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)
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
  • Location: cerebral hemisphere, lateral aspect
  • Typical presentation: affects speech and eye movements
  • Symptoms:
    • Hemiparesis
    • Hemisensory deficit
      • 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
    • 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
  • NIH Stroke Scale

The differential diagnosis for a stroke is broad:

  • Lower motor neuron lesions (e.g., Bell's Palsy)
    • Bell's Palsy = HSV infection near facial nerve
      • Early corticosteroid treatment
    • Ramsay Hunt = Shingles infection (VZV) near facial nerve
      • Early treatment with valacyclovir prevents permanent damage
      • Early corticosteroids help too
  • Hypokalemia (periodic episodic paralysis)
  • Episodic ataxia
  • Hypoglycemia
  • Electrolyte disturbance
  • Tumours
  • MS exacerbation
  • TIA

Upper Motor Neuron Lesion (Stroke) vs. Lower Motor Neuron Lesion (Bell's Palsy) Fig. 1

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

Normal Upper Motor Neuron Lesion (Stroke) Lower Motor Neuron Lesion (Bell's Palsy)
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

Upper Motor Neuron Lesion vs. Lower Motor Neuron Lesion Fig. 1

  • 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
  • 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

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