Last reviewed: February 2020
Last updated: December  2018



History and exam

Key diagnostic factors

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

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

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

Diagnostic investigations

1st investigations to order

  • CT head
  • MRI brain
  • serum glucose
  • serum electrolytes
  • serum BUN and creatinine
  • cardiac enzymes
  • ECG
  • CBC
  • prothrombin time and PTT (with INR)
More 1st investigations to order

Investigations to consider

  • serum toxicology screen
  • CXR
  • CT or magnetic resonance angiography
  • CT or magnetic resonance venography
  • carotid ultrasound
  • transcranial Doppler ultrasound
  • conventional (invasive) angiography
More investigations to consider

Emerging tests

  • CT- or MRI-perfusion-weighted imaging
More emerging tests

Treatment algorithm


Assistant Professor of Internal Medicine

Medical School

University of Thessaly

Secretary General

Hellenic Stroke Organization

Larissa University Hospital




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.

Dr George Ntaios would like to gratefully acknowledge Dr Alireza Minagar, the previous contributor to this topic. AM declares that he has no competing interests.

Peer reviewersVIEW ALL

Neurology Registrar

Neurology Service

Centre Hospitalier Universitaire Vaudois (CHUV)




JM declares that he has no competing interests.

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.

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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