What are the clinical presentations of different types of strokes?

Clinical Presentations of Different Territory Strokes

Different stroke territories present with distinct clinical patterns that help identify the affected vascular distribution, with hemorrhagic strokes typically featuring more abrupt onset, headache, vomiting, and altered consciousness compared to ischemic strokes.

Ischemic Stroke Presentations by Territory

Middle Cerebral Artery (MCA) Territory

• Clinical features:
  • Contralateral hemiparesis (face and arm > leg)
  • Contralateral hemisensory loss
  • Homonymous hemianopia
  • If dominant hemisphere: aphasia (expressive, receptive, or global)
  • If non-dominant hemisphere: spatial neglect, anosognosia
  • Gaze preference toward the side of the lesion

Anterior Cerebral Artery (ACA) Territory

• Clinical features:
  • Contralateral leg weakness > arm weakness (inverted pattern compared to MCA)
  • Abulia (lack of initiative, apathy)
  • Urinary incontinence
  • Grasp reflex
  • Transcortical motor aphasia (if dominant hemisphere)

Posterior Cerebral Artery (PCA) Territory

• Clinical features:
  • Homonymous hemianopia or quadrantanopia
  • Visual agnosia, prosopagnosia (inability to recognize faces)
  • Color anomia (inability to name colors)
  • Alexia without agraphia (if dominant hemisphere)
  • Memory impairment (with thalamic or medial temporal involvement)
  • Sensory loss (with thalamic involvement)

Vertebrobasilar Territory (Brainstem and Cerebellum)

• Clinical features:
  • Vertigo, nausea, vomiting
  • Ataxia, dysmetria
  • Diplopia, nystagmus
  • Crossed sensory or motor deficits (ipsilateral face, contralateral body)
  • Dysphagia, dysarthria
  • Horner's syndrome
  • "Locked-in syndrome" (basilar artery occlusion)

Lacunar Syndromes (Small Vessel Disease)

• Pure motor hemiparesis: Weakness of face, arm, and leg without sensory or cortical deficits
• Pure sensory stroke: Hemisensory loss without motor or cortical deficits
• Ataxic hemiparesis: Weakness with ipsilateral ataxia
• Dysarthria-clumsy hand syndrome: Facial weakness, dysarthria, and hand clumsiness
• Sensorimotor stroke: Combined motor and sensory deficits

Hemorrhagic Stroke Presentations

Intracerebral Hemorrhage (ICH)

• General features 1:

  • More sudden onset than ischemic stroke
  • Rapid progression of focal deficits over minutes to hours
  • Headache (more common than in ischemic stroke)
  • Vomiting (more common than in ischemic or subarachnoid hemorrhage)
  • Elevated blood pressure
  • Impaired level of consciousness
  • Seizures may occur

• Location-specific presentations:

  • Deep hemorrhages (basal ganglia, thalamus):

    • Often hypertension-related
    • Contralateral hemiparesis
    • Hemisensory loss
    • Possible aphasia or neglect depending on side

  • Lobar hemorrhages:

    • Often due to cerebral amyloid angiopathy in elderly non-hypertensive patients
    • Focal deficits based on lobe affected
    • Higher risk of seizures

  • Cerebellar hemorrhages:

    • Ataxia, vertigo, nausea, vomiting
    • Ipsilateral limb ataxia
    • Possible rapid deterioration due to brainstem compression

  • Brainstem hemorrhages:

    • Often rapidly fatal
    • Quadriparesis
    • Cranial nerve palsies
    • Coma

Subarachnoid Hemorrhage

• Clinical features:
  • Thunderclap headache ("worst headache of life")
  • Meningismus (neck stiffness)
  • Photophobia
  • Altered consciousness
  • Focal neurological deficits less common initially

Diagnostic Approach

Initial Assessment

• Brain imaging is mandatory 1, 2:
  • Non-contrast CT scan should be performed immediately (within 25 minutes of arrival)
  • Hemorrhagic stroke is immediately visible on CT as hyperdense (bright white) areas
  • Early signs of ischemic stroke may be subtle in first 3-6 hours (CT sensitivity only 25-30%)

Key Differentiating Features Between Ischemic and Hemorrhagic Stroke 1

• Factors suggesting hemorrhagic stroke:
  • Coma on arrival
  • Severe headache
  • Vomiting
  • Current warfarin therapy
  • Systolic BP >220 mmHg
  • Glucose >170 mg/dL in non-diabetic patients

Clinical Pitfalls and Caveats

1. Don't rely solely on clinical features to differentiate stroke types 1:

   • Clinical findings overlap between ischemic and hemorrhagic strokes
   • Brain imaging is essential for definitive diagnosis

2. Beware of stroke mimics 1:

   • Unrecognized seizures
   • Confusional states
   • Syncope
   • Toxic or metabolic disorders (especially hypoglycemia)
   • Brain tumors
   • Subdural hematoma

3. Time is critical for treatment decisions 1:

   • Document exact time of symptom onset (last known well)
   • For patients waking with symptoms, time of onset is when last known to be normal

4. Posterior circulation strokes may be missed 1, 3:

   • Often present with nonspecific symptoms (dizziness, nausea)
   • May be misdiagnosed as peripheral vertigo or other conditions

5. Stroke severity assessment is crucial 1:

   • Use standardized scales (NIHSS)
   • Volume of ICH and Glasgow Coma Scale score are powerful predictors of 30-day mortality