Ischemic stroke

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 21 Oct 2024

Last updated: 01 May 2024

Ischemic stroke is a leading cause of morbidity and mortality.

Approximately 85% of strokes are ischemic, caused by arterial occlusion.

A clinical emergency: timely diagnosis, triage, and intervention improves outcomes.

Care of patients in dedicated stroke units improves survival and function.

Intravenous thrombolysis with recombinant tissue plasminogen activator (r-tPA) is effective when given within 4.5 hours of stroke onset, and remains the standard of care. Intravenous alteplase may be beneficial when given between 4.5 and 9.0 hours after stroke onset in patients shown by perfusion imaging to have salvageable brain tissue. Tenecteplase may be beneficial in treating acute ischemic stroke within 4.5 hours of onset.

Mechanical thrombectomy within 6 hours of stroke onset (with intravenous thrombolysis) is effective for treating ischemic stroke caused by large vessel occlusion. Thrombectomy may also be considered (without intravenous thrombolysis) for carefully selected patients.

Definition

Stroke is defined as an acute neurologic deficit caused by cerebrovascular abnormality. It is further subdivided into ischemic stroke (caused by arterial occlusion or stenosis) and hemorrhagic stroke (caused by vascular rupture, resulting in intraparenchymal and/or subarachnoid hemorrhage).

This topic deals with ischemic stroke.

Transient ischemic attack (TIA) is defined as a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. Patients with TIAs are at high risk for early ischemic stroke.[1]

History and exam

Key diagnostic factors

vision loss or visual field deficit
weakness
aphasia
ataxia (impaired coordination)

Full details

Other diagnostic factors

history of transient ischemic attack (TIA)
sudden onset of symptoms
negative symptoms (i.e., loss of function)
altered sensation
headache
diplopia
sensory loss
dysarthria
"Crossed" syndromes
gaze paresis
arrhythmias, murmurs, or pulmonary edema
vertigo/dizziness
nausea and/or vomiting
neck or facial pain
miosis, ptosis, and facial anhidrosis (hemilateral)
altered level of consciousness/coma
confusion

Full details

Risk factors

hypertension
older age
sickle cell disease
family history of stroke
history of transient ischemic attack (TIA)
history of ischemic stroke
cerebral microbleeds
smoking
diabetes mellitus
atrial fibrillation
comorbid cardiac conditions
carotid artery stenosis
intracranial atherosclerosis (ICAS)
dyslipidemia
lower levels of education
ethnicity
poor diet and nutrition
low birth weight
physical inactivity
obesity
alcohol misuse
estrogen-containing therapy
migraine
severe obstructive sleep apnea
long sleep duration and poor sleep quality
illicit drug use
hyperhomocysteinemia
elevated lipoprotein(a)
hypercoagulable states
elevated C-reactive protein
aortic arch plaques
patent foramen ovale
air pollution
e-cigarettes
Infections (e.g., COVID-19) and vaccine-induced thrombotic thrombocytopenia

Full details

Diagnostic tests

1st tests to order

CT head
MRI brain
CT angiography or magnetic resonance angiography
CT or MRI perfusion
serum glucose
serum electrolytes
serum BUN and creatinine
cardiac enzymes
ECG
CBC
coagulopathy screen

Full details

Tests to consider

serum toxicology screen
infection screen
genetic testing
CXR
CT or magnetic resonance or digital subtraction venography
carotid ultrasound
echocardiogram
transcranial Doppler ultrasound
conventional (invasive) angiography

Full details

Treatment algorithm

ACUTE

without cerebral venous sinus thrombosis

with cerebral venous sinus thrombosis

Contributors

Authors

David Wang, DO, FAHA, FAAN

Professor of Neurology

Co-Director

Petznick Stroke Center

Neurovascular Division

Barrow Neurological Institute

Phoenix

Disclosures

DW received honorarium from Boehringer Ingelheim for lectures on the use of thrombolytics for acute ischemic stroke. He has also received honorarium from Amgen and Zhongmei Huadong Pharmaceuticals for speaking. DW was Chair, Stroke Section of the American Academy of Neurology, 2017-2019. He was Chair, Quality and Safety Subcommittee of the American Academy of Neurology (term ended June 2018). DW is an author of references cited in this topic.

Yi Dong, MD, PhD

Department of Neurology

Huashan Hospital

Fudan University

Shanghai

China

Disclosures

YD declares that she has no competing interests.

Yilong Wang, MD, PhD

Professor of Neurology

Deputy Director, Department of Neurology

Beijing Tiantan Hospital, Capital Medical University

Beijing

China

Disclosures

YW declares that he has no competing interests.

Acknowledgements

Dr David Wang, Dr Yi Dong, and Dr Yilong Wang would like to gratefully acknowledge Dr George Ntaios and Dr Alireza Minagar, the previous contributors to this topic.

Disclosures

GN is on the advisory boards for, and has received honoraria, speaker fees, and research support from: Amgen, Bayer, Boehringer-Ingelheim, BMS/Pfizer, Elpen, Galenica, Medtronic, Sanofi, and Winmedica. AM declares that he has no competing interests.

Peer reviewers

Julien Morier, MD

Neurology Registrar

Neurology Service

Centre Hospitalier Universitaire Vaudois (CHUV)

Lausanne

Switzerland

Disclosures

JM declares that he has no competing interests.

Louis R. Caplan, MD

Lecturer in Neurology

Hospital Chief

Cerebrovascular/Stroke Division

Beth Israel Deaconess Medical Center

Division of Cerebrovascular/Stroke

Boston

Disclosures

LRC declares that he has no competing interests.

Tony Rudd, MD

National Clinical Director

Stroke NHS England

Professor, Stroke Medicine

Kings College London

Chair, Intercollegiate Stroke Working Party

Royal College of Physicians

London

Disclosures

TR declares that he has no competing interests.

Differentials
- Intracerebral hemorrhage
- Transient ischemic attack
- Transient global amnesia
More Differentials
Guidelines
- Diagnosis and management of cerebral venous thrombosis: a scientific statement from the American Heart Association
- Diagnosis and management of cerebral venous thrombosis: a scientific statement from the American Heart Association
More Guidelines
Patient information
Stroke: treatment
Feeding tube insertion
More Patient information
Calculators
NIH Stroke Score
ABCD2 Score to Predict Stroke Risk after TIA
More Calculators
Videos
Tracheal intubation: animated demonstration
Bag-valve-mask ventilation: animated demonstration
More videos
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Ischemic stroke

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

without cerebral venous sinus thrombosis

with cerebral venous sinus thrombosis

Contributors

Authors

David Wang, DO, FAHA, FAAN

Disclosures

Yi Dong, MD, PhD

Disclosures

Yilong Wang, MD, PhD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Julien Morier, MD

Disclosures

Louis R. Caplan, MD

Disclosures

Tony Rudd, MD

Disclosures

Differentials

Guidelines

Patient information

Calculators

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

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