Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Ischemic Stroke Clinical Presentation

  • Author: Edward C Jauch, MD, MS, FAHA, FACEP; Chief Editor: Helmi L Lutsep, MD  more...
 
Updated: Nov 23, 2015
 

History

A focused medical history for patients with ischemic stroke aims to identify risk factors for atherosclerotic and cardiac disease, including the following (see Etiology):

  • Hypertension
  • Diabetes mellitus
  • Tobacco use
  • High cholesterol
  • History of coronary artery disease, coronary artery bypass, or atrial fibrillation

In younger patients, elicit a history of the following:

  • Recent trauma
  • Coagulopathies
  • Illicit drug use (especially cocaine)
  • Migraines
  • Oral contraceptive use

Stroke should be considered in any patient presenting with an acute neurologic deficit (focal or global) or altered level of consciousness. No historical feature distinguishes ischemic from hemorrhagic stroke, although nausea, vomiting, headache, and a sudden change in the patient’s level of consciousness are more common in hemorrhagic strokes.

Consider stroke in any patient presenting with acute neurologic deficit or any alteration in level of consciousness. Common signs and symptoms of stroke include the abrupt onset of any of the following:

  • Hemiparesis, monoparesis, or (rarely) quadriparesis
  • Hemisensory deficits
  • Monocular or binocular visual loss
  • Visual field deficits
  • Diplopia
  • Dysarthria
  • Facial droop
  • Ataxia
  • Vertigo (rarely in isolation)
  • Aphasia
  • Sudden decrease in the level of consciousness

Although such symptoms can occur alone, they are more likely to occur in combination.

Establishing the time at which the patient was last without stroke symptoms, or last known to be normal, is especially critical when fibrinolytic therapy is an option. Unfortunately, the median time from symptom onset to emergency department (ED) presentation ranges from 4-24 hours in the United States.[1]

Multiple factors contribute to delays in seeking care for symptoms of stroke. Many strokes occur while patients are sleeping and are not discovered until the patient wakes (this phenomenon is also known as "wake-up" stroke). Stroke can leave some patients too incapacitated to call for help. Occasionally, a stroke goes unrecognized by patients or their caregivers.[4, 56]

If the patient awakens with symptoms, then the time of onset is defined as the time at which the patient was last seen to be without symptoms. Input from family members, coworkers, and bystanders may be required to help establish the exact time of onset, especially in right hemispheric strokes accompanied by neglect or left hemispheric strokes with aphasia.

Next

Physical Examination

The goals of the physical examination are as follows:

  • Detect extracranial causes of stroke symptoms
  • Distinguish stroke from stroke mimics
  • Determine and document for future comparison the degree of deficit
  • Localize the lesion
  • Identify comorbidities
  • Identify conditions that may influence treatment decisions (eg, trauma, active bleeding, active infection)

The physical examination always includes a careful head and neck examination for signs of trauma, infection, and meningeal irritation. A careful search for the cardiovascular causes of stroke requires examination of the following:

  • Ocular fundi (retinopathy, emboli, hemorrhage)
  • Heart (irregular rhythm, murmur, gallop)
  • Peripheral vasculature (palpation of carotid, radial, and femoral pulses; auscultation for carotid bruit)

The physical examination must encompass all of the major organ systems, starting with airway, breathing, and circulation (ABCs) and the vital signs. Patients with a decreased level of consciousness should be assessed to ensure that they are able to protect their airway. Patients with stroke, especially hemorrhagic stroke, can suffer quick clinical deterioration; therefore, constant reassessment is critical.

Ischemic strokes, unless large or involving the brainstem, do not tend to cause immediate problems with airway patency, breathing, or circulation compromise. On the other hand, patients with intracerebral or subarachnoid hemorrhage frequently require intervention for airway protection and ventilation.

Vital signs, while nonspecific, can point to impending clinical deterioration and may assist in narrowing the differential diagnosis. Many patients with stroke are hypertensive at baseline, and their blood pressure may become more elevated after stroke. While hypertension at presentation is common, blood pressure decreases spontaneously over time in most patients.

Head and neck, cardiac, and extremities examination

A careful examination of the head and neck is essential. Contusions, lacerations, and deformities may suggest trauma as the etiology for the patient's symptoms. Auscultation of the neck may elicit a bruit, suggesting carotid disease as the cause of the stroke.

Cardiac arrhythmias, such as atrial fibrillation, are found commonly in patients with stroke. Similarly, strokes may occur concurrently with other acute cardiac conditions, such as acute myocardial infarction and acute heart failure; thus, auscultation for murmurs and gallops is recommended.

Carotid or vertebrobasilar dissections and, less commonly, thoracic aortic dissections may cause ischemic stroke. Unequal pulses or blood pressures in the extremities may reflect the presence of aortic dissections.

Neurologic examination

With the availability of fibrinolytic therapy for acute ischemic stroke in selected patients, the physician must be able to perform a brief but accurate neurologic examination on patients with suspected stroke syndromes. The goals of the neurologic examination include the following:

  • Confirming the presence of a stroke syndrome (to be defined further with cranial CT scanning)
  • Distinguishing stroke from stroke mimics
  • Establishing a neurologic baseline should the patient's condition improve or deteriorate
  • Establishing stroke severity to assist in prognosis and therapeutic selection

Essential components of the neurologic examination include the following evaluations:

  • Cranial nerves
  • Motor function
  • Sensory function
  • Cerebellar function
  • Gait
  • Deep tendon reflexes
  • Language (expressive and receptive capabilities)
  • Mental status and level of consciousness

The skull and spine also should be examined, and signs of meningismus should be sought.

National Institutes of Health Stroke Scale

A useful tool in quantifying neurologic impairment is the National Institutes of Health Stroke Scale (NIHSS) (see Table 2, below). The NIHSS enables the healthcare provider to rapidly determine the severity and possible location of the stroke. NIHSS scores are strongly associated with outcome and can help to identify those patients who are likely to benefit from fibrinolytic therapy and those who are at higher risk of developing hemorrhagic complications of fibrinolytic use.

The NIHSS is easily performed; it focuses on the following 6 major areas of the neurologic examination:

  • level of consciousness
  • Visual function
  • Motor function
  • Sensation and neglect
  • Cerebellar function
  • Language

The NIHSS is a 42-point scale. Patients with minor strokes usually have a score of less than 5. An NIHSS score of greater than 10 correlates with an 80% likelihood of proximal vessel occlusions (as identified on CT or standard angiograms). However, discretion must be used in assessing the magnitude of the clinical deficit and resulting disability; for instance, if a patient's only deficit is mutism, the NIHSS score will be 3. Additionally, the scale does not measure some deficits associated with posterior circulation strokes (ie, vertigo, ataxia).[57]

Table 2. National Institutes of Health Stroke Scale (Open Table in a new window)

  Category Description Score
1a level of consciousness (LOC) Alert



Drowsy



Stuporous



Coma



0



1



2



3



1b LOC questions (month, age) Answers both correctly



Answers 1 correctly



Incorrect on both



0



1



2



1c LOC commands (open and close eyes,



grip and release nonparetic hand)



