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Ischemic stroke

Last updated: September 27, 2021

Summarytoggle arrow icon

Ischemic stroke is an acute neurological condition caused by impaired cerebral blood flow (e.g., vascular occlusion or systemic hypoperfusion). The most important risk factors are chronic systemic hypertension and cardiovascular disease. Clinically, ischemic stroke is characterized by the acute onset of focal neurological deficits, which are dependent on the cerebral territory covered by the relevant vessel. If ischemic stroke is suspected, a noncontrast head CT should immediately be performed to rule out intracranial hemorrhage and blood glucose should be measured as it is a stroke mimic. Revascularization of the vessels affected in ischemic stroke, e.g., via tissue plasminogen activator (tPA) or thrombectomy, can preserve brain tissue and improve outcomes if given early. Further treatment consists of supportive care, neuroprotective measures, management of underlying causes, and secondary prevention with antiplatelet therapy and treatment of modifiable risk factors (i.e., hypertension, atherosclerosis).

Recommendations in this article are primarily consistent with the 2019 American Heart Association (AHA) guidelines for the early management of patients with acute ischemic stroke and the 2021 AHA guidelines for secondary stroke prevention. [1][2]

Transient ischemic attack, intracerebral hemorrhage, and subarachnoid hemorrhage are covered in separate articles. See also “Overview of stroke.”

For both ischemic and hemorrhagic strokes, age is the most important nonmodifiable risk factor and arterial hypertension is the most important modifiable risk factor!


Epidemiological data refers to the US, unless otherwise specified.


Patterns of necrosis in ischemic stroke [14]

Infarction of brain tissue is typically followed by liquefactive necrosis, in contrast to the coagulative necrosis seen after infarction in other organs.

Selective neuronal necrosis


  • Definition: the death of all cell types in a given region of the brain, including neurons, glial cells, and vascular cells
  • Mechanism: permanent ischemia
  • Histology: cystic lesions and loss of tissue architecture

Histologic changes in the infarcted region [14][15]

Time from start of ischemia Histologic features
12–24 hours
1–3 days
3–5 days
5–15 days
> 15 days

To recall the areas most vulnerable to hypoxia: Vulnerable hippos Need PURe water (hippocampus, Neocortex, PURkinje cells, and watershed areas).


Stroke should be ruled out in patients presenting with first-time epileptic seizures and subsequent neurological deficits, as the seizure may have been caused by an acute cerebral pathology.

The differential diagnoses listed here are not exhaustive.

Primary survey

Clinical assessment and management should occur simultaneously with the goals of stabilizing the patient, keeping the door-to-neuroimaging time to a minimum, and identifying candidates for reperfusion therapy as soon as possible. [1][16][17]

Only POC glucose and noncontrast neuroimaging (e.g., CT head or MR brain) are required prior to thrombolytic therapy. Do not delay treatment to complete the remainder of the diagnostic evaluation. A classic clinical presentation without evidence of a stroke mimic or intracranial bleeding on initial neuroimaging is typically enough to diagnose acute ischemic stroke in time-limited settings. [1]

Malignant infarctions in the MCA territory or large PICA infarctions may require surgical intervention before edema reaches its maximum extent to prevent brain herniation. [1]

Blood pressure management in acute ischemic stroke [1]

The following scales can be calculated at initial presentation to guide treatment decisions and estimate prognosis, or repeated to monitor progression and response to therapy during admission, rehabilitation, and follow-up. They are also used as outcome measures in clinical trials.

National Institutes of Health Stroke Scale (NIHSS) [19]

  • A severity score that quantifies neurological impairment for specific categories within the following broad domains:
  • Scores between are assigned for each category are combined and totals can range from 0 (no impairment) to 42 (most severe).

The NIHSS is weighted towards anterior circulation strokes and underestimates stroke severity in the posterior circulation. [20]

National Institute of Health Stroke Scale (NIHSS) [1][19]
Category Task Score
1a: Level of consciousness

Assess alertness.

