What are the classic presentations of stroke and how can I logically deduce the area of infarct based on a patient's symptoms and physical examination findings, considering demographics and past medical history, including previous strokes, transient ischemic attacks (TIAs), hypertension, diabetes, high cholesterol, and smoking?

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Classic Stroke Presentations: Clinical Cases

Case 1: Middle Cerebral Artery (MCA) Territory Stroke

67-year-old man with hypertension and diabetes suddenly develops right-sided weakness and inability to speak while eating breakfast at 8 AM.

On examination:

  • Right hemiparesis (arm > leg)
  • Right facial droop
  • Global aphasia (cannot speak or comprehend)
  • Right homonymous hemianopsia
  • Eyes deviate to the left
  • NIHSS score: 18

This is a left MCA territory stroke. 1

Case 2: Lacunar Stroke - Pure Motor Hemiparesis

72-year-old woman with poorly controlled hypertension (BP 180/100) and diabetes develops sudden weakness of the entire right side of her body while walking. No other symptoms.

On examination:

  • Right face, arm, and leg weakness (equal distribution)
  • No sensory loss
  • No visual field defects
  • No aphasia or neglect
  • Alert and oriented
  • NIHSS score: 5

This is a lacunar stroke in the internal capsule/corona radiata. 2, 1

Case 3: Posterior Circulation Stroke - Basilar Artery

58-year-old man with smoking history suddenly develops severe vertigo, double vision, and difficulty swallowing while at work.

On examination:

  • Bilateral horizontal nystagmus
  • Bilateral internuclear ophthalmoplegia
  • Dysarthria and dysphagia
  • Ataxia of all limbs
  • Decreased level of consciousness
  • Nausea and vomiting
  • NIHSS score: 12

This is a basilar artery stroke affecting the brainstem. 1

Case 4: Lacunar Stroke - Pure Sensory Stroke

65-year-old diabetic man suddenly develops numbness and tingling on the entire left side of his body, including face, arm, and leg.

On examination:

  • Decreased sensation to pinprick and light touch on left face, arm, trunk, and leg
  • No motor weakness
  • No visual defects
  • No aphasia
  • Normal coordination
  • NIHSS score: 1

This is a lacunar stroke in the thalamus (ventral posterolateral nucleus). 2, 1

Case 5: Posterior Cerebral Artery (PCA) Stroke

70-year-old woman with atrial fibrillation (not on anticoagulation) suddenly cannot see to her right side while watching TV.

On examination:

  • Left homonymous hemianopsia with macular sparing
  • No motor weakness
  • No sensory loss
  • No aphasia
  • Alert and oriented
  • NIHSS score: 2

This is a right posterior cerebral artery stroke affecting the occipital lobe. 2

Case 6: Anterior Cerebral Artery (ACA) Stroke

55-year-old man suddenly develops weakness in his left leg while standing up from a chair. His arm is relatively spared.

On examination:

  • Left leg weakness (4/5) with minimal arm involvement (5/5)
  • Left foot drop
  • Grasp reflex present
  • Abulia (decreased spontaneous speech and movement)
  • Urinary incontinence
  • NIHSS score: 4

This is a right anterior cerebral artery stroke. 2

Case 7: Cerebellar Stroke

68-year-old woman with hypertension suddenly develops severe vertigo, vomiting, and inability to walk.

On examination:

  • Severe truncal ataxia (cannot sit without support)
  • Right limb ataxia on finger-to-nose testing
  • Dysmetria and dysdiadochokinesia
  • Nystagmus to the right
  • Normal strength
  • Severe nausea and vomiting
  • Risk of brainstem compression

This is a right cerebellar hemisphere stroke. 1

Case 8: Lacunar Stroke - Ataxic Hemiparesis

60-year-old diabetic man develops left leg weakness and clumsiness while walking.

On examination:

  • Left leg weakness (4/5)
  • Left leg ataxia out of proportion to weakness
  • Left arm mildly affected
  • No sensory loss
  • No cortical signs
  • NIHSS score: 3

This is a lacunar stroke in the basis pontis or internal capsule. 2, 1

Case 9: Lacunar Stroke - Dysarthria-Clumsy Hand Syndrome

75-year-old hypertensive man suddenly develops slurred speech and difficulty writing with his right hand.

On examination:

  • Severe dysarthria
  • Right hand clumsiness and mild weakness
  • Difficulty with fine motor tasks
  • Mild right facial weakness
  • No sensory loss
  • No aphasia (comprehension intact)
  • NIHSS score: 3

This is a lacunar stroke in the basis pontis or genu of internal capsule. 2, 1

Case 10: Cardioembolic Stroke - MCA Territory

82-year-old woman with atrial fibrillation (not anticoagulated) suddenly becomes unresponsive while sitting in a chair. Last seen normal 2 hours ago.

On examination:

  • Left gaze preference
  • Right hemiplegia (0/5 arm and leg)
  • Right hemianesthesia
  • Right homonymous hemianopsia
  • Global