Obeys both correctly



Obeys 1 correctly



Incorrect on both



0



1



2



2 Best gaze (follow finger) Normal



Partial gaze palsy



Forced deviation



0



1



2



3 Best visual (visual fields) No visual loss



Partial hemianopia



Complete hemianopia



Bilateral hemianopia



0



1



2



3



4 Facial palsy (show teeth, raise brows,



squeeze eyes shut)



Normal



Minor



Partial



Complete



0



1



2



3



5 Motor arm left* (raise 90°, hold 10 seconds) No drift



Drift



Cannot resist gravity



No effort against gravity



No movement



0



1



2



3



4



6 Motor arm right* (raise 90°, hold 10 seconds) No drift



Drift



Cannot resist gravity



No effort against gravity



No movement



0



1



2



3



4



7 Motor leg left* (raise 30°, hold 5 seconds) No drift



Drift



Cannot resist gravity



No effort against gravity



No movement



0



1



2



3



4



8 Motor leg right* (raise 30°, hold 5 seconds) No drift



Drift



Cannot resist gravity



No effort against gravity



No movement



0



1



2



3



4



9 Limb ataxia (finger-nose, heel-shin) Absent



Present in 1 limb



Present in 2 limbs



0



1



2



10 Sensory (pinprick to face, arm, leg) Normal



Partial loss



Severe loss



0



1



2



11 Extinction/neglect (double simultaneous testing) No neglect



Partial neglect



Complete neglect



0



1



2



12 Dysarthria (speech clarity to "mama,



baseball, huckleberry, tip-top, fifty-fifty")



Normal articulation



Mild to moderate dysarthria



Near to unintelligible or worse



0



1



2



13 Best language** (name items,



describe pictures)



No aphasia



Mild to moderate aphasia



Severe aphasia



Mute



0



1



2



3



  Total - 0-42
* For limbs with amputation, joint fusion, etc, score 9 and explain.



** For intubation or other physical barriers to speech, score 9 and explain. Do not add 9 to the total score. NIH Stroke Scale (PDF)



Middle cerebral artery stroke

Middle cerebral artery (MCA) occlusions commonly produce the following:

  • Contralateral hemiparesis
  • Contralateral hypesthesia
  • Ipsilateral hemianopsia
  • Gaze preference toward the side of the lesion
  • Agnosia
  • Receptive or expressive aphasia, if the lesion occurs in the dominant hemisphere
  • Neglect, inattention, and extinction of double simultaneous stimulation, with some nondominant hemisphere lesions

The MCA supplies the upper extremity motor strip. Consequently, weakness of the arm and face is usually worse than that of the lower limb.

Anterior cerebral artery stroke

Anterior cerebral artery (ACA) occlusions primarily affect frontal lobe function. Findings in ACA stroke may include the following:

  • Disinhibition and speech perseveration
  • Primitive reflexes (eg, grasping, sucking reflexes)
  • Altered mental status
  • Impaired judgment
  • Contralateral weakness (greater in legs than arms)
  • Contralateral cortical sensory deficits
  • Gait apraxia
  • Urinary incontinence

Posterior cerebral artery stroke

Posterior cerebral artery (PCA) occlusions affect vision and thought. Manifestations include the following:

  • Contralateral homonymous hemianopsia
  • Cortical blindness
  • Visual agnosia
  • Altered mental status
  • Impaired memory

Vertebrobasilar artery occlusions are particularly difficult to localize, because they may cause a wide variety of cranial nerve, cerebellar, and brainstem deficits. These include the following:

  • Vertigo
  • Nystagmus
  • Diplopia
  • Visual field deficits
  • Dysphagia
  • Dysarthria
  • Facial hypesthesia
  • Syncope
  • Ataxia

A hallmark of posterior circulation stroke is the presence of crossed findings: ipsilateral cranial nerve deficits and contralateral motor deficits. This contrasts with anterior stroke, which produces only unilateral findings.

Lacunar stroke

Lacunar strokes result from occlusion of the small, perforating arteries of the deep subcortical areas of the brain. The infarcts are generally from 2-20 mm in diameter. The most common lacunar syndromes include pure motor, pure sensory, and ataxic hemiparetic strokes. By virtue of their small size and well-defined subcortical location, lacunar infarcts do not lead to impairments in cognition, memory, speech, or level of consciousness.

Previous
 
 
Contributor Information and Disclosures
Author

Edward C Jauch, MD, MS, FAHA, FACEP Professor, Director, Division of Emergency Medicine, Professor, Department of Neurosciences, Vice Chair of Research, Department of Medicine, Medical University of South Carolina College of Medicine; Adjunct Professor, Department of Bioengineering, Clemson University

Edward C Jauch, MD, MS, FAHA, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, American Medical Association, National Stroke Association, Society for Academic Emergency Medicine, South Carolina Medical Association

Disclosure: Received grant/research funds from Genentech for site pi.

Coauthor(s)

Brian Stettler, MD Assistant Professor, Program Director, Emergency Medicine Residency Program, Department of Emergency Medicine, and Faculty Greater Cincinnati/Northern Kentucky Stroke Team, University of Cincinnati

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2.

Acknowledgements

Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians

Disclosure: Nothing to disclose.

Joseph U Becker, MD Fellow, Global Health and International Emergency Medicine, Stanford University School of Medicine

Joseph U Becker, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Salvador Cruz-Flores, MD, MPH, FAHA, FCCM Professor of Neurology and Epidemiology, Sidney W Souers Endowed Chair, Director of Souers Stroke Institute, Cerebrovascular and Neurointensive Care Section, Director, Vascular Neurology Fellowship Training Program, Interim Chairman, Department of Neurology and Psychiatry, St Louis University School of Medicine; Director, Neuroscience Intensive Care Unit (5ICU), St Louis University Hospital

Salvador Cruz-Flores, MD, MPH, FAHA, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Neurology, American College of Physicians, American Heart Association, American Society of Neuroimaging, American Stroke Association, National Stroke Association, Neurocritical Care Society, and Society of Critical Care Medicine

Disclosure: Axio inc Honoraria Review panel membership; Roche Honoraria Review panel membership; Lilly Honoraria Review panel membership; Biotronik Honoraria Review panel membership

J Stephen Huff, MD Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard S Krause, MD Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Charles R Wira III, MD Assistant Professor, Section of Emergency Medicine, Yale University School of Medicine; DEM Liaison and Attending Physician, Yale Acute Stroke Service, Department of Neurology, Yale-New Haven Hospital

Charles R Wira III, MD is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, American Stroke Association, Neurocritical Care Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

References
  1. [Guideline] Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007 May. 38(5):1655-711. [Medline].

  2. Adams HP Jr, Davis PH, Leira EC, Chang KC, Bendixen BH, Clarke WR, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999 Jul 13. 53(1):126-31. [Medline].

  3. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995 Dec 14. 333(24):1581-7. [Medline].

  4. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, et al, et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015 Jan 27. 131 (4):e29-322. [Medline].

  5. Ovbiagele B, Goldstein LB, Higashida RT, Howard VJ, Johnston SC, Khavjou OA, et al. Forecasting the future of stroke in the United States: a policy statement from the American Heart Association and American Stroke Association. Stroke. 2013 Aug. 44 (8):2361-75. [Medline].

