围与颈内动脉分水岭样分布一致，那么卒中发生就不是由房颤引起，而是由颈动脉问题导致。对卒中影像学解读可提供多种途径帮助我们在复杂危险因素中找出卒中病因。因此，这就是我们开发新分类方法所要做的事情：收集患者所有信息，在多种致病危险因素中寻求更好的途径对卒中进行分类。毕竟许多患者，尤其是老年患者，将会有多种危险因素。当然，这也是我们新开发的系统最具价值和吸引力的方面。

<International Circulation>： If you are going to be treating patients with aggressive， systematic medical therapy， how relevant is an accurate stroke diagnosis?

　　《国际循环网》：如果你想积极、系统的对患者进行医疗干预，一个准确的卒中诊断有多大相关性呢？
Dr. Koroshetz: It remains to be proven that aggressive medical therapy is an effective therapy. The NIH has funded a number of studies to check if warfarin or aspirin was better. While warfarin was clearly better in cardioembolism， in studies outside of cardioemoblism， it did not show benefit. Warfarin is clearly beneficial in particular subtype. The other one are dual anti-platelet agents. There are a number of industry studies to look at DAP and they have basically failed to show benefit. NIH funded another one on DAP therapy vs. Single AP in small vessel strokes， like the lacunae strokes. These are very common and make up 30%～40% of strokes due to hypertension. The results of these were presented at the ISC. It was shown that the duel anti-platelet agents did not have added benefit. While there was some decrease in stroke， it was matched by an increase in hemorrhage. At the stroke meeting， beside the SPS3 (The Secondary Prevention of Small Subcortical Strokes) study results， which showed no benefit， another study was done in TIA and minor stroke. This study was done in China. The same DAP showed benefit. A similar study is currently ongoing in the US looking at the same population. There， these TIAs and minor strokes benefited from DAP， while small vessel， chronic treatment did not. The big studies， were they did not show benefit， had a mix of patients， but they were chronic patients. Now， it looks like there may be an early window in TIA—which can be small vessel or large artery sclerotic types—may show benefit.

　　Dr. Koroshetz: 积极的医疗干预是有效的疗法仍需证明。国立卫生研究院（NIH）已资助许多项目研究华法林和阿司匹林哪一种药物作用更好。在抗心源性栓塞方面，华法林明显效果好，但除此之外，华法林并没有表现出明显优越性。华法林只是在特定卒中亚型中有效。另一种药物是双抗血小板药（DAP）。有许多公司都在研究DAPs，但基本上没有发现什么效果。NIH资助的另一项目是关于DAP疗法和AP对小血管性卒中的作用，如腔隙性卒中。这些小血管卒中非常常见，占高血压卒中30%～40%。这些研究结果在国际卒中大会（ISC）都有展示。试验结果表明DAP对患者没有额外益处。虽然DAP会减少卒中发生，但同时也增加脑出血风险。在ISC上除SPS3研究（结果证明DAP无效）外，还有一个关于DAP在TIA和微小卒中中作用的研究，这个研究是在中国做的，研究结果认为DAP有效。另一个受试对象与此相似的试验在美国进行研究。研究表明TIA患者和微小卒中患者从DAP治疗中获益，而小血管疾病性卒中和慢性卒中患者没有获益。究其原因可能是SPS3研究入选对象的卒中类型比较复杂，且有较多的慢性卒中患者。这样看来，似乎在TIA（小血管性或大动脉粥样硬化性）早期治疗窗治疗的患者受益。