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Topic 1134 Version 24.0 https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 16/29 7/5/23, 11:52 AM Clinical diagnosis of stroke subtypes - UpToDate GRAPHICS Pathophysiologic ischemic stroke classification Large vessel atherothrombotic stroke More common Bifurcation of the common carotid artery Siphon portion of the common carotid artery Middle cerebral artery stem Intracranial vertebral arteries proximal to middle basilar artery Origin of the vertebral arteries Less common Origin of the common carotid artery Posterior cerebral artery stem Origin of the major branches of the basilar-vertebral arteries Origin of the branches of the anterior, middle, and posterior cerebral arteries Small vessel (lacunar) stroke Mechanism Lipohyalinotic occlusion Less frequently proximal atherothrombotic occlusion Least likely embolic occlusion Most common locations Penetrating branches of the anterior, middle, and posterior cerebral and basilar arteries Cardioaortic embolic stroke Cardiac sources definite - antithrombotic therapy generally used Left atrial thrombus Left ventricular thrombus Atrial fibrillation and paroxysmal atrial fibrillation Sustained atrial flutter Recent myocardial infarction (within one month) Rheumatic mitral or aortic valve disease Bioprosthetic and mechanical heart valve https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 17/29 7/5/23, 11:52 AM Clinical diagnosis of stroke subtypes - UpToDate Chronic myocardial infarction with ejection fraction <28 percent Symptomatic heart failure with ejection fraction <30 percent Dilated cardiomyopathy Cardiac sources definite - anticoagulation hazardous Bacterial endocarditis (exception nonbacterial) Atrial myxoma Cardiac sources possible Mitral annular calcification Patent foramen ovale Atrial septal aneurysm Atrial septal aneurysm with patent foramen ovale Left ventricular aneurysm without thrombus Isolated left atrial spontaneous echo contrast ("smoke") without mitral stenosis or atrial fibrillation Mitral valve strands Ascending aortic atheromatous disease (>4 mm) True unknown source embolic stroke Other Dissection Moyamoya Binswanger's disease Primary thrombosis Cerebral mass Graphic 55099 Version 4.0 https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 18/29 7/5/23, 11:52 AM Clinical diagnosis of stroke subtypes - UpToDate Stuttering time course of thrombotic stroke The course of weakness of the right limb in a patient with a thrombotic stroke reveals fluctuating symptoms, varying between normal and abnormal, progressing in a stepwise or stuttering fashion with some periods of improvement. Graphic 64107 Version 2.0 https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 19/29 7/5/23, 11:52 AM Clinical diagnosis of stroke subtypes - UpToDate Time course of embolic stroke Embolic stroke occurs suddenly, with symptoms maximal at onset. This patient had multiple embolic events with different clinical symptoms (initially weakness, followed by paresthesias). Graphic 73261 Version 1.0 https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 20/29 7/5/23, 11:52 AM Clinical diagnosis of stroke subtypes - UpToDate Time course of neurologic changes in intracerebral hemorrhage Schematic representation of rapid downhill course in terms of unusual behavior (solid line), hemimotor function (dotted line), and consciousness (dash-dotted line) in a patient with intracerebral (intraparenchymal) hemorrhage. Graphic 61491 Version 3.0 https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 21/29 7/5/23, 11:52 AM Clinical diagnosis of stroke subtypes - UpToDate Headache and vomiting in stroke subtypes The frequency of sentinel headache, onset headache, and vomiting in three subtypes of stroke: subarachnoid hemorrhage, intraparenchymal (intracerebral) hemorrhage, and ischemic stroke. Onset headache was present in virtually all patients with SAH and about one-half of those with IPH; all of these symptoms were infrequent in patients with IS. SAH: subarachnoid hemorrhage; IPH: intraparenchymal (intracerebral) hemorrhage; IS: ischemic stroke. Data from: Gorelick PB, Hier DB, Caplan LR, Langenberg P. Headache in acute cerebrovascular disease. Neurology 1986; 36:1445. Graphic 60831 Version 4.0 https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 22/29 7/5/23, 11:52 AM Clinical diagnosis of stroke subtypes - UpToDate Characteristics of stroke subtypes Stroke type Clinical course Risk factors Other clues Intracerebral hemorrhage Gradual onset and progression during minutes or hours in most patients, but may present abruptly with Hypertension, trauma, bleeding diatheses, illicit drugs (eg, amphetamines, cocaine), vascular malformations. More common in Black people and Asian people than May be precipitated by sex or other physical activity. Patient may have maximal deficit at onset. in White people. reduced alertness. Subarachnoid hemorrhage Abrupt onset of sudden, severe headache. Focal brain dysfunction less common than with other Smoking, hypertension, moderate to heavy alcohol use, genetic susceptibility (eg, polycystic kidney disease, family history of May be precipitated by sex or other physical activity. types. subarachnoid hemorrhage) and Patient may have sympathomimetic drugs (eg, cocaine) reduced alertness. Ischemic Stuttering progression Atherosclerotic risk factors (age, May have neck (thrombotic) with periods of improvement. Lacunes smoking, diabetes mellitus, etc). Males affected more commonly than bruit. develop over hours or at females. May have history of TIA. most a few days; large artery ischemia may evolve over longer periods. Ischemic