  6. Sacco RL, Shi T, Zamanillo MC, Kargman DE. Predictors of mortality and recurrence after hospitalized cerebral infarction in an urban community: the Northern Manhattan Stroke Study. Neurology. 1994 Apr. 44(4):626-34. [Medline].

  7. Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet. 2008 May 10. 371(9624):1612-23. [Medline].

  8. Dirnagl U, Iadecola C, Moskowitz MA. Pathobiology of ischaemic stroke: an integrated view. Trends Neurosci. 1999 Sep. 22(9):391-7. [Medline].

  9. Yuan J, Yankner BA. Apoptosis in the nervous system. Nature. 2000 Oct 12. 407(6805):802-9. [Medline].

  10. Latchaw RE, Yonas H, Hunter GJ, Yuh WT, Ueda T, Sorensen AG, et al. Guidelines and recommendations for perfusion imaging in cerebral ischemia: A scientific statement for healthcare professionals by the writing group on perfusion imaging, from the Council on Cardiovascular Radiology of the American Heart Association. Stroke. 2003 Apr. 34(4):1084-104. [Medline].

  11. Kasner SE, Grotta JC. Emergency identification and treatment of acute ischemic stroke. Ann Emerg Med. 1997 Nov. 30(5):642-53. [Medline].

  12. Gotoh O, Asano T, Koide T, Takakura K. Ischemic brain edema following occlusion of the middle cerebral artery in the rat. I: The time courses of the brain water, sodium and potassium contents and blood-brain barrier permeability to 125I-albumin. Stroke. 1985 Jan-Feb. 16(1):101-9. [Medline].

  13. Bell BA, Symon L, Branston NM. CBF and time thresholds for the formation of ischemic cerebral edema, and effect of reperfusion in baboons. J Neurosurg. 1985 Jan. 62(1):31-41. [Medline].

  14. Mullins ME, Lev MH, Schellingerhout D, Gonzalez RG, Schaefer PW. Intracranial hemorrhage complicating acute stroke: how common is hemorrhagic stroke on initial head CT scan and how often is initial clinical diagnosis of acute stroke eventually confirmed?. AJNR Am J Neuroradiol. 2005 Oct. 26(9):2207-12. [Medline].

  15. Lyden PD, Zivin JA. Hemorrhagic transformation after cerebral ischemia: mechanisms and incidence. Cerebrovasc Brain Metab Rev. 1993 Spring. 5(1):1-16. [Medline].

  16. Nighoghossian N, Hermier M, Adeleine P, Blanc-Lasserre K, Derex L, Honnorat J, et al. Old microbleeds are a potential risk factor for cerebral bleeding after ischemic stroke: a gradient-echo T2*-weighted brain MRI study. Stroke. 2002 Mar. 33(3):735-42. [Medline].

  17. González RG. Imaging-guided acute ischemic stroke therapy: From "time is brain" to "physiology is brain". AJNR Am J Neuroradiol. 2006 Apr. 27(4):728-35. [Medline].

  18. Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep. 126(3 Suppl):483S-512S. [Medline].

  19. Dubey N, Bakshi R, Wasay M, Dmochowski J. Early computed tomography hypodensity predicts hemorrhage after intravenous tissue plasminogen activator in acute ischemic stroke. J Neuroimaging. 2001 Apr. 11(2):184-8. [Medline].

  20. Brooks M. Migraine Linked to Double Risk for Silent Stroke. Medscape Medical News. Available at http://www.medscape.com/viewarticle/825451. Accessed: May 27, 2014.

  21. Anderson P. Migraine with aura 'major' contributor to all stroke types. Medscape Medical News. June 27, 2013. [Full Text].

  22. [Guideline] Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011 Feb. 42(2):517-84. [Medline]. [Full Text].

  23. Kurl S, Laukkanen JA, Rauramaa R, Lakka TA, Sivenius J, Salonen JT. Cardiorespiratory fitness and the risk for stroke in men. Arch Intern Med. 2003 Jul 28. 163(14):1682-8. [Medline].

  24. Bushnell C, McCullough LD, Awad IA, Chireau MV, Fedder WN, Furie KL, et al. Guidelines for the Prevention of Stroke in Women: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2014 Feb 6. [Medline].

  25. Hughes S. First AHA/ASA Guidelines to Reduce Stroke Risk in Women. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/820277. Accessed: February 11, 2014.

  26. Marsden PA, Heng HH, Scherer SW, Stewart RJ, Hall AV, Shi XM, et al. Structure and chromosomal localization of the human constitutive endothelial nitric oxide synthase gene. J Biol Chem. 1993 Aug 15. 268(23):17478-88. [Medline].

  27. Miller DK, Gillard JW, Vickers PJ, Sadowski S, Léveillé C, Mancini JA, et al. Identification and isolation of a membrane protein necessary for leukotriene production. Nature. 1990 Jan 18. 343(6255):278-81. [Medline].

  28. Kubo M, Hata J, Ninomiya T, Matsuda K, Yonemoto K, Nakano T, et al. A nonsynonymous SNP in PRKCH (protein kinase C eta) increases the risk of cerebral infarction. Nat Genet. 2007 Feb. 39(2):212-7. [Medline].

  29. Mudd SH, Skovby F, Levy HL, Pettigrew KD, Wilcken B, Pyeritz RE, et al. The natural history of homocystinuria due to cystathionine beta-synthase deficiency. Am J Hum Genet. 1985 Jan. 37(1):1-31. [Medline]. [Full Text].

  30. Testai FD, Gorelick PB. Inherited metabolic disorders and stroke part 2: homocystinuria, organic acidurias, and urea cycle disorders. Arch Neurol. 2010 Feb. 67(2):148-53. [Medline].

  31. Jensson O, Gudmundsson G, Arnason A, Blöndal H, Petursdottir I, Thorsteinsson L, et al. Hereditary cystatin C (gamma-trace) amyloid angiopathy of the CNS causing cerebral hemorrhage. Acta Neurol Scand. 1987 Aug. 76(2):102-14. [Medline].

  32. Oberstein SA. Diagnostic strategies in CADASIL. Neurology. 2003 Jun 24. 60(12):2020; author reply 2020. [Medline].

  33. Dichgans M. Cognition in CADASIL. Stroke. 2009 Mar. 40(3 Suppl):S45-7. [Medline].

  34. Cheng YC, O'Connell JR, Cole JW, Stine OC, Dueker N, McArdle PF, et al. Genome-wide association analysis of ischemic stroke in young adults. G3 (Bethesda). 2011 Nov. 1(6):505-14. [Medline]. [Full Text].

  35. The International Stroke Genetics Consortium (ISGC); the Wellcome Trust Case Control Consortium 2 (WTCCC2), Bellenguez C, Bevan S, Gschwendtner A, Spencer CC, et al. Genome-wide association study identifies a variant in HDAC9 associated with large vessel ischemic stroke. Nat Genet. 2012 Feb 5. 44(3):328-33. [Medline]. [Full Text].

  36. Arregui M, Fisher E, Knüppel S, Buijsse B, di Giuseppe R, Fritsche A, et al. Significant associations of the rs2943634 (2q36.3) genetic polymorphism with adiponectin, high density lipoprotein cholesterol and ischemic stroke. Gene. 2012 Feb 25. 494(2):190-5. [Medline].

