
Am Fam Physician. 2022;105(6):616-624
Author disclosure: No relevant financial relationships.
Stroke accounts for significant morbidity and mortality and is the fifth leading cause of death in the United States, with direct and indirect costs of more than $100 billion annually. Expedient recognition of acute neurologic deficits with appropriate history, physical examination, and glucose testing will help diagnose stroke and rule out mimicking presentations. The National Institutes of Health Stroke Scale should be used to determine stroke severity and to monitor for evolving changes in clinical presentation. Initial neuroimaging is used to differentiate between ischemic and hemorrhagic stroke or other pathologic processes. If a stroke is determined to be ischemic within four and a half hours of last known well or baseline state, determining the patient's eligibility for the administration of intravenous recombinant tissue plasminogen activator is necessary to proceed with informed decision-making for diagnostic workup and appropriate treatment options. Additional evaluation with specialized magnetic resonance imaging studies can help determine if patients can receive recombinant tissue plasminogen activator within nine hours of last known well. Subarachnoid hemorrhage should be considered in the differential diagnosis if the patient presents with rapid onset of severe headache. If radiographic imaging is negative for hemorrhage when there is high suspicion for delayed presentation of stroke, a lumbar puncture should be considered for further evaluation. Patients with cerebellar symptoms should be evaluated with a HINTS (head-impulse, nystagmus, test of skew) examination because it is more sensitive for cerebellar stroke than early magnetic resonance imaging. Additional cerebrovascular imaging should be considered in patients with large vessel occlusions presenting within 24 hours of last known well to assess benefits of endovascular interventions. Once initial interventions have been implemented, poststroke evaluations such as telemetry, echocardiography, and carotid imaging should be performed as clinically indicated to determine the etiology of the stroke.
Risk Factors
Classification of Strokes
Stroke classification is based on the underlying pathologic process and vascular distribution. Appropriate classification of a stroke assists in formulating definitive treatment decisions and communicating potential short- and long-term prognoses. In the United States, approximately 87% of all strokes are ischemic, 10% are intracerebral hemorrhages, and 3% are subarachnoid hemorrhages.1
An ischemic stroke is defined as an episode of neurologic dysfunction secondary to a focal CNS infarction. A silent ischemic infarction is defined as imaging or neuropathologic evidence of an infarction without neurologic dysfunction.
Intracerebral and spontaneous subarachnoid hemorrhages are defined as rapidly developing neurologic dysfunction secondary to the focal accumulation of blood in the brain parenchyma and in the subarachnoid space, respectively, and are not precipitated by trauma. A silent cerebral hemorrhage is similar to a silent ischemic stroke in that both are without clinical symptoms. Imaging shows a focal collection of blood within the brain parenchyma or ventricular system, often presenting in the form of microhemorrhages.2
Clinical Diagnosis
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