Overview of stroke

Last updated: July 4, 2022

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A stroke is an acute neurologic condition resulting from a disruption in cerebral perfusion, either due to ischemia (ischemic strokes) or hemorrhage (hemorrhagic strokes). Hemorrhagic strokes are further classified as intracerebral or subarachnoid. Systemic hypertension and other cardiovascular diseases are common risk factors for both ischemic and hemorrhagic strokes. Clinically, strokes are characterized by the acute onset of focal neurologic deficits, including hemiparesis, paresthesias, and hemianopsia. The pattern of clinical features is dictated by the affected vessel. Distinguishing between ischemic and hemorrhagic strokes based on physical examination is difficult and requires initial evaluation with a noncontrast head CT. Further neurovascular imaging may be required before deciding on treatment options. In ischemic strokes, immediate revascularization of the affected vessel is vital to preserve brain tissue and prevent further damage. Hemorrhagic strokes are treated with supportive measures and neurosurgical evacuation of blood. Long-term management of all types of stroke focuses on the management of modifiable risk factors (i.e., hypertension and atherosclerosis).

For more information, see respective articles “Ischemic stroke,” “Intracerebral hemorrhage,” and “Subarachnoid hemorrhage.”

The following table focuses on nontraumatic cerebral ischemia and intracranial hemorrhage. See “Overview of traumatic intracranial hemorrhage” for traumatic causes.

Overview
Ischemic stroke Intracerebral hemorrhage Subarachnoid hemorrhage
Epidemiology
Etiology
Risk factors
Clinical features
Diagnosis
  • Noncontrast head CT to rule out hemorrhage
  • MRI
  • CTA/MRA
  • Noncontrast head CT
  • MRI
  • CTA/MRA
Findings on noncontrast head CT
Treatment
Pathology

For both ischemic and hemorrhagic strokes, age is the most important nonmodifiable risk factor and arterial hypertension is the most important modifiable risk factor!

Epidemiological data refers to the US, unless otherwise specified.

References:[4]

Clinical features of stroke by affected vessel
Affected vessel Clinical features [5][6]

Middle cerebral artery (MCA) (most commonly affected vessel)

  • Contralateral weakness and sensory loss more marked in the upper limbs and lower half of the face than in lower limbs
  • Gaze deviates toward the side of infarction
  • Contralateral homonymous hemianopia without macular sparing or superior/inferior quadrantanopia [6][7]
  • Aphasia if in dominant hemisphere (usually left MCA territory)
  • Hemineglect if in nondominant hemisphere (usually right MCA territory)
    • Unawareness of and unresponsiveness to unilateral stimuli due to a brain unilateral injury, most commonly strokes (not due to a primary motor or sensory lesion)
    • Typically associated with right hemisphere damage resulting in neglect (esp. visual) of the left side [8]
    • The lesion is usually contralateral to the stimuli
      • Motor neglect
      • Sensory or perceptual neglect
Anterior cerebral artery (ACA)
Posterior cerebral artery (PCA)
Posterior inferior cerebellar artery
Anterior inferior cerebellar artery
Lenticulostriate arteries (penetrating arteries
Basilar artery
Extracranial arteries Internal carotid artery
Common carotid artery
Vertebral artery
Anterior spinal artery

References:[11][14][15]

Lacunar syndromes [6][16]

Lacunar stroke type Location Clinical features
Pure motor stroke
Pure sensory stroke
Sensorimotor stroke
Ataxic hemiparesis
  • Ipsilateral weakness with impaired coordination (e.g., ataxia, gait instability) [17][18]
Dysarthria-clumsy hand syndrome
Hemiballismus
  • Contralateral, involuntary, large flinging movements of the arm or leg

Infarction of the posterior limb of the internal capsule is the most common type of lacunar stroke and may manifest clinically with pure motor stroke, pure sensory stroke (rare), sensorimotor stroke, dysarthria-clumsy hand syndrome, and/or ataxic hemiparesis.

Brainstem syndromes [6][19]

General considerations

Midbrain syndromes [20][21][22]

Pontine syndromes

Syndrome Affected vessel Affected structures Resulting symptom

Ventral pontine syndrome (Millard-Gubler syndrome)

Lateral pontine syndrome (Marie-Foix syndrome)
Inferior medial pontine syndrome (Foville syndrome)
Locked-in syndrome

Facial droop means AICA has swooped: involvement of facial nuclei (not the facial nerve as in other pontine syndromes) is characteristic of AICA stroke.

