Last reviewed: 25 Sep 2021
Last updated: 10 Jul 2020



History and exam

Key diagnostic factors

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

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
  • 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

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
  • illicit drug use
  • hyperhomocysteinemia
  • elevated lipoprotein(a)
  • hypercoagulable states
  • elevated C-reactive protein
  • aortic arch plaques
  • patent foramen ovale

Diagnostic investigations

1st investigations to order

  • CT head
  • MRI brain
  • CT or magnetic resonance angiography
  • CT or MRI perfusion
  • serum glucose
  • serum electrolytes
  • serum BUN and creatinine
  • cardiac enzymes
  • ECG
  • CBC
  • prothrombin time and PTT (with INR)

Investigations to consider

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

Treatment algorithm



David Wang, DO, FAHA, FAAN

Professor of Neurology

Co-Director, Neurovascular Division & Stroke Program

Neurology Department

Barrow Neurological Institute




DW is 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




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




YW declares that he has no competing interests.


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.


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)




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




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




TR declares that he has no competing interests.

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