Ischemic stroke

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Última revisão: 5 Aug 2025

Última atualização: 05 Aug 2025

Ischemic stroke is a leading cause of morbidity and mortality in the world.

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

Stroke is 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 hours after stroke onset in patients shown by perfusion imaging to have salvageable brain tissue. Tenecteplase is as effective as alteplase in treating acute ischemic stroke within 4.5 hours of onset.

Intravenous thrombolysis plus mechanical thrombectomy to treat large vessel occlusive (LVO) stroke within 6 hours of stroke onset (with intravenous thrombolysis) is effective. Thrombectomy to treat LVO stroke is effective within 24 hours of onset if a penumbra is identified by multimodality imaging studies. Thrombectomy may improve functional outcome in LVO patients with a large core infarction or poor collateral circulation within 24 hours of onset.

Definição

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]

História e exame físico

Principais fatores diagnósticos

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

Detalhes completos

Outros fatores diagnósticos

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

Detalhes completos

Fatores de risco

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
use of oral estrogen-containing therapy
pregnancy
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 (PFO)
air pollution
e-cigarettes
infections
endometriosis

Detalhes completos

Investigações diagnósticas

Primeiras investigações a serem solicitadas

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

Detalhes completos

Investigações a serem consideradas

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

Detalhes completos

Algoritmo de tratamento

AGUDA

without cerebral venous sinus thrombosis

with cerebral venous sinus thrombosis

Colaboradores

Autores

David Wang, DO, FAHA, FAAN

Professor of Neurology

Co-Director

Petznick Stroke Center

Neurovascular Division

Barrow Neurological Institute

Phoenix

Declarações

DW received honorarium from Boehringer Ingelheim for lectures on the use of thrombolytics for acute ischemic stroke. He has also received honorarium from Amgen, Zhongmei Huadong, and ShiYao 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

Declarações

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

Declarações

YW declares that he has no competing interests.

Agradecimentos

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.

Declarações

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.

Revisores

Nishant K. Mishra, MD, PhD, FRCP, FAHA

Assistant Professor of Neurology

Yale University

New Haven

Declarações

NM declares that he has no competing interests.

Julien Morier, MD

Neurology Registrar

Neurology Service

Centre Hospitalier Universitaire Vaudois (CHUV)

Lausanne

Switzerland

Declarações

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

Declarações

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

Declarações

TR declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

Referências

Nossas equipes internas de editoria e de evidências trabalham em conjunto com colaboradores internacionais especializados e pares revisores para garantir que forneçamos acesso às informações o mais clinicamente relevantes possível.

Principais artigos

Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association. Stroke. 2021 Jul;52(7):e364-467.Texto completo Resumo

Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-418.Texto completo Resumo

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Diagnósticos diferenciais
- Intracerebral hemorrhage
- Transient ischemic attack
- Transient global amnesia
Mais Diagnósticos diferenciais
Diretrizes
- Diagnosis and management of cerebral venous thrombosis: a scientific statement from the American Heart Association
- European Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischaemic stroke
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Ischemic stroke

Resumo

Definição

História e exame físico

Principais fatores diagnósticos

Outros fatores diagnósticos

Fatores de risco

Investigações diagnósticas

Primeiras investigações a serem solicitadas

Investigações a serem consideradas

Algoritmo de tratamento

without cerebral venous sinus thrombosis

with cerebral venous sinus thrombosis

Colaboradores

Autores

David Wang, DO, FAHA, FAAN

Declarações

Yi Dong, MD, PhD

Declarações

Yilong Wang, MD, PhD

Declarações

Agradecimentos

Declarações

Revisores

Nishant K. Mishra, MD, PhD, FRCP, FAHA

Declarações

Julien Morier, MD

Declarações

Louis R. Caplan, MD

Declarações

Tony Rudd, MD

Declarações

Peer reviewer acknowledgements

Disclosures

Referências

Principais artigos

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Diagnósticos diferenciais

Diretrizes

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

Log in to access all of BMJ Best Practice