eMedicine Specialties > Neurology > Neuro-vascular Diseases

Anterior Circulation Stroke: Differential Diagnoses & Workup

Author: Alison Elizabeth Baird, MBBS, PhD, MPH, FRACP, Professor of Neurology and Physiology/Pharmacology, Director of Division of Cerebrovascular Disease and Stroke, State University of New York Downstate Medical Center
Contributor Information and Disclosures

Updated: Sep 17, 2008

Differential Diagnoses

Cardioembolic Stroke
Metastatic Disease to the Brain
Cavernous Sinus Syndromes
Migraine Variants
Cerebral Aneurysms
Primary CNS Lymphoma
Glioblastoma Multiforme
Seizures and Epilepsy: Overview and Classification
Head Injury
Subarachnoid Hemorrhage
Herpes Simplex Encephalitis
Subdural Hematoma
Intracranial Hemorrhage
Transient Global Amnesia
Low-Grade Astrocytoma
Viral Encephalitis
Meningioma

Other Problems to Be Considered

Brain tumor
Hypoglycemia
Brain abscess
Carotid disease and stroke

Workup

Laboratory Studies

  • The following laboratory tests are indicated in the patient with stroke both to assist in their acute care and to uncover any underlying medical conditions that could complicate the clinical course.
    • Coagulation profile
    • Glucose level
    • Electrolytes levels
    • Liver function tests
    • Erythrocyte sedimentation rate (ESR)
    • Complete blood count (CBC)

Imaging Studies

  • Brain CT scan
    • Noncontrast CT scan of the brain is required emergently to rule out cerebral hemorrhage, subdural hematoma, and other intracerebral pathology prior to the administration of thrombolytic therapy.
    • Early signs of infarction that can be detected with CT scan include loss of gray-white matter differentiation and cortical sulcal effacement. The hyperdense MCA sign is indicative of thrombus in the MCA. The Alberta Stroke Programme Early CT Score (ASPECTS) score may have prognostic utility (a favorable score is >7/10) but did not show utility in clinical decision-making for recombinant tissue plasminogen activator (rt-PA) therapy in a recent study.
    • Other advances in CT scan include the advent of CT angiography and CT perfusion imaging.
  • MRI
    • New MR sequences such as diffusion-weighted imaging (DWI) allow detection of ischemic lesions within minutes of stroke onset. Lesions appear as hyperintense and are easily distinguishable from the surrounding brain.
    • Even very small lesions can be detected, and old lesions may be distinguished from new ones by measuring the apparent diffusion coefficient.
    • In combination with MR angiography (MRA) and MR perfusion imaging, this modality allows multiple aspects of the ischemic process to be identified in a scanning session of approximately 25 minutes. This is available in many tertiary referral centers. Contrast-enhanced MRA using a neurovascular array permits rapid imaging of the vasculature from the aortic arch to the circle of Willis in as short as 2 minutes. This method seems sensitive for the detection of extracranial vascular disease, including vertebral and internal carotid artery dissections.
  • Transcranial Doppler ultrasonography
    • Transcranial Doppler ultrasonography is used for rapid and noninvasive identification of the site of major arterial occlusion in the MCA, internal carotid artery, and ACA.
    • It also is used to identify embolic load with emboli detection.
  • Chest radiography - This is used to determine heart size and pulmonary status.

Other Tests

  • Cardiac echocardiography
    • Cardiac echocardiography helps in ruling out a cardiac source of cerebral embolism and in identifying aortic arch atheroma.
    • Transesophageal echocardiography is the investigation of choice, as it has higher detection rates for lesions in the left atrium (eg, thrombus) and the aortic arch.
  • Imaging of the neck vessels
    • Imaging of the neck vessels helps in ruling out a significant carotid artery stenosis as a cause of stroke that may require surgical intervention.
    • Perform imaging with ultrasound, MRA, or conventional digital subtraction angiography.
  • Hypercoagulability screen - For patients with cryptogenic stroke and a possibility of a hypercoagulable etiology
  • ECG

Procedures

  • Intravenous thrombolysis is recommended for patients with ischemic stroke presenting within the first 3 hours.
  • Intravenous thrombolysis beyond the first 3 hours is under investigation. One trial, ECASS 3, is investigating the efficacy and safety of IV tPA 3-4.5 hours after symptom onset. Small trials have suggested that patients may respond to tPA after 3 hours if a perfusion-diffusion mismatch pattern can be identified (believed to be indicative of the presence of potentially viable tissue).
  • Intra-arterial thrombolysis may be considered in highly select patients with middle cerebral artery occlusions presenting within 6 hours of onset and who are not eligible for intravenous thrombolysis. Some highly select patients with basilar artery thrombosis may be considered for intra-arterial thrombolysis up to 24 hours after onset.
  • Mechanical clot disruption using the Merci clot retrieval device for acute ischemic stroke treated within 8 hours of symptom onset received clearance from the Food and Drug Administration (FDA) in 2004. Another mechanical device, the Penumbra System, received FDA clearance in 2007. Both devices may be used for patients with persistent clots after intravenous thrombolysis.

More on Anterior Circulation Stroke

Overview: Anterior Circulation Stroke
Differential Diagnoses & Workup: Anterior Circulation Stroke
Treatment & Medication: Anterior Circulation Stroke
Follow-up: Anterior Circulation Stroke
Multimedia: Anterior Circulation Stroke
References
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References

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Further Reading

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Keywords

carotid artery territory ischemic stroke, major hemispheric syndrome, middle cerebral artery stroke, MCA stroke, MCA syndrome, anterior cerebral artery stroke, ACA stroke, lacunar stroke, reperfusion, anterior circulation stroke

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Contributor Information and Disclosures

Author

Alison Elizabeth Baird, MBBS, PhD, MPH, FRACP, Professor of Neurology and Physiology/Pharmacology, Director of Division of Cerebrovascular Disease and Stroke, State University of New York Downstate Medical Center
Alison Elizabeth Baird, MBBS, PhD, MPH, FRACP is a member of the following medical societies: American Academy of Neurology, American Heart Association, Australian & New Zealand Association of Neurologists, Royal Australasian College of Physicians, Society for Neuroscience, Stroke Council of the American Heart Association, and Stroke Society of Australasia
Disclosure: Nothing to disclose.

Medical Editor

Draga Jichici, MD, FRCP, Associate Clinical Professor, Department of Medicine, Division of Neurology and Critical Care Medicine, McMaster University, Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health & Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Concentric Medical Consulting fee Review panel membership; Abbott Consulting fee Consulting; Sanofi  Consulting

 
 
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