Last reviewed: 19 Dec 2021
Last updated: 04 Jun 2021



History and exam

Key diagnostic factors

  • unilateral weakness or paralysis in the face, arm or leg
  • dysphasia
  • ataxia
  • visual disturbance
  • risk factors

Other diagnostic factors

  • sensory loss (numbness)
  • dysarthria
  • headache
  • gaze paresis
  • arrhythmias, murmurs, or pulmonary oedema
  • vertigo
  • nausea and/or vomiting
  • neck or facial pain
  • miosis, ptosis, and facial anhidrosis (hemilateral)
  • decreased level of consciousness or coma

Risk factors

  • older age
  • family history of stroke
  • history of ischaemic stroke
  • hypertension
  • smoking
  • diabetes mellitus
  • atrial fibrillation
  • comorbid cardiac conditions
  • carotid artery stenosis
  • sickle cell disease
  • dyslipidaemia
  • lower levels of education
  • African-American or Hispanic ancestry
  • poor diet and nutrition
  • physical inactivity
  • obesity
  • alcohol abuse
  • oestrogen-containing therapy
  • illicit drug use
  • migraine
  • hyperhomocysteinaemia
  • elevated lipoprotein(a)
  • hypercoagulable states
  • elevated C-reactive protein
  • aortic arch plaques

Diagnostic investigations

1st investigations to order

  • non-contrast CT head
  • serum glucose
  • serum electrolytes
  • serum urea and creatinine
  • cardiac enzymes
  • FBC
  • ECG
  • prothrombin time and PTT (with INR)

Investigations to consider

  • serum toxicology screen
  • diffusion-weighted MRI head
  • CT angiography or MR angiography ± contrast
  • CT or MRI perfusion-weighted imaging
  • carotid ultrasound

Treatment algorithm


Expert advisers

Matthew Jones, MD, FRCP

Consultant Neurologist

Greater Manchester Neurosciences Centre

Salford Royal Foundation Trust

Honorary Senior Lecturer

University of Manchester




MJ declares that he has no competing interests.

Rachael Power, MBChB, MRCP

Neurology Registrar

Manchester Centre for Clinical Neurosciences




RP has been sponsored by Novartis to attend the International Headache Conference.


BMJ Best Practice would like to gratefully acknowledge the previous expert contributor for this topic, whose work has been retained in parts of the content:

George Ntaios, MD, MSc (ESO Stroke Medicine), PhD, FESO

Assistant Professor of Internal Medicine

Medical School

University of Thessaly



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.

Peer reviewers

Kayvan Khadjooi, MD, FRCP, PGCertMedEd

Consultant in Stroke Medicine

Addenbrooke’s Hospital

Associate Lecturer

School of Clinical Medicine

University of Cambridge




KK has received travel grants for conferences/speaker honoraria from Bayer, Boehringer, Daiichi-Sankyo, Pfizer, and Shire.


Helena Delgado-Cohen,

Section Editor, BMJ Best Practice


HDC declares that she has no competing interests.

Tannaz Aliabadi-Oglesby,

Lead Section Editor, BMJ Best Practice


TAO declares that she has no competing interests.

Julie Costello,

Comorbidities Editor, BMJ Best Practice


JC declares that she has no competing interests.

Adam Mitchell,

Drug Editor, BMJ Best Practice


AM declares that he has no competing interests.

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