  37. Ikram MA, Seshadri S, Bis JC, Fornage M, DeStefano AL, Aulchenko YS, et al. Genomewide association studies of stroke. N Engl J Med. 2009 Apr 23. 360(17):1718-28. [Medline]. [Full Text].

  38. Arboix A, Alio J. Acute cardioembolic cerebral infarction: answers to clinical questions. Curr Cardiol Rev. 2012 Feb. 8(1):54-67. [Medline]. [Full Text].

  39. Witt BJ, Ballman KV, Brown RD Jr, Meverden RA, Jacobsen SJ, Roger VL. The incidence of stroke after myocardial infarction: a meta-analysis. Am J Med. 2006 Apr. 119(4):354.e1-9. [Medline].

  40. Wessels T, Wessels C, Ellsiepen A, Reuter I, Trittmacher S, Stolz E. Contribution of diffusion-weighted imaging in determination of stroke etiology. AJNR Am J Neuroradiol. 2006 Jan. 27(1):35-9. [Medline].

  41. Roh JK, Kang DW, Lee SH, Yoon BW, Chang KH. Significance of acute multiple brain infarction on diffusion-weighted imaging. Stroke. 2000 Mar. 31(3):688-94. [Medline].

  42. Adams H, Adams R, Del Zoppo G, Goldstein LB. Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update a scientific statement from the Stroke Council of the American Heart Association/American Stroke Association. Stroke. 2005 Apr. 36(4):916-23. [Medline].

  43. Derdeyn CP, Khosla A, Videen TO, Fritsch SM, Carpenter DL, Grubb RL Jr. Severe hemodynamic impairment and border zone--region infarction. Radiology. 2001 Jul. 220(1):195-201. [Medline].

  44. Pollanen MS, Deck JH. Directed embolization is an alternate cause of cerebral watershed infarction. Arch Pathol Lab Med. 1989 Oct. 113(10):1139-41. [Medline].

  45. Waterston JA, Brown MM, Butler P, Swash M. Small deep cerebral infarcts associated with occlusive internal carotid artery disease. A hemodynamic phenomenon?. Arch Neurol. 1990 Sep. 47(9):953-7. [Medline].

  46. U.S. Centers for Disease Control and Prevention and the Heart Disease and Stroke Statistics - 2007 Update, published by the American Heart Association. Available at http://www.strokecenter.org/patients/stats.htm. Accessed: September 2008.

  47. Towfighi A, Saver JL. Stroke declines from third to fourth leading cause of death in the United States: historical perspective and challenges ahead. Stroke. 2011 Aug. 42(8):2351-5. [Medline].

  48. MacKay J, Mensah GA. World Health Organization. Global Burden of Stroke. The Atlas of Heart Disease and Stroke. Available at http://www.who.int/cardiovascular_diseases/en/cvd_atlas_15_burden_stroke.pdf.

  49. Schneider AT, Kissela B, Woo D, Kleindorfer D, Alwell K, Miller R, et al. Ischemic stroke subtypes: a population-based study of incidence rates among blacks and whites. Stroke. 2004 Jul. 35(7):1552-6. [Medline].

  50. Fonarow GC, Saver JL, Smith EE, Broderick JP, Kleindorfer DO, Sacco RL, et al. Relationship of national institutes of health stroke scale to 30-day mortality in medicare beneficiaries with acute ischemic stroke. J Am Heart Assoc. 2012 Feb. 1(1):42-50. [Medline]. [Full Text].

  51. von Kummer R, Allen KL, Holle R, Bozzao L, Bastianello S, Manelfe C, et al. Acute stroke: usefulness of early CT findings before thrombolytic therapy. Radiology. 1997 Nov. 205(2):327-33. [Medline].

  52. Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA. 1995 Oct 4. 274(13):1017-25. [Medline].

  53. Bruno A, Levine SR, Frankel MR, Brott TG, Lin Y, Tilley BC, et al. Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial. Neurology. 2002 Sep 10. 59(5):669-74. [Medline].

  54. Bruno A, Biller J, Adams HP Jr, Clarke WR, Woolson RF, Williams LS, et al. Acute blood glucose level and outcome from ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. Neurology. 1999 Jan 15. 52(2):280-4. [Medline].

  55. Baird TA, Parsons MW, Phanh T, Butcher KS, Desmond PM, Tress BM, et al. Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome. Stroke. 2003 Sep. 34(9):2208-14. [Medline].

  56. Mandelzweig L, Goldbourt U, Boyko V, Tanne D. Perceptual, social, and behavioral factors associated with delays in seeking medical care in patients with symptoms of acute stroke. Stroke. 2006 May. 37(5):1248-53. [Medline].

  57. National Institutes of Health Stroke Scale. Available at http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf. Accessed: October 2008.

  58. Huff JS. Stroke mimics and chameleons. Emerg Med Clin North Am. 2002 Aug. 20(3):583-95. [Medline].

  59. Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Arch Neurol. 1995 Nov. 52(11):1119-22. [Medline].

  60. Runchey S, McGee S. Does this patient have a hemorrhagic stroke?: clinical findings distinguishing hemorrhagic stroke from ischemic stroke. JAMA. 2010 Jun 9. 303(22):2280-6. [Medline].

  61. Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann E, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurolo... Stroke. 2009 Jun. 40(6):2276-93. [Medline].

  62. Tintinalli J, Kellen G, Stapczynski J. American College of Emergency Physicians. Emergency Medicine: A Comprehensive Study Guide. 6th. New York: McGraw Hill; 2004. 1382-1390.

  63. Leira EC, Chang KC, Davis PH, Clarke WR, Woolson RF, Hansen MD, et al. Can we predict early recurrence in acute stroke?. Cerebrovasc Dis. 2004. 18(2):139-44. [Medline].

  64. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005 Sep 3-9. 366(9488):809-17. [Medline].

  65. Byrne JV. The aneurysm "clip or coil" debate. Acta Neurochir (Wien). 2006 Feb. 148(2):115-20. [Medline].

  66. Sorensen AG, Buonanno FS, Gonzalez RG, Schwamm LH, Lev MH, Huang-Hellinger FR, et al. Hyperacute stroke: evaluation with combined multisection diffusion-weighted and hemodynamically weighted echo-planar MR imaging. Radiology. 1996 May. 199(2):391-401. [Medline].

  67. González RG, Schaefer PW, Buonanno FS, Schwamm LH, Budzik RF, Rordorf G, et al. Diffusion-weighted MR imaging: diagnostic accuracy in patients imaged within 6 hours of stroke symptom onset. Radiology. 1999 Jan. 210(1):155-62. [Medline].

  68. Marks MP, Olivot JM, Kemp S, Lansberg MG, Bammer R, Wechsler LR, et al. Patients with acute stroke treated with intravenous tPA 3-6 hours after stroke onset: correlations between MR angiography findings and perfusion- and diffusion-weighted imaging in the DEFUSE study. Radiology. 2008 Nov. 249(2):614-23. [Medline]. [Full Text].

  69. Schellinger PD, Bryan RN, Caplan LR, Detre JA, Edelman RR, Jaigobin C, et al. Evidence-based guideline: The role of diffusion and perfusion MRI for the diagnosis of acute ischemic stroke: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2010 Jul 13. 75(2):177-85. [Medline].