Sudden onset with Atherosclerotic risk factors as listed Can be (embolic) deficit maximal at onset. Clinical findings may above. Males affected more commonly than females. History of precipitated by getting up at improve quickly. heart disease (valvular, atrial night to urinate fibrillation, endocarditis). or sudden coughing or sneezing. Graphic 69907 Version 5.0 https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 23/29 7/5/23, 11:52 AM Clinical diagnosis of stroke subtypes - UpToDate Time course of lacunar infarction Penetrating artery occlusions usually cause symptoms that develop over a short period of time, hours or at most a few days, compared to large artery-related brain ischemia which can evolve over a longer period. A stuttering course may ensue, as with large artery thrombosis. This patient had a pure motor hemiparesis. Graphic 52246 Version 1.0 https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 24/29 7/5/23, 11:52 AM Clinical diagnosis of stroke subtypes - UpToDate Cardioaortic sources of cerebral embolism Sources with high primary risk for Sources with low or uncertain primary ischemic stroke risk for ischemic stroke Atrial fibrillation Cardiac sources of embolism: Paroxysmal atrial fibrillation Mitral annular calcification Left atrial thrombus Patent foramen ovale Left ventricular thrombus Atrial septal aneurysm Sick sinus syndrome Atrial septal aneurysm and patent foramen ovale Atrial flutter Left ventricular aneurysm without thrombus Recent myocardial infarction (within one month prior to stroke) Left atrial spontaneous echo contrast ("smoke") Mitral stenosis or rheumatic valve disease Congestive heart failure with ejection fraction <30% Mechanical heart valves Bioprosthetic heart valves Chronic myocardial infarction together with low ejection fraction (<28%) Apical akinesia Dilated cardiomyopathy (prior established Wall motion abnormalities (hypokinesia, diagnosis or left ventricular dilatation with an ejection fraction of <40% or fractional shortening akinesia, dyskinesia) other than apical akinesia of <25%) Nonbacterial thrombotic endocarditis Hypertrophic cardiomyopathy Infective endocarditis Left ventricular hypertrophy Papillary fibroelastoma Left ventricular hypertrabeculation/non- compaction Left atrial myxoma Recent aortic valve replacement or coronary artery bypass graft surgery Presence of left ventricular assist device Paroxysmal supraventricular tachycardia Aortic sources of embolism: Complex atheroma in the ascending aorta or proximal arch (protruding with >4 mm thickness, or mobile debris, or plaque ulceration) The high- and low-risk cardioaortic sources in this table are separated using an arbitrary 2% annual https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 25/29 7/5/23, 11:52 AM Clinical diagnosis of stroke subtypes - UpToDate or one-time primary stroke risk threshold. Data from: 1. Ay H, Benner T, Arsava EM, et al. A computerized algorithm for etiologic classi cation of ischemic stroke: the Causative Classi cation of Stroke System. Stroke 2007; 38:2979. 2. Ay H, Furie KL, Singhal A, et al. An evidence-based causative classi cation system for acute ischemic stroke. Ann Neurol 2005; 58:688. 3. Arsava EM, Ballabio E, Benner T, et al. The Causative Classi cation of Stroke system: an international reliability and optimization study. Neurology 2010; 75:1277. 4. Kamel H, Elkind MS, Bhave PD, et al. Paroxysmal supraventricular tachycardia and the risk of ischemic stroke. Stroke 2013; 44:1550. 5. Kirklin JK, Pagani FD, Kormos RL, et al. Eighth annual INTERMACS report: Special focus on framing the impact of adverse events. J Heart Lung Transplant 2017; 36:1080. Reproduced and modi ed with permission from: Ay H, Furie KL, Singhal A, et al. An evidence-based causative classi cation system for acute ischemic stroke. Ann Neurol 2005; 58:688. Copyright 2005 American Neurological Association. Graphic 60843 Version 11.0 https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 26/29 7/5/23, 11:52 AM Clinical diagnosis of stroke subtypes - UpToDate Stroke mortality related to blood pressure and age Stroke mortality rate, pictured on a log scale with 95% CI, in each decade of age in relation to the estimated usual systolic and diastolic blood pressure at the start of that decade. Stroke mortality increases with both higher pressures and older ages. For diastolic pressure, each age-specific regression line ignores the left-hand point (ie, at slightly less than 75 mmHg) for which the risk lies significantly above the fitted regression line (as indicated by the broken line below 75 mmHg). CI: confidence interval. Data from Prospective Studies Collaboration, Lancet 2002; 360:1903. Graphic 66793 Version 5.0 https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 27/29 7/5/23, 11:52 AM Clinical diagnosis of stroke subtypes - UpToDate Occlusion of middle and anterior cerebral arteries Reproduced with permission from: Netter, FH, Caplan, LR. Cerebrovascular Disease, Section III, Plate 8. In: The Netter Collection of Medical Illustrations, Vol 1, Nervous System, Part II, Neurologic and Neuromuscular Disorders, Netter, FH, Jones, HR, Dingle, RV (Eds), MediMedia USA, Inc 1986. Copyright 1986 Elsevier. Graphic 69630 Version 1.0 https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 28/29 7/5/23, 11:52 AM Clinical diagnosis of stroke subtypes - UpToDate Contributor Disclosures Louis R Caplan, MD No relevant financial relationship(s) with ineligible companies to disclose. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. John F Dashe, MD, PhD No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes/print 29/29