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 a typical presentation of stroke.[66]

Weakness of all three suggests deep hemispheric involvement, although this may not differentiate stroke mechanism.

Hemiparesis is a feature of any type of stroke that occludes the penetrating arteries that supply the posterior limb of the internal capsule.

  • If it is purely the penetrating arteries involved then the patient may have one of the lacunar syndromes (e.g., pure motor hemiparesis, pure sensory stroke, ataxic hemiparesis, etc.).[92]

  • If it is the middle cerebral artery (from which the penetrating arteries branch off) that is occluded, there will be hemiparesis but with other neurological deficits.

As with most stroke signs and symptoms, bilateral involvement is uncommon and may reflect alternative aetiologies. See Differentials .

dysphasia

Impairment in any language function, either expressive or receptive, is a sign of dominant hemispheric ischaemia.[66]

ataxia

In the absence of muscle weakness, ataxia points to ischaemia involving the cerebellum or its connections with the rest of the brain.

Posterior circulation strokes are more commonly associated with difficulty with fine motor coordination and gait than anterior circulation strokes.

visual disturbance

Loss of sight in one eye may occur and is often transient.

  • This is a common early warning signal for cervical carotid stenosis. It can present as amaurosis fugax or retinal stroke (branch or central retinal artery occlusion); recognise and investigate with the same urgency. See Carotid artery stenosis.

Homonymous hemianopia involves vision loss on the same side of the visual field in both eyes.

Diplopia may occur in patients with posterior circulation ischaemia.[75]

risk factors

Consider risk factors that make people more likely to have a stroke:

  • Age ≥55 years[11]

  • History of transient ischaemic attack (TIA)[23][93]

  • History of ischaemic stroke[78]

  • Family history of stroke at a young age[21]

  • Hypertension[79]

  • Smoking[27]

  • Diabetes mellitus[28]

  • Atrial fibrillation[29][80]

  • Comorbid cardiac conditions[30]

  • Carotid artery stenosis[31][32]

  • Sickle cell disease [94]

  • Dyslipidaemia[81]

Other diagnostic factors

common

sensory loss (numbness)

Patients often describe sensory loss and paraesthesias as 'numbness'.

  • Unilateral sensory loss on neurological examination may involve some or all primary modalities.

  • Cortical sensory loss usually impairs fine sensory processing abilities such as two-point discrimination, graphaesthesia, and stereognosis.

dysarthria

May accompany facial weakness, or brainstem or cerebellar dysfunction.

headache

Headache is not uncommon in acute stroke but may indicate other pathologies such as:

  • Intracerebral haemorrhage (may be insidious and gradually increasing).

  • Subarachnoid haemorrhage (severe and of sudden-onset “thunderclap headache”).

  • Intracranial hypertension (which may be caused by, for example, a cerebral venous sinus thrombosis or space-occupying lesion).

  • Migraine.

See  Differentials .

gaze paresis

Often horizontal and unidirectional.

More common in anterior circulation strokes than in posterior circulation strokes.

Consider seizure with wrong-way eye deviation (i.e., gaze deviation away from the side of the brain lesion, towards the hemiparetic side).

arrhythmias, murmurs, or pulmonary oedema

Associated with cardiac comorbidities, which predispose patients to stroke.

  • Atrial fibrillation is the cause of one fifth of ischaemic strokes and is one of the strongest individual stroke risk factors.[29][80] See New-onset atrial fibrillation.

uncommon

vertigo

This is a common presentation of posterior circulation ischaemia.[75]

  • Typically reported as a spinning sensation; may also be described as feeling like being “on a ship in choppy seas”.

  • It is often associated with nystagmus.

nausea and/or vomiting

May be due to posterior circulation ischaemia, or reflect increased intracranial pressure.[75]

neck or facial pain

May be associated with arterial dissection.

miosis, ptosis, and facial anhidrosis (hemilateral)

Horner's syndrome may be associated with posterior circulation strokes.[75]

Practical tip

In anterior circulation stroke accompanied by Horner’s syndrome, consider whether carotid artery dissection could be the cause.

decreased level of consciousness or coma

A decreased level of consciousness may accompany large anterior circulation, thalamic, bihemispheric, or brain stem strokes.

Consider seizure (Todd’s paresis) in people with reduced consciousness.

Coma is more common in people with brain stem ischaemia.

Practical tip

Haemorrhagic stroke is more often associated with seizures, decreased level of consciousness, and signs of increased intracranial pressure than ischaemic stroke.

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