History and exam
Key diagnostic factors
common
unilateral weakness or paralysis in the face, arm, or leg
Complete or partial loss of muscle strength in face, arm, and/or leg is among the most common presentations of stroke.
As with most stroke signs and symptoms, bilateral involvement is uncommon and may reflect alternative aetiology (but can be seen with bilateral brainstem or spinal infarcts).
sensory loss (numbness)
Patients often describe sensory loss and paraesthesias as “numbness”, “tingling” or “pins and needles”.
Sensory inattention is a useful cortical sign, localising to the contralateral parietal region.
Cortical sensory loss usually impairs fine sensory processing abilities such as two-point discrimination, graphaesthesia, or stereognosis.
Thalamic haemorrhages can present with sensory loss and pseudoathetosis.
dysphasia
Expressive or receptive dysphasia may occur.
Impairment in any language function (fluency, naming, repetition, comprehension) is a sign of dominant hemispheric stroke.
Differentiate fluent, non-repetitive (Wernicke's) aphasia from confusion; aphasia is a specific sign of dominant hemisphere injury.
dysarthria
May accompany facial weakness or cerebellar dysfunction.
visual disturbance
Homonymous hemianopia (i.e., visual field loss on the left or right side of the vertical midline on the same side of both eyes) may result from haemorrhage in the visual pathways, including the occipital lobe.
Diplopia may result from brain stem haemorrhage.
photophobia
Spontaneous intracerebral haemorrhage (ICH) can often cause photophobia.
headache
Usually of insidious onset and gradually increasing intensity in ICH.
More common in ICH than in ischaemic stroke, but the absence of headache does not rule out ICH.
Thunderclap headache (defined as sudden, severe headache that reaches maximum intensity upon onset) is characteristic of subarachnoid haemorrhage. See Subarachnoid haemorrhage.
ataxia
In the absence of muscle weakness, impaired coordination points to haemorrhage involving the cerebellum or its connections with the rest of the brain.
Other diagnostic factors
uncommon
vertigo
Often reported as a spinning sensation; may also be described as feeling like being “on a ship in choppy seas”.
Typically seen in cerebellar or brainstem haemorrhage.
nausea/vomiting
May either be due to posterior circulation haemorrhage or reflect increased intracranial pressure.
With cerebellar haemorrhage, nausea and vomiting may be the only presenting symptoms, with an unremarkable neurological examination except for gait ataxia.
decreased level of consciousness/coma
Urgently diagnose (rule out haemorrhage) and manage (breathing and airway protection) any patient with altered consciousness or in a coma.
Reduced alertness may accompany large hemispheric haemorrhages or posterior fossa haemorrhages.
Coma is more common in people with brain stem haemorrhage.
Exclude conditions mimicking stroke (e.g., seizures).
confusion
Common especially in older people with previous strokes or cognitive dysfunction.
gaze paresis
Often horizontal and unidirectional.
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