  70. Sorensen AG, Copen WA, Ostergaard L, Buonanno FS, Gonzalez RG, Rordorf G, et al. Hyperacute stroke: simultaneous measurement of relative cerebral blood volume, relative cerebral blood flow, and mean tissue transit time. Radiology. 1999 Feb. 210(2):519-27. [Medline].

  71. Camerlingo M, Casto L, Censori B, Ferraro B, Gazzaniga GC, Mamoli A. Transcranial Doppler in acute ischemic stroke of the middle cerebral artery territories. Acta Neurol Scand. 1993 Aug. 88(2):108-11. [Medline].

  72. Sagar G, Riley P, Vohrah A. Is admission chest radiography of any clinical value in acute stroke patients?. Clin Radiol. 1996 Jul. 51(7):499-502. [Medline].

  73. Meerwaldt R, Slart RH, van Dam GM, Luijckx GJ, Tio RA, Zeebregts CJ. PET/SPECT imaging: from carotid vulnerability to brain viability. Eur J Radiol. 2010 Apr. 74(1):104-9. [Medline].

  74. Handschu R, Poppe R, Rauss J, Neundörfer B, Erbguth F. Emergency calls in acute stroke. Stroke. 2003 Apr. 34(4):1005-9. [Medline].

  75. Williams JE, Rosamond WD, Morris DL. Stroke symptom attribution and time to emergency department arrival: the delay in accessing stroke healthcare study. Acad Emerg Med. 2000 Jan. 7(1):93-6. [Medline].

  76. Zweifler RM, Mendizabal JE, Cunningham S, Shah AK, Rothrock JF. Hospital presentation after stroke in a community sample: the Mobile Stroke Project. South Med J. 2002 Nov. 95(11):1263-8. [Medline].

  77. Lacy CR, Suh DC, Bueno M, Kostis JB. Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.). Stroke. 2001 Jan. 32(1):63-9. [Medline].

  78. Puolakka T, Väyrynen T, Häppölä O, Soinne L, Kuisma M, Lindsberg PJ. Sequential analysis of pretreatment delays in stroke thrombolysis. Acad Emerg Med. 2010 Sep. 17(9):965-9. [Medline].

  79. Ford AL, Williams JA, Spencer M, McCammon C, Khoury N, Sampson TR, et al. Reducing door-to-needle times using Toyota's lean manufacturing principles and value stream analysis. Stroke. 2012 Dec. 43(12):3395-8. [Medline]. [Full Text].

  80. Bruno A, Kent TA, Coull BM, Shankar RR, Saha C, Becker KJ, et al. Treatment of hyperglycemia in ischemic stroke (THIS): a randomized pilot trial. Stroke. 2008 Feb. 39(2):384-9. [Medline].

  81. Bellolio MF, Gilmore RM, Stead LG. Insulin for glycaemic control in acute ischaemic stroke. Cochrane Database Syst Rev. 2011 Sep 7. 9:CD005346. [Medline].

  82. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008 Sep 25. 359(13):1317-29. [Medline].

  83. [Guideline] Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009 Aug. 40(8):2945-8. [Medline]. [Full Text].

  84. Wahlgren N, Ahmed N, Dávalos A, Hacke W, Millán M, Muir K, et al. Thrombolysis with alteplase 3-4.5 h after acute ischaemic stroke (SITS-ISTR): an observational study. Lancet. 2008 Oct 11. 372(9646):1303-9. [Medline].

  85. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2013 Jan 31. [Medline].

  86. Brooks M. Stroke a Race Against the Clock, Review Confirms. Medscape Medical News. Available at http://www.medscape.com/viewarticle/830611. Accessed: September 2, 2014.

  87. Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. 2014 Aug 5. [Medline].

  88. Strbian D, Ringleb P, Michel P,et al. Ultra-early intravenous stroke thrombolysis: do all patients benefit similarly?. Stroke. 2013 Aug 22. [Medline].

  89. Brooks M. Ultra-Early' Thrombolysis Cuts Disability in Mild Stroke. Medscape Medical News. Aug 28 2013. [Full Text].

  90. Diedler J, Ahmed N, Sykora M, Uyttenboogaart M, Overgaard K, Luijckx GJ, et al. Safety of intravenous thrombolysis for acute ischemic stroke in patients receiving antiplatelet therapy at stroke onset. Stroke. 2010 Feb. 41(2):288-94. [Medline].

  91. Xian Y, Federspiel JJ, Grau-Sepulveda M, Hernandez AF, Schwamm LH, Bhatt DL, et al. Risks and Benefits Associated With Prestroke Antiplatelet Therapy Among Patients With Acute Ischemic Stroke Treated With Intravenous Tissue Plasminogen Activator. JAMA Neurol. 2015 Nov 9. 1-10. [Medline].

  92. Alexandrov AV, Molina CA, Grotta JC, Garami Z, Ford SR, Alvarez-Sabin J, et al. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med. 2004 Nov 18. 351(21):2170-8. [Medline].

  93. Tsivgoulis G, Eggers J, Ribo M, Perren F, Saqqur M, Rubiera M, et al. Safety and efficacy of ultrasound-enhanced thrombolysis: a comprehensive review and meta-analysis of randomized and nonrandomized studies. Stroke. 2010 Feb. 41(2):280-7. [Medline].

  94. Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med. 2013 Mar 7. 368(10):893-903. [Medline]. [Full Text].

  95. Schonewille WJ, Wijman CA, Michel P, Rueckert CM, Weimar C, Mattle HP, et al. Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. Lancet Neurol. 2009 Aug. 8(8):724-30. [Medline].

  96. Lindsberg PJ, Mattle HP. Therapy of basilar artery occlusion: a systematic analysis comparing intra-arterial and intravenous thrombolysis. Stroke. 2006 Mar. 37(3):922-8. [Medline].

  97. CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. CAST (Chinese Acute Stroke Trial) Collaborative Group. Lancet. 1997 Jun 7. 349(9066):1641-9. [Medline].

  98. The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet. 1997 May 31. 349(9065):1569-81. [Medline].

  99. Abciximab in acute ischemic stroke: a randomized, double-blind, placebo-controlled, dose-escalation study. The Abciximab in Ischemic Stroke Investigators. Stroke. 2000 Mar. 31(3):601-9. [Medline].

  100. Adams HP Jr, Effron MB, Torner J, Dávalos A, Frayne J, Teal P, et al. Emergency administration of abciximab for treatment of patients with acute ischemic stroke: results of an international phase III trial: Abciximab in Emergency Treatment of Stroke Trial (AbESTT-II). Stroke. 2008 Jan. 39(1):87-99. [Medline].

  101. Sare GM, Geeganage C, Bath PM. High blood pressure in acute ischaemic stroke--broadening therapeutic horizons. Cerebrovasc Dis. 2009. 27 Suppl 1:156-61. [Medline].

  102. Potter JF, Robinson TG, Ford GA, Mistri A, James M, Chernova J, et al. Controlling hypertension and hypotension immediately post-stroke (CHHIPS): a randomised, placebo-controlled, double-blind pilot trial. Lancet Neurol. 2009 Jan. 8(1):48-56. [Medline].

