Stroke: Oxfordshire community stroke project

Classification

TACI – total anterior circulation infarct

Triad of:

• Contralateral hemiparesis (and/or hemisensory loss), affecting face, arm, and leg
• Higher cortical dysfunction, e.g. dysphasia or visuospatial disturbance (neglect)
• Homonymous hemianopia

If the patient is confused or untestable, the latter two signs are typically assumed.

PACI – partial anterior circulation infarct

• Two features of TACI only
• Isolated higher cortical dysfunction (e.g. dysphasia or visuospatial disturbance)
• Limited motor or sensory deficit (e.g. confined to one limb or face/hand)

LACI – lacunar infarct

Four classical subtypes:

1. Pure motor stroke (face, arm, leg) — most common
2. Pure sensory stroke
3. Sensorimotor stroke
4. Ataxic hemiparesis

POCI – posterior circulation infarct

1. Brainstem signs ± isolated homonymous hemianopia:
   • Ipsilateral cranial nerve with contralateral motor/sensory deficit
   • Bilateral motor/sensory signs
   • Conjugate eye movement disorder
   • Coma (especially basilar artery occlusion)
2. Cerebellar signs:
   • Without associated ipsilateral hemiparesis/sensory signs
3. Isolated homonymous hemianopia

Anatomical locations

Subtype	Likely Vascular Territory	Common Aetiology
TACI	Proximal MCA ± ACA or ICA	Embolism from heart or proximal arteries
PACI	Smaller MCA > ACA infarcts	Same as TACI
LACI	Deep perforator vessels (basal ganglia, pons)	Small vessel disease
POCI	Posterior cerebrum, brainstem, cerebellum	Embolism or thrombosis of large/small vessels

Relative prognosis

Subtype	Prognosis
TACI	Poor — high risk of long-term dependency or death
PACI	Intermediate — better than TACI, but recurrence risk is high
LACI	Good — often clinically silent, underdiagnosed, frequent incidental MRI/CT findings
POCI	Highly variable — from mild deficits to death

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References

Publications

• Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet. 1991 Jun 22;337(8756):1521-6
• Mead GE, Lewis SC, Wardlaw JM, Dennis MS, Warlow CP. How well does the Oxfordshire community stroke project classification predict the site and size of the infarct on brain imaging? J Neurol Neurosurg Psychiatry. 2000 May;68(5):558-62.
• Dewey HM, Bernhardt J. Acute stroke patients–early hospital management. Aust Fam Physician. 2007 Nov;36(11):904-12
• de Andrade JBC, Mohr JP, Lima FO, Barros LCM, de Meira GAR, Silva Junior EAB, Robles AC, Silva GS. Predictors of congruency between clinical and radiographic Oxfordshire Community Stroke Project Classification subtypes. J Clin Neurosci. 2023 Sep;115:47-52
• Clinical Guidelines for Acute Stroke Management – National Stroke Foundation
• Brazis PW, Masdeu JC, Biller J. Localization in Clinical Neurology. 8e 2021
• Fuller G. Neurological Examination Made Easy. 6e 2019
• O’Brien M. Aids to the Examination of the Peripheral Nervous System. 6e 2023

FOAMed

• Coni R. Neuro 101: Cerebral Hemispheres. LITFL
• Nickson C. Stroke Thrombolysis. LITFL