Medullary syndromes

Syndrome Affected vessel Affected structures Resulting symptom
Medial medullary syndrome (Dejerine syndrome) Paramedian branches of the anterior spinal artery and/or vertebral arteries Nucleus and fibers of the hypoglossal nerve Ipsilateral tongue palsy (deviation of the tip to the ipsilateral side)
Corticospinal tract Contralateral hemiparesis
Medial lemniscus Contralateral decrease in proprioception
Lateral medullary syndrome (Wallenberg syndrome) Posterior inferior cerebellar artery Nucleus ambiguus (CN IX, X, XI)

Ipsilateral bulbar palsy (dysphagia, dysphonia, hiccups, decreased gag reflex)

Vestibular nuclei Ipsilateral nystagmus and vertigo
Lateral spinothalamic tract Contralateral decrease in pain and temperature sensations in the trunk and limbs
Spinal trigeminal nucleus Ipsilateral decrease in pain and temperature sensations in the face
Inferior cerebellar peduncle Ipsilateral limb ataxia and dysmetria
Sympathetic fibers Ipsilateral Horner syndrome

To remember the cause and the symptoms of the lateral medullary syndrome: Try not to pick a (PICA) horse (hoarseness) that can't eat (dysphagia).

Clinical features of strokes affecting other regions

Overview of clinical features of strokes affecting other regions
Location of lesion Clinical features [6][13]
Putamen
Cerebellum
Thalamus
Cortex
Watershed border-zone

References:[24][25][26]

Initial evaluation

Imaging [27][28]

Laboratory evaluation

Laboratory studies should not delay imaging for patients with acute stroke. [27]

See ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage for specific management.

If symptoms of a suspected ischemic stroke began less than 4.5 hours prior to presentation and there are no signs of intracranial bleeding, begin reperfusion therapy immediately!

Stabilization and monitoring [27]

See “Secondary brain injury and neuroprotective measures.”

Blood pressure management [27][30]

Nitrates should be avoided because they can increase intracranial pressure.

References:[28][30][31][32]

Medical complications

Neurologic complications [33]

References:[33]

We list the most important complications. The selection is not exhaustive.