  103. Sandset EC, Bath PM, Boysen G, Jatuzis D, Kõrv J, Lüders S, et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet. 2011 Feb 26. 377(9767):741-50. [Medline].

  104. Jeffrey S. CATIS: No Benefit of BP Reduction in Acute Phase of Stroke. Medscape Medical News. Available at http://www.medscape.com/viewarticle/814531. Accessed: November 24, 2013.

  105. He J, Zhang Y, Xu T, Zhao Q, Wang D, Chen CS, et al. Effects of Immediate Blood Pressure Reduction on Death and Major Disability in Patients With Acute Ischemic Stroke: The CATIS Randomized Clinical Trial. JAMA. 2013 Nov 17. [Medline].

  106. [Guideline] Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, et al. 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015 Jun 29. [Medline].

  107. Gobin YP, Starkman S, Duckwiler GR, Grobelny T, Kidwell CS, Jahan R, et al. MERCI 1: a phase 1 study of Mechanical Embolus Removal in Cerebral Ischemia. Stroke. 2004 Dec. 35(12):2848-54. [Medline].

  108. Smith WS, Sung G, Starkman S, Saver JL, Kidwell CS, Gobin YP, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. 2005 Jul. 36(7):1432-8. [Medline].

  109. Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008 Apr. 39(4):1205-12. [Medline].

  110. Bose A, Henkes H, Alfke K, Reith W, Mayer TE, Berlis A. The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism. AJNR Am J Neuroradiol. 2008 Aug. 29(7):1409-13. [Medline].

  111. Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 2012 Oct 6. 380(9849):1241-9. [Medline].

  112. Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet. 2012 Oct 6. 380(9849):1231-40. [Medline].

  113. Anderson P. Medical management still bests intracranial stenting. Medscape Medical News. October 31, 2013. [Full Text].

  114. Derdeyn CP, Chimowitz MI, Lynn MJ, Fiorella D, Turan TN, Janis LS, et al. Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial. Lancet. 2013 Oct 25. [Medline].

  115. Rothwell PM, Markus HS. Improved medical treatment in secondary prevention of stroke. Lancet. 2013 Oct 25. [Medline].

  116. Marion DW. Controlled normothermia in neurologic intensive care. Crit Care Med. 2004 Feb. 32(2 Suppl):S43-5. [Medline].

  117. Olsen TS, Weber UJ, Kammersgaard LP. Therapeutic hypothermia for acute stroke. Lancet Neurol. 2003 Jul. 2(7):410-6. [Medline].

  118. Hemmen TM, Raman R, Guluma KZ, Meyer BC, Gomes JA, Cruz-Flores S, et al. Intravenous thrombolysis plus hypothermia for acute treatment of ischemic stroke (ICTuS-L): final results. Stroke. 2010 Oct. 41(10):2265-70. [Medline].

  119. den Hertog HM, van der Worp HB, van Gemert HM, Algra A, Kappelle LJ, van Gijn J, et al. The Paracetamol (Acetaminophen) In Stroke (PAIS) trial: a multicentre, randomised, placebo-controlled, phase III trial. Lancet Neurol. 2009 May. 8(5):434-40. [Medline].

  120. Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol. 2009 Apr. 8(4):326-33. [Medline].

  121. Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke. 2007 Sep. 38(9):2518-25. [Medline].

  122. Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007 Mar. 6(3):215-22. [Medline].

  123. Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke. 2007 Sep. 38(9):2506-17. [Medline].

  124. Wijdicks EF, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, et al. Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2014 Jan 30. [Medline].

  125. Hughes S. AHA/ASA Guideline on Stroke With Brain Swelling. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/820481. Accessed: February 25, 2014.

  126. Padma V, Fisher M, Moonis M. Role of heparin and low-molecular-weight heparins in the management of acute ischemic stroke. Expert Rev Cardiovasc Ther. 2006 May. 4(3):405-15. [Medline].

  127. CLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration. Dennis M, Sandercock P, Reid J, Graham C, Forbes J, Murray G. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet. 2013 Aug 10. 382(9891):516-24. [Medline].

  128. Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration. BMJ. 1994 Jan 8. 308(6921):81-106. [Medline]. [Full Text].

  129. Amarenco P, Bogousslavsky J, Callahan A 3rd, Goldstein LB, Hennerici M, Rudolph AE, et al. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006 Aug 10. 355(6):549-59. [Medline].

  130. Chimowitz MI, Lynn MJ, Howlett-Smith H, Stern BJ, Hertzberg VS, Frankel MR, et al. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med. 2005 Mar 31. 352(13):1305-16. [Medline].

  131. Baigent C, Blackwell L, Collins R, Emberson J, Godwin J, Peto R, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009 May 30. 373(9678):1849-60. [Medline]. [Full Text].

  132. Ridker PM, Cook NR, Lee IM, Gordon D, Gaziano JM, Manson JE, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med. 2005 Mar 31. 352(13):1293-304. [Medline].

  133. [Guideline] Hughes S. New AHA/ASA Stroke Secondary Prevention Guidelines. Medscape Medical News. May 2 2014. [Full Text].

  134. [Guideline] Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2014 May 1. [Medline]. [Full Text].

  135. Geeganage CM, Diener HC, Algra A, Chen C, Topol EJ, Dengler R, et al. Dual or mono antiplatelet therapy for patients with acute ischemic stroke or transient ischemic attack: systematic review and meta-analysis of randomized controlled trials. Stroke. 2012 Apr. 43(4):1058-66. [Medline].

  136. Halkes PH, van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A. Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): randomised controlled trial. Lancet. 2006 May 20. 367(9523):1665-73. [Medline].

  137. Dengler R, Diener HC, Schwartz A, Grond M, Schumacher H, Machnig T, et al. Early treatment with aspirin plus extended-release dipyridamole for transient ischaemic attack or ischaemic stroke within 24 h of symptom onset (EARLY trial): a randomised, open-label, blinded-endpoint trial. Lancet Neurol. 2010 Feb. 9(2):159-66. [Medline].

  138. Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet. 2004 Jul 24-30. 364(9431):331-7. [Medline].

  139. Connolly S, Pogue J, Hart R, Pfeffer M, Hohnloser S, Chrolavicius S, et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006 Jun 10. 367(9526):1903-12. [Medline].

  140. [Guideline] Wann LS, Curtis AB, Ellenbogen KA, Estes NA 3rd, Ezekowitz MD, Jackman WM, et al. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on Dabigatran): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2011 Mar 15. 123(10):1144-50. [Medline]. [Full Text].

  141. Uchino K, Hernandez AV. Dabigatran association with higher risk of acute coronary events: meta-analysis of noninferiority randomized controlled trials. Arch Intern Med. 2012 Mar 12. 172(5):397-402. [Medline].

  142. [Guideline] Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke. 2011 Jan. 42(1):227-76. [Medline]. [Full Text].

  143. Hughes S. Endovascular Stroke Therapy Proven at Last: MR CLEAN Published. Medscape Medical News. Dec 17 2014. [Full Text].

  144. Berkhemer OA, Fransen PS, Beumer D, et al. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. N Engl J Med. 2014 Dec 17. [Medline].

