Ischemic stroke history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]

History and Symptoms

Detailed history may suggest the underlying cause for ischemic stroke:

Vessel involved	Site of infarction	History and symptoms
Anterior cerebral artery Rare Collateral circulation by anterior communicating artery	Frontal lobe Frontal cortex, Primary motor cortex Parietal lobe Primary sensory cortex	Motor weakness opposite the side of lesion Sensory loss on the same side of lesion Urinary incontinence Transcortical aphasia Abulia Behavioral abnormalities Hemineglect (left ACA)
Middle cerebral artery Most common site of infarction	Right superficial division (RSD) Motor cortex (left head,neck and arm) Sensory cortex (left head, trunk and arm) Left superficial division (LSD) Broca's area (expressive speech area) Wernick's area (receptive speech area) Motor cortex (right head, neck and arm) Sensory cortex (right head, neck and arm) Lenticulostriate branches Striatum (caudate and putamen) Globus pallidus Internal capsule (anterior limb and genu)	Left arm and face weakness Hemineglect Right arm and facial weakness Non fluent aphasia (Broca's aphasia) Fluent aphasia (wernick's aphasia) Pure upper motor weakness (internal capsule lesion)
Posterior cerebral artery	Superficial branch Occipital cortex Splenium of corpus callosum Deep branch Thalamus Internal capsule (posterior limb)	A B C D
Vertebrobasilar artery	Midbrain Medulla Cerebellum Pons Thalamus Occipital cortex	Midbrain syndrome Pontine syndrome Lateral medullary syndrome (Wallenberg syndrome-PICA) Medial medullary syndrome Cerebellar infarction
???		B C D

Warning Signs of CVA include:

• Sudden, severe headache with no known cause
• Sudden trouble seeing in one or both eyes
• Sudden confusion, trouble speaking or understanding
• Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
• Sudden trouble walking, dizziness, loss of balance or coordination

Stroke symptoms typically develop rapidly (seconds to minutes). The symptoms of a stroke are related to the anatomical location of the damage; nature and severity of the symptoms can therefore vary widely. Ischemic strokes usually only affect regional areas of the brain perfused by the blocked artery. Hemorrhagic strokes can affect local areas, but often can also cause more global symptoms due to bleeding and increased intracranial pressure. On the basis of the history and neurological examination, as well as the presence of risk factors, the anatomical nature of the stroke (i.e. which part of the brain is affected) can be diagnosed, even if the exact cause is not known.

If the area of the brain affected contains one of the three prominent Central nervous system pathways—the spinothalamic tract, corticospinal tract, and dorsal column (medial lemniscus), symptoms may include:

• Hemiplegia and central facial palsy
• Numbness
• Reduced sensory or vibratory sensation

In most cases, the symptoms affect only one side of the body (unilateral). The defect in the brain is usually on the contralateral side of the body (depending on which part of the brain is affected). However, the presence of any one of these symptoms does not necessarily suggest a stroke, since these pathways also travel in the spinal cord and spinal cord lesions can also produce these symptoms.

In addition to the above CNS pathways, the brainstem also consists of the 12 cranial nerves. A stroke affecting the brainstem therefore can produce symptoms relating to deficits in these cranial nerves:

• Altered smell, taste, hearing, or vision (total or partial)
• Drooping of eyelid (ptosis) and weakness of ocular muscles
• Decreased reflexes: gag, swallow, pupil reactivity to light
• Decreased sensation and central facial palsy
• Difficulty maintaining balance and nystagmus
• Altered breathing and heart rate
• Weakness of sternocleidomastoid muscle resulting in inability to turn head to the opposite side
• Weakness of muscles in tongue resulting in inability to protrude and/or move from side to side

If the cerebral cortex is involved, the CNS pathways are affected in addition to the following symptoms:

• Aphasia which is inability to speak or comprehend depending on involvement of Broca's or Wernicke's area
• Apraxia (altered voluntary movements)
• Visual field defect
• Memory deficits secondary to involvement of temporal lobe
• Hemineglect occurs contralateral to the side of parietal lobe involvement
• disorganized thinking, confusion, hypersexual gestures (with involvement of frontal lobe)
• Anosognosia (persistent denial of the existence of a, usually stroke-related, deficit)

If the cerebellum is involved, the patient may have the following:

• Ataxia
• Altered movement coordination
• vertigo and or disequilibrium

Loss of consciousness, headache, and vomiting usually occurs more often in hemorrhagic stroke than in thrombosis because of the increased intracranial pressure from the leaking blood compressing on the brain.

If symptoms are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an embolic stroke.