The Causative Classification of Stroke system An international reliability and optimization study

Int Stroke Genetics Consortium, E. M. Arsava, E. Ballabio, T. Benner, J. W. Cole, M. P. Delgado-Martinez, M. Dichgans, F. Fazekas, K. L. Furie, K. Illoh, K. Jood, S. Kittner, A. G. Lindgren, J. J. Majersik, M. J. Macleod, W. J. Meurer, J. Montaner, A. A. Olugbodi, A. Pasdar, P. RedforsR. Schmidt, P. Sharma, A. B. Singhal, A. G. Sorensen, C. Sudlow, V. Thijs, B. B. Worrall, J. Rosand, H. Ay

Research output: Contribution to journalArticlepeer-review


Background: Valid and reliable ischemic stroke subtype determination is crucial for well-powered multicenter studies. The Causative Classification of Stroke System (CCS, available at is a computerized, evidence-based algorithm that provides both causative and phenotypic stroke subtypes in a rule-based manner. We determined whether CCS demonstrates high interrater reliability in order to be useful for international multicenter studies.

Methods: Twenty members of the International Stroke Genetics Consortium from 13 centers in 8 countries, who were not involved in the design and development of the CCS, independently assessed the same 50 consecutive patients with acute ischemic stroke through reviews of abstracted case summaries. Agreement among ratings was measured by kappa statistic.

Results: The kappa value for causative classification was 0.80 (95% confidence interval [ CI] 0.78-0.81) for the 5-subtype, 0.79 (95% CI 0.77-0.80) for the 8-subtype, and 0.70 (95% CI 0.69-0.71) for the 16-subtype CCS. Correction of a software-related factor that generated ambiguity improved agreement: kappa = 0.81 (95% CI 0.79-0.82) for the 5-subtype, 0.79 (95% CI 0.77-0.80) for the 8-subtype, and 0.79 (95% CI 0.78-0.80) for the 16-subtype CCS. The kappa value for phenotypic classification was 0.79 (95% CI 0.77-0.82) for supra-aortic large artery atherosclerosis, 0.95 (95% CI 0.93-0.98) for cardioembolism, 0.88 (95% CI 0.85-0.91) for small artery occlusion, and 0.79 (0.76-0.82) for other uncommon causes.

Conclusions: CCS allows classification of stroke subtypes by multiple investigators with high reliability, supporting its potential for improving stroke classification in multicenter studies and ensuring accurate means of communication among different researchers, institutions, and eras. Neurology (R) 2010;75:1277-1284

Original languageEnglish
Pages (from-to)1277-1284
Number of pages8
Issue number14
Publication statusPublished - 5 Oct 2010

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