  145. Anderson P. Wait on elective surgery after stroke. Medscape Medical News. July 17, 2014. [Full Text].

  146. Chiong W, Kim AS, Huang IA, Farahany NA, Josephson SA. Testing the presumption of consent to emergency treatment for acute ischemic stroke. JAMA. 2014 Apr 23-30. 311(16):1689-91. [Medline].

  147. Ebinger M, Winter B, Wendt M, Weber JE, Waldschmidt C, Rozanski M, et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA. 2014 Apr 23-30. 311(16):1622-31. [Medline].

  148. Fonarow GC, Zhao X, Smith EE, Saver JL, Reeves MJ, Bhatt DL, et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA. 2014 Apr 23-30. 311(16):1632-40. [Medline].

  149. Hughes S. DESTINY II: benefit of surgery for stroke with swelling. Medscape Medical News. March 24, 2014. [Full Text].

  150. Jeffrey S. TARGET: STROKE Cuts Door-to-Needle Time, Improves Outcomes. Medscape Medical News. Available at http://www.medscape.com/viewarticle/824008. Accessed: April 29, 2014.

  151. Jørgensen ME, Torp-Pedersen C, Gislason GH, Jensen PF, Berger SM, Christiansen CB, et al. Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery. JAMA. 2014 Jul 16. 312(3):269-77. [Medline].

  152. Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 2014 Mar 20. 370(12):1091-100. [Medline].

  153. Ropper AH. Hemicraniectomy--to halve or halve not. N Engl J Med. 2014 Mar 20. 370(12):1159-60. [Medline].

  154. Shiber JR, Fontane E, Adewale A. Stroke registry: hemorrhagic vs ischemic strokes. Am J Emerg Med. 2010 Mar. 28(3):331-3. [Medline].

 
Previous
Next
 
Maximum intensity projection (MIP) image from a computed tomography angiogram (CTA) demonstrates a filling defect or high-grade stenosis at the branching point of the right middle cerebral artery (MCA) trunk (red circle), suspicious for thrombus or embolus. CTA is highly accurate in detecting large- vessel stenosis and occlusions, which account for approximately one third of ischemic strokes.
Axial noncontrast computed tomography (NCCT) scan demonstrates diffuse hypodensity in the right lentiform nucleus with mass effect upon the frontal horn of the right lateral ventricle in a 70-year-old woman with a history of left-sided weakness for several hours.
Magnetic resonance imaging (MRI) scan in a 70-year-old woman with a history of left-sided weakness for several hours. An axial T2 fluid-attenuated inversion recovery (FLAIR) image (left) demonstrates high signal in the lentiform nucleus with mass effect. The axial diffusion-weighted image (middle) demonstrates high signal in the same area, with corresponding low signal on the apparent diffusion coefficient (ADC) maps, consistent with true restricted diffusion and an acute infarction. Maximum intensity projection from a 3-dimensional (3-D) time-of-flight magnetic resonance angiogram (MRA, right) demonstrates occlusion of the distal middle cerebral artery (MCA) trunk (red circle).
Cardioembolic stroke: Axial diffusion-weighted images demonstrate scattered foci of high signal in the subcortical and deep white matter bilaterally in a patient with a known cardiac source for embolization. An area of low signal in the left gangliocapsular region may be secondary to prior hemorrhage or subacute to chronic lacunar infarct. Recurrent strokes are most commonly secondary to cardioembolic phenomenon.
Axial noncontrast computed tomography (CT) scan demonstrates a focal area of hypodensity in the left posterior limb of the internal capsule in a 60-year-old man with acute onset of right-sided weakness. The lesion demonstrates high signal on the fluid-attenuated inversion recovery (FLAIR) sequence (middle image) and diffusion-weighted magnetic resonance imaging (MRI) scan (right image), with low signal on the apparent diffusion coefficient (ADC) maps indicating an acute lacunar infarction. Lacunar infarcts are typically no more than 1.5 cm in size and can occur in the deep gray matter structures, corona radiata, brainstem, and cerebellum.
Magnetic resonance imaging (MRI) scan was obtained in a 62-year-old man with hypertension and diabetes and a history of transient episodes of right-sided weakness and aphasia. The fluid-attenuated inversion recovery (FLAIR) image (left) demonstrates patchy areas of high signal arranged in a linear fashion in the deep white matter, bilaterally. This configuration is typical for deep border-zone, or watershed, infarction, in this case the anterior and posterior middle cerebral artery (MCA) watershed areas. The left-sided infarcts have corresponding low signal on the apparent diffusion coefficient (ADC) map (right), signifying acuity. An old left posterior parietal infarct is noted as well.
A 48-year-old man presented with acute left-sided hemiplegia, facial palsy, and right-sided gaze preference. Angiogram with selective injection of the right internal carotid artery demonstrates occlusion of the M1 segment of the right middle cerebral artery (MCA) and A2 segment of the right anterior cerebral artery (ACA; images courtesy of Concentric Medical).
Follow-up imaging after mechanical embolectomy in 48-year-old man with acute left-sided hemiplegia, facial palsy, and right-sided gaze preference demonstrates complete recanalization of the right middle cerebral artery (MCA) and partial recanalization of the right A2 segment (images courtesy of Concentric Medical).
Cerebral angiogram performed approximately 4.5 hours after symptom onset in a 31-year-old man demonstrates an occlusion of the distal basilar artery (images courtesy of Concentric Medical).
Image on the left demonstrates deployment of a clot retrieval device in a 31-year-old man. Followup angiogram after embolectomy demonstrates recanalization of the distal basilar artery with filling of the superior cerebellar arteries and posterior cerebral arteries. The patient had complete resolution of symptoms following embolectomy (images courtesy of Concentric Medical).
Noncontrast computed tomography (CT) scan in a 52-year-old man with a history of worsening right-sided weakness and aphasia demonstrates diffuse hypodensity and sulcal effacement with mass effect involving the left anterior and middle cerebral artery territories consistent with acute infarction. There are scattered curvilinear areas of hyperdensity noted suggestive of developing petechial hemorrhage in this large area of infarction.
Magnetic resonance angiogram (MRA) in a 52-year-old man demonstrates occlusion of the left precavernous supraclinoid internal carotid artery (ICA, red circle), occlusion or high-grade stenosis of the distal middle cerebral artery (MCA) trunk and attenuation of multiple M2 branches. The diffusion-weighted image (right) demonstrates high signal confirmed to be true restricted diffusion on the apparent diffusion coefficient (ADC) map consistent with acute infarction.
Lateral view of a cerebral angiogram illustrates the branches of the anterior cerebral artery (ACA) and Sylvian triangle. The pericallosal artery has been described to arise distal to the anterior communicating artery or distal to the origin of the callosomarginal branch of the ACA. The segmental anatomy of the ACA has been described as follows: the A1 segment extends from the internal carotid artery (ICA) bifurcation to the anterior communicating artery; A2 extends to the junction of the rostrum and genu of the corpus callosum; A3 extends into the bend of the genu of the corpus callosum; A4 and A5 extend posteriorly above the callosal body and superior portion of the splenium. The Sylvian triangle overlies the opercular branches of the middle cerebral artery (MCA), with the apex representing the Sylvian point.
Frontal projection from a right vertebral artery angiogram illustrates the posterior circulation. The vertebral arteries join to form the basilar artery. The posterior inferior cerebellar arteries (PICAs) arise from the distal vertebral arteries. The anterior inferior cerebellar arteries (AICAs) arise from the proximal basilar artery. The superior cerebellar arteries (SICAs) arise distally from the basilar artery prior to its bifurcation into the posterior cerebral arteries (PCAs).
Frontal view of a cerebral angiogram with selective injection of the left internal carotid artery (ICA) illustrates the anterior circulation. The anterior cerebral artery (ACA) consists of the A1 segment proximal to the anterior communicating artery, with the A2 segment distal to it. The middle cerebral artery (MCA) can be divided into 4 segments: the M1 (horizontal segment) extends to the anterior basal portion of the insular cortex (the limen insulae) and gives off lateral lenticulostriate branches, the M2 (insular segment), M3 (opercular branches), and M4 (distal cortical branches on the lateral hemispheric convexities).
Regions of interest are selected for arterial and venous input (image on left) for dynamic susceptibility-weighted perfusion magnetic resonance imaging (MRI). Signal-time curves (image on right) obtained from these regions of interest demonstrate transient signal drop following the administration of intravenous contrast. The information obtained from the dynamic parenchymal signal changes postcontrast is used to generate maps of different perfusion parameters.
Vascular distributions: Middle cerebral artery (MCA) infarction. Noncontrast computed tomography (CT) scanning demonstrates a large acute infarction in the MCA territory involving the lateral surfaces of the left frontal, parietal, and temporal lobes, as well as the left insular and subinsular regions, with mass effect and rightward midline shift. There is sparing of the caudate head and at least part of the lentiform nucleus and internal capsule, which receive blood supply from the lateral lenticulostriate branches of the M1 segment of the MCA. Note the lack of involvement of the medial frontal lobe (anterior cerebral artery [ACA] territory), thalami, and paramedian occipital lobe (posterior cerebral artery [PCA] territory).
Vascular distributions: Anterior choroidal artery infarction. The diffusion-weighted image (left) demonstrates high signal with associated signal dropout on the apparent diffusion coefficient (ADC) map involving the posterior limb of the internal capsule. This is the typical distribution of the anterior choroidal artery, the last branch of the internal carotid artery (ICA) before bifurcating into the anterior and middle cerebral arteries. The anterior choroidal artery may also arise from the middle cerebral artery (MCA).
Vascular distributions: Anterior cerebral artery (ACA) infarction. Diffusion-weighted image on the left demonstrates high signal in the paramedian frontal and high parietal regions. The opposite diffusion-weighted image in a different patient demonstrates restricted diffusion in a larger ACA infarction involving the left paramedian frontal and posterior parietal regions. There is also infarction of the lateral temporoparietal regions bilaterally (both middle cerebral artery [MCA] distributions), greater on the left indicating multivessel involvement and suggesting emboli.
Vascular distributions: Posterior cerebral artery (PCA) infarction. The noncontrast computed tomography (CT) images demonstrate PCA distribution infarction involving the right occipital and inferomedial temporal lobes. The image on the right demonstrates additional involvement of the thalamus, also part of the PCA territory.
The supratentorial vascular territories of the major cerebral arteries are demonstrated superimposed on axial (left) and coronal (right) T2-weighted images through the level of the basal ganglia and thalami. The middle cerebral artery (MCA; red) supplies the lateral aspects of the hemispheres, including the lateral frontal, parietal, and anterior temporal lobes; insula; and basal ganglia. The anterior cerebral artery (ACA; blue) supplies the medial frontal and parietal lobes. The posterior cerebral artery (PCA; green) supplies the thalami and occipital and inferior temporal lobes. The anterior choroidal artery (yellow) supplies the posterior limb of the internal capsule and part of the hippocampus extending to the anterior and superior surface of the occipital horn of the lateral ventricle.
Table 1. Vascular Supply to the Brain
VASCULAR TERRITORY Structures Supplied
Anterior Circulation (Carotid)
Anterior Cerebral Artery Cortical branches: medial frontal and parietal lobe