1b: Orientation questions

Ask month and age.

  • 0: Answers both correctly
  • 1: Answers one correctly
  • 2: Answers neither question correctly

1c: Commands

Patient opens/closes eyes and makes a fist.

  • 0: Follows both commands [19]
  • 1: Follows one command
  • 2: Does not follow commands

2: Gaze

Patient follows examiner's finger in horizontal movements.

  • 0: Normal movement
  • 1: Partial gaze palsy
  • 2: Forced deviation or complete gaze palsy

3: Visual fields

Present visual stimuli in the patient's visual field quadrants.

4: Facial palsy

Patient shows teeth, raises eyebrows, squeezes eyes shut.

  • 0: Normal movement
  • 1: Minor facial paralysis
  • 2: Partial facial paralysis
  • 3: Complete unilateral or bilateral facial paralysis

5a: Motor: left arm

5b: Motor: right arm

Patient elevates each arm to 45° from a supine position or 90° if sitting with open palms facing downwards.

  • 0: No drift
  • 1: Arm drifts within 10 seconds
  • 2: Arm falls within 10 seconds but shows some effort against gravity
  • 3: Arm falls; no effort possible against gravity
  • 4: No movement

(Separate scores are given for left arm and right arm.)

6a: Motor: left leg

6b: Motor: right leg

Patient elevates each leg to 30° from a supine position.

  • 0: No drift
  • 1: Leg drifts within 5 seconds
  • 2: Leg falls within 5 seconds but shows some effort against gravity
  • 3: Leg falls; no effort possible against gravity
  • 4: No movement

(Separate scores are given for left leg and right leg.)

7: Limb ataxia

Patient performs finger-to-nose and heel-shin tests on both sides.

8: Sensory

Test sensation of face, arms, and legs.

  • 0: Normal sensation
  • 1: Mild sensory loss
  • 2: Severe sensory loss

9: Language

Patient names items, describes a picture, or reads a sentence.

10: Dysarthria

Ask patient to read or repeat words.

11: Sensory extinction or inattention

Offer simultaneous tactile and visual stimuli.

  • 0: No extinction or inattention
  • 1: Extinction or inattention in one sensory modality
  • 2: Complete inattention to one side or extinction to ≥ 1 sensory modality
  • Instructions
    • Assess each category in order.
    • Score only what the patient does, without making assumptions about their capabilities.
    • Do not coach the patient or change scores retroactively.
  • Interpretation: There is currently no consensus on which NIHSS scores serve as cutoffs for stroke severity. [21]
    • Minor stroke is most commonly defined as NIHSS ≤ 5 or NIHSS ≤ 3. [1][21][22][23]
    • Very severe stroke is defined by the 2019 AHA guideline as NIHSS > 25. [1]
    • Can also be used to assess prognosis, although cutoffs vary. [17][24][25]

Modified Rankin scale [26][27]

  • A scale used to quantify the degree of disability and dependence in daily activities before and after cerebral stroke.
  • The scale ranges from 0 (no symptoms) to 6 (death).
Modified Rankin scale
Disability Symptoms Score
None Absent 0
Insignificant Present, but not affecting usual activities 1
Slight Affecting some activities, but not affecting independence 2
Moderate Necessitating assistance for some ADLs, but not for walking 3
Moderately severe Necessitating assistance for walking and most ADLs 4
Severe Necessitating full-time care for all ADLs (e.g., bedbound, incontinent) 5
Death 6

Diagnostic approach [2][28][29][30]

Obtain noncontrast neuroimaging as soon as possible.

The decision to obtain advanced imaging should not delay the administration of thrombolytic therapy in appropriate candidates. [1]

Immediate laboratory studies [1][2][13][32]

Cardiac evaluation [1][2]

All patients with a suspected ischemic stroke should receive an initial ECG and cardiac monitoring.

