Ischemic stroke

Last reviewed: 26 Aug 2022
Last updated: 31 Aug 2022

Summary

Definition

History and exam

Key diagnostic factors

  • vision loss or visual field deficit
  • weakness
  • aphasia
  • ataxia (impaired coordination)
More key diagnostic factors

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
Other diagnostic factors

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
More risk factors

Diagnostic investigations

1st investigations 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
More 1st investigations to order

Investigations 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
More investigations to consider

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

AZ

Disclosures

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

MA

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

UK

Disclosures

TR declares that he has no competing interests.

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