Approach to Stroke

A stroke (also called a cerebrovascular accident, CVA) is an acute disturbance of the cerebral perfusion or vasculature. Approximately 85% of strokes are ischemic (blockage of a vessel) and remainder are hemorrhagic.

CHA₂DS₂-VASc Score

Ntaios G, et al. CHADS2, CHA2DS2-VASc, and long-term stroke outcome in patients without atrial fibrillation. March 12, 2013 80:1009-1017
Criteria Points
Age • <65 years old = 0
• 65-74 years old = +1
• ≥75 years old = +2
Sex • Male = 0
• Female = +1
Congestive heart failure history +1
Hypertension history +1
Stroke/TIA/thromboembolism history +2
Vascular disease history
(Prior MI, peripheral artery disease, or aortic plaque)
+1
Diabetes mellitus history +1

CHA₂DS₂-VASc Score Interpretation

Lip G et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010 Feb;137(2):263-72. doi: 10.1378/chest.09-1584. Epub 2009 Sep 17.
CHA₂DS₂-VASc Score Risk of ischemic stroke Risk of stroke/TIA/systemic embolism
0 0.2% 0.3%
1 0.6% 0.9%
2 2.2% 2.9%
3 3.2% 4.6%
4 4.8% 6.7%
5 7.2% 10.0%
6 9.7% 13.6%
7 11.2% 15.7%
8 10.8% 15.2%
9 12.2% 17.4%

Strokes can be caused by anyone of the following pathophysiological processes:

  • Large artery atherosclerosis (20%)
  • Small vessel lacunar (lacunar = deep vessels) stroke (25%)
  • Cardioembolism (due to arrythmias such as atrial fibrillation) (20%)
  • Cryptogenic (i.e. - cannot be determined) (30%)

Atherosclerosis, Atrial Fibrillation (Cardioembolism), and Stroke Risk

  • Anytime an individual has atrial fibrillation, there is an increased stroke risk!
  • If an individual symptomatic carotid stenosis, with symptoms such unilateral weakness or amaurosis fugax (i.e. - transient loss of vision in one eye), there is a 25% chance of stroke in the next year!
  • Therefore, for these individuals it is recommended that the receive a carotid endartectomy
    • If asymptomatic, they be can treated with anti-platelets
  • Location: cerebral hemisphere, medial aspect
  • Typical presentation: more motor symptoms
  • Symptoms:
    • Leg weakness > Arm weakness
    • Abulia (diminished motivation)
    • Paralysis of foot and leg with or without paresis of arm
    • Cortical sensory loss over leg
    • Grasp and sucking reflexes
    • Urinary incontinence
    • Gait apraxia
  • Location: cerebral hemisphere, lateral aspect
  • Typical presentation: affects speech and eye movements
  • Symptoms:
    • Hemiparesis
    • Hemisensory deficit
    • Aphasia
      • Expressive aphasia (i.e. - Broca's aphasia), characterized by hesitant speech with word-finding difficulty and preserved comprehension
      • Receptive aphasia (i.e. - Wernicke's aphasia), characterized by poor comprehension, jargon speech
    • Unilateral neglect, apraxias
    • Homonymous hemianopia or quadrantanopia
    • Gaze preference with eyes deviated toward side of lesion
  • Location: Cerebral hemisphere, posterior aspect
  • Typical presentation: Cerebellar findings and visual deficits
  • Symptoms:
    • Visual field defects
    • Vertigo
    • Diplopia
    • Ataxia
    • Homonymous hemianopia
    • Cortical blindness
    • Memory deficit
    • Dense sensory loss, spontaneous pain, dysesthesias, choreoathetosis
  • Location: brainstem, lateral medulla
  • Symptoms:
    • Vertigo, nystagmus
    • Horner's syndrome (miosis, ptosis, decreased sweating)
    • Ataxia, falling toward side of lesion
    • Impaired pain and thermal sense over half body with or without face
  • Location: Brainstem, midbrain
  • Symptoms:
    • Third nerve palsy and contralateral hemiplegia
    • Paralysis/paresis of vertical eye movement
    • Convergence nystagmus
    • Disorientation
  • Antiplatelet Treatment
    • If on ASA already, then add Plavix (Clopidogrel) 300mg loading dose for the first day, then 75mg daily
    • If no prior antiplatelet meds:
      • Start ASA 325mg PO STAT, then clopidogrel
  • Neuroimaging
    • For any acute confusion with exertion, worry about aneurysm, repeat CT head and also do with contrast and MRI if no other focal findings
  • Blood Pressure
    • Maintain blood pressure: BP around 200/120 for the first 24 hours, as you want to maintain cerebral perfusion
  • Further Management
    • Prophylaxis for DVT
    • Lower lipids
    • Gradual BP reduction
  • Treat with tPA (alteplase) within 3 hours!
    • Used to be 4.5 hours? 6 hours?
  • Intra-arterial tPA
    • Direct local to the site of occlusion via catheter
    • This gives you up to 6 hours rather than the 3 to 4.5 hours
    • A lower dose can be used, and there are DECREASED systemic effects
    • Then treat with aspirin after 48 hours
  • NIH Stroke Scale

The differential diagnosis for a stroke is broad:

  • Hypokalemia (periodic episodic paralysis)
  • Episodic ataxia
  • Hypoglycemia
  • Electrolyte disturbance
  • Tumours
  • MS exacerbation
  • TIA

Comparison: Upper Motor Neuron Lesion vs. Lower Motor Neuron Lesion

Normal Upper Motor Neuron Lesion (Stroke) Lower Motor Neuron Lesion (Bell's Palsy)
Physical Exam
Facial involvement None Lower face Lower + upper face involvement
When asking patient to smile and raise eyebrows (testing CN VII) Normal anatomic landmarks during smiling and raising the eyebrows. • Mouth drooping
• Forehead wrinkles intact
• Mouth drooping
• The forehead is not wrinkled and the palpebral fissure is widened

Comparison: Bell’s Palsy vs. Stroke

Bell's Palsy Acute Stroke
Age 20x-50s > 60
Onset Hours to few days Seconds to minutes
Upper face Always affected +/- affected
Lower face Always affected Always affected
Associated symptoms Typically none Weakness, numbness, speech difficulty, slurred speech, diplopia, swallowing difficulty, vertigo, ataxia

Mangement of TIA

  • If you're suspecting a TIA, the characteristics are:
    • Symptoms are self-limiting, resolves, and goes back to baseline
    • The deficits is maximal at onset, it does not get progressively worse (compared to a stroke)
    • Acute onset lasting 30 mins to 1 hour
    • Usually no findings on imaging
    • Usually involves the MCA due to travelling of clot from ICA
  • Risk factors
    • Amarosis fugax, facial droop, aphasia
  • Work up
    • FBG, HbA1C, fasting lipid profile
    • 24-hour Holter Monitor
    • Clopidogrel 75mg PO daily, 300mg loading dose first
    • ASA 81mg PO daily
    • Insulin sliding scale if Type II Diabetes
    • CT Head

Stroke Guidelines

Guideline Location Year PDF Website
Heart and Stroke Foundation of Canada Canada 2019 PDF Link
National Health Service (NHS) UK 2012 - Link
American Heart Association (AHA) and American Stroke Association (ASA) USA 2016 Link -
For Providers