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  1. Ahmad FB, Anderson RN. The Leading Causes of Death in the US for 2020. JAMA. 2021; 325 (18): p.1829. doi: 10.1001/jama.2021.5469 . | Open in Read by QxMD
  2. Stroke Facts. https://www.cdc.gov/stroke/facts.htm. Updated: December 30, 2016. Accessed: March 28, 2017.
  3. Balami JS, Chen RL, Buchan AM. Stroke syndromes and clinical management. QJM. 2013; 106 (7): p.607-615. doi: 10.1093/qjmed/hct057 . | Open in Read by QxMD
  4. Blumenfeld H. Neuroanatomy Through Clinical Cases. Wiley-Blackwell ; 2010
  5. Goodwin D. Homonymous hemianopia: challenges and solutions. Clinical Ophthalmology. 2014 : p.1919. doi: 10.2147/opth.s59452 . | Open in Read by QxMD
  6. Li K, Malhotra PA. Spatial neglect. Pract Neurol. 2015; 15 (5): p.333-339. doi: 10.1136/practneurol-2015-001115 . | Open in Read by QxMD
  7. Larner AJ. A Dictionary of Neurological Signs. Springer International Publishing ; 2016
  8. De Renzi E, Perani D, Carlesimo GA, Silveri MC, Fazio F. Prosopagnosia can be associated with damage confined to the right hemisphere—An MRI and PET study and a review of the literature. Neuropsychologia. 1994; 32 (8): p.893-902. doi: 10.1016/0028-3932(94)90041-8 . | Open in Read by QxMD
  9. Schmahmann JD. Vascular Syndromes of the Thalamus. Stroke. 2003; 34 (9): p.2264-2278. doi: 10.1161/01.STR.0000087786.38997.9E . | Open in Read by QxMD
  10. Pirau L, Lui F. Vertebrobasilar Insufficiency. StatPearls [Internet]. 2019 .
  11. Stroke Syndromes. http://www.strokecenter.org/professionals/stroke-diagnosis/stroke-syndromes/. . Accessed: March 26, 2019.
  12. Brunicardi F, Andersen D, Billiar T, et al.. Schwartz's Principles of Surgery. McGraw-Hill Education ; 2014
  13. Kim M, Na DL, Kim GM, Adaird JC, Lee KH , Heilman KM. Ipsilesional neglect: behavioural and anatomical features. J Neurol Neurosurg Psychiatry. 1999; 67 (1): p.35-38. doi: 10.1136/jnnp.67.1.35 . | Open in Read by QxMD
  14. Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease.. Stroke. 2009; 40 (6): p.2276-93. doi: 10.1161/STROKEAHA.108.192218 . | Open in Read by QxMD
  15. Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. McGraw-Hill Education ; 2015
  16. Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018; 49 (3). doi: 10.1161/str.0000000000000158 . | Open in Read by QxMD
  17. EC J, JL S, Jr AH, et al.. Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Stroke. 2013; 44 (3): p.870-947. doi: 10.1161/STR.0b013e318284056a . | Open in Read by QxMD
  18. Provost C, Soudant M, Legrand L, et al. Magnetic Resonance Imaging or Computed Tomography Before Treatment in Acute Ischemic Stroke. Stroke. 2019; 50 (3): p.659-664. doi: 10.1161/strokeaha.118.023882 . | Open in Read by QxMD
  19. Connolly ES, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012; 43 (6): p.1711-1737. doi: 10.1161/STR.0b013e3182587839 . | Open in Read by QxMD
  20. Hemphill JC, Greenberg SM, Anderson CS et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke. 2015; 46 (7). doi: 10.1161/STR.0000000000000069 . | Open in Read by QxMD
  21. Barrett KM, Meschia JF. Acute Ischemic Stroke Management: Medical Management. Semin Neurol. 2011; 30 (5): p.461-468. doi: 10.1055/s-0030-1268859 . | Open in Read by QxMD
  22. Balami JS, Buchan AM. Complications of intracerebral haemorrhage. Lancet Neurol. 2012; 11 (1): p.101-118. doi: 10.1016/S1474-4422(11)70264-2 . | Open in Read by QxMD
  23. Rordorf G, McDonald C, Kasner SE, Wilterdink JL. Spontaneous Intracerebral Hemorrhage: Treatment and Prognosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-treatment-and-prognosis.Last updated: May 21, 2014. Accessed: March 29, 2017.
  24. Andersen G, Vestergaard K, Ingeman-Nielsen M, Jensen TS. Incidence of central post-stroke pain.. Pain. 1995; 61 (2): p.187-93.
  25. O'Donnell MJ, Diener HC, Sacco RL, et al. Chronic pain syndromes after ischemic stroke: PRoFESS trial.. Stroke. 2013; 44 (5): p.1238-43. doi: 10.1161/STROKEAHA.111.671008 . | Open in Read by QxMD
  26. Marsh EB, Llinas RH, Schneider ALC, et al. Predicting Hemorrhagic Transformation of Acute Ischemic Stroke. Medicine. 2016; 95 (2): p.e2430. doi: 10.1097/md.0000000000002430 . | Open in Read by QxMD