Medial lenticulostriate branches: caudate head, globus pallidus, anterior limb of internal capsule



Middle Cerebral Artery Cortical branches: lateral frontal and parietal lobes lateral and anterior temporal lobe



Lateral lenticulostriate branches: globus pallidus and putamen, internal capsule



Anterior Choroidal Artery Optic tracts, medial temporal lobe, ventrolateral thalamus, corona radiata, posterior limb of the internal capsule
Posterior Circulation (Vertebrobasilar)
Posterior Cerebral Artery Cortical branches: occipital lobes, medial and posterior temporal and parietal lobes



Perforating branches: brainstem, posterior thalamus and midbrain



Posterior Inferior Cerebellar Artery Inferior vermis; posterior and inferior cerebellar hemispheres
Anterior Inferior Cerebellar Artery Anterolateral cerebellum
Superior Cerebellar Artery Superior vermis; superior cerebellum
Table 2. National Institutes of Health Stroke Scale
  Category Description Score
1a level of consciousness (LOC) Alert



Drowsy



Stuporous



Coma



0



1



2



3



1b LOC questions (month, age) Answers both correctly



Answers 1 correctly



Incorrect on both



0



1



2



1c LOC commands (open and close eyes,



grip and release nonparetic hand)



Obeys both correctly



Obeys 1 correctly



Incorrect on both



0



1



2



2 Best gaze (follow finger) Normal



Partial gaze palsy



Forced deviation



0



1



2



3 Best visual (visual fields) No visual loss



Partial hemianopia



Complete hemianopia



Bilateral hemianopia



0



1



2



3



4 Facial palsy (show teeth, raise brows,



squeeze eyes shut)



Normal



Minor



Partial



Complete



0



1



2



3



5 Motor arm left* (raise 90°, hold 10 seconds) No drift



Drift



Cannot resist gravity



No effort against gravity



No movement



0



1



2



3



4



6 Motor arm right* (raise 90°, hold 10 seconds) No drift



Drift



Cannot resist gravity



No effort against gravity



No movement



0



1



2



3



4



7 Motor leg left* (raise 30°, hold 5 seconds) No drift



Drift



Cannot resist gravity



No effort against gravity



No movement



0



1



2



3



4



8 Motor leg right* (raise 30°, hold 5 seconds) No drift



Drift



Cannot resist gravity



No effort against gravity



No movement



0



1



2



3



4



9 Limb ataxia (finger-nose, heel-shin) Absent



Present in 1 limb



Present in 2 limbs



0



1



2



10 Sensory (pinprick to face, arm, leg) Normal



Partial loss



Severe loss



0



1



2



11 Extinction/neglect (double simultaneous testing) No neglect



Partial neglect



Complete neglect



0



1



2



12 Dysarthria (speech clarity to "mama,



baseball, huckleberry, tip-top, fifty-fifty")



Normal articulation



Mild to moderate dysarthria



Near to unintelligible or worse



0



1



2



13 Best language** (name items,



describe pictures)



No aphasia



Mild to moderate aphasia



Severe aphasia



Mute



0



1



2



3



  Total - 0-42
* For limbs with amputation, joint fusion, etc, score 9 and explain.



** For intubation or other physical barriers to speech, score 9 and explain. Do not add 9 to the total score. NIH Stroke Scale (PDF)



Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.