Additional investigations [1][13][32]

Consider these in select patients, e.g., to identify the underlying cause, assess the risk of recurrence, and evaluate comorbidities or complications.

Noncontrast CT head [29][30][37][38][39]

Infarctions in the cerebellum and brainstem may be harder to detect with noncontrast head CT than infarctions in other regions. [43]

MRI brain [1][37][44]

DWI-FLAIR mismatch indicates hyperacute ischemic stroke that occurred within the past 6 hours. [46]

Neurovascular studies [1][2][13]

In potential candidates for mechanical thrombectomy, perform CTA immediately following noncontrast CT. If indicated, thrombolysis can be performed simultaneously. [1]

If indicated, do not delay CTA to wait for creatinine or TSH levels, as the risk of iodine-induced hyperthyroidism and contrast-induced nephropathy is relatively low, especially in patients with no known history of thyroid or renal abnormalities. [35][39][52][53]

Therapeutic approach [1]

General principles [1]

Time is brain! Reperfusion therapy should not be delayed. However, intracranial hemorrhage is a contraindication for reperfusion therapy and must be ruled out first.

Intravenous thrombolysis [1]

Inclusion and exclusion criteria for thrombolysis are not strict and treatment decisions should be made in consultation with a neurologist taking into account multiple individual patient factors.

If a patient is unable to consent to treatment (e.g., altered mental status, aphasia) and a legal representative is not immediately present, IV alteplase can still be administered in eligible patients with disabling stroke symptoms. [1]

Do not wait on coagulation parameters before administering tPA in patients with no known history of coagulopathy or thrombocytopenia. Discontinue treatment if platelets are < 100,000/mm3, INR > 1.7 or PT is abnormally elevated. [1]

Exclusion criteria for thrombolysis in acute ischemic stroke [1]

Absolute contraindications

Relative contraindications

Preexisting conditions
Acute findings

Some conditions commonly misconceived as contraindications for thrombolysis therapy include antiplatelet therapy, end-stage renal disease, and concurrent MI. In patients with preexisting disability or dementia, treatment decisions should be based on prestroke functionality and quality of life. [1]

Severe hypo- or hyperglycemia (glucose < 50 mg/dL or > 400 mg/dL) and severe hypertension > 185/110 mm Hg should be treated before tPA administration. [1]

Complications of IV thrombolytic therapy [1]

Additional measures after thrombolysis

  • Check blood pressure and neurological status frequently.
  • Avoid invasive procedures, if possible.
  • Obtain a follow-up head CT (without IV contrast) or brain MRI 24 hours after thrombolysis, prior to starting anticoagulants or antiplatelet agents.

Mechanical thrombectomy [1]

Patients who are eligible for tPA should receive thrombolysis immediately, while mechanical thrombectomy is being considered. If indicated, mechanical thrombectomy should be performed without delay to assess the response to thrombolysis. [1]

Neuroprotective measures

Follow standard measures, including the following specific targets for acute ischemic stroke: [1]

Supportive care

Further therapeutic goals consist of identifying and treating risk factors and underlying conditions to prevent recurrent stroke. [1][32]

Antiplatelet therapy [1][2][32]

Wait at least 24 hours before initiating antiplatelet treatment after thrombolysis.

Management of underlying causes [1][2][32]

Treatment of modifiable risk factors [2]

The single most important treatable risk factor for secondary stroke prevention is hypertension.

Initial evaluation

After stabilization

We list the most important complications. The selection is not exhaustive.

Primary stroke prevention [59]

Management of modifiable risk factors decreases the likelihood of a first stroke. [60]

Lacunar infarct [9][61]

Infarction of the posterior limb of the internal capsule is the most common type of lacunar stroke and may manifest clinically with pure motor stroke, pure sensory stroke (rare), sensorimotor stroke, dysarthria-clumsy hand syndrome, and/or ataxic hemiparesis.

Watershed infarct [4][62]

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