  27. Marcell László J, Hortobágyi T. Hemorrhagic transformation of ischemic stroke. Vascular Diseases and Therapeutics. 2017; 2 (4). doi: 10.15761/vdt.1000130 . | Open in Read by QxMD
  28. Schonewille WJ, Tuhrim S, Singer MB, Atlas SW. Diffusion-weighted MRI in acute lacunar syndromes. A clinical-radiological correlation study.. Stroke. 1999; 30 (10): p.2066-9.
  29. Kikuchi S, Mochizuki H, Moriya A, et al. Ataxic Hemiparesis: Neurophysiological Analysis by Cerebellar Transcranial Magnetic Stimulation. The Cerebellum. 2011; 11 (1): p.259-263. doi: 10.1007/s12311-011-0303-0 . | Open in Read by QxMD
  30. Nagaratnam N, Xavier C, Fabian R. Stroke Subtype—Ataxic Hemiparesis. Neurorehabil Neural Repair. 1999; 13 (2): p.149-153. doi: 10.1177/154596839901300207 . | Open in Read by QxMD
  31. Sciacca S, Lynch J, Davagnanam I, Barker R. Midbrain, Pons, and Medulla: Anatomy and Syndromes. RadioGraphics. 2019; 39 (4): p.1110-1125. doi: 10.1148/rg.2019180126 . | Open in Read by QxMD
  32. Witsch J, Narula R, Amin H, Schindler JL. Mystery Case: Bilateral Claude syndrome. Neurology. 2019; 93 (13): p.599-600. doi: 10.1212/wnl.0000000000008176 . | Open in Read by QxMD
  33. Liu GT, Crenner CW, Logigian EL, Charness ME, Samuels MA. Midbrain syndromes of Benedikt, Claude, and Nothnagel: Setting the record straight. Neurology. 1992; 42 (9): p.1820-1820. doi: 10.1212/wnl.42.9.1820 . | Open in Read by QxMD
  34. S. W. Seo, J. H. Heo, K. Y. Lee, W. C. Shin, D. I. Chang, S. M. Kim, K. Heo. Localization of Claude's syndrome. Neurology. 2001; 57 (12): p.2304-2307. doi: 10.1212/wnl.57.12.2304 . | Open in Read by QxMD
  35. Porth C, Matfin G. Pathophysiology. Lippincott Williams & Wilkins ; 2009
  36. Kim JS. Pure Sensory Stroke: Clinical-Radiological Correlates of 21 Cases. Stroke. 1992; 23 (7): p.983-987.
  37. Glass JD, Levey AI, Rothstein JD. The dysarthria-clumsy hand syndrome: a distinct clinical entity related to pontine infarction. Ann Neurol. 1990; 27 (5): p.487-494. doi: 10.1002/ana.410270506 . | Open in Read by QxMD
  38. Park J. Movement disorders following cerebrovascular lesion in the basal ganglia circuit. J Mov Disord. 2016; 9 (2): p.71-9. doi: 10.14802/jmd.16005 . | Open in Read by QxMD
  39. Standring S. Gray's Anatomy: The Anatomical Basis of Clinical Practice. Elsevier Health Sciences ; 2016
  40. Appelros P, Stegmayr B, Terént A. Sex differences in stroke epidemiology: a systematic review. Stroke. 2009; 40 (4). doi: 10.1161/STROKEAHA.108.540781 . | Open in Read by QxMD
  41. Ariesen MJ, Claus SP, Rinkel GJ, Algra A. Risk factors for intracerebral hemorrhage in the general population: a systematic review. Stroke. 2003; 34 (8): p.2060-2065. doi: 10.1161/01.STR.0000080678.09344.8D . | Open in Read by QxMD
  42. Meretoja A, Strbian D, Putaala J et al. SMASH-U: a proposal for etiologic classification of intracerebral hemorrhage. Stroke. 2012; 43 (10): p.2592-2597. doi: 10.1161/STROKEAHA.112.661603 . | Open in Read by QxMD
  43. Yew KS, Cheng EM. Diagnosis of Acute Stroke. Am Fam Physician. 2015; 91 (8): p.528-536.
  44. Berlit P. Diagnosis and treatment of cerebral vasculitis. Ther Adv Neurol Disord. 2010; 3 (1): p.29–42.
  45. Chen M. Stroke as a Complication of Medical Disease. Semin Neurol. 2009; 29 (2): p.154-162. doi: 10.1055/s-0029-1213735 . | Open in Read by QxMD
  46. Goldstein LB, Bushnell CD, Adams RJ et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010; 42 (2): p.517-584. doi: 10.1161/STR.0b013e3181fcb238 . | Open in Read by QxMD
  47. Kernan WN, Ovbiagele B, Black HR et al. Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack. Stroke. 2014; 45 (7): p.2160-2236. doi: 10.1161/STR.0000000000000024 . | Open in Read by QxMD
  48. Goljan EF. Rapid Review Pathology. Elsevier Saunders ; 2018
  49. Mena H, Cadavid D, Rushing EJ. Human cerebral infarct: a proposed histopathologic classification based on 137 cases. Acta Neuropathol. 2004; 108 (6): p.524-530. doi: 10.1007/s00401-004-0918-z . | Open in Read by QxMD
  50. Amarenco P, Lavallée PC, Monteiro Tavares L, et al. Five-Year Risk of Stroke after TIA or Minor Ischemic Stroke.. N Engl J Med. 2018; 378 (23): p.2182-2190. doi: 10.1056/NEJMoa1802712 . | Open in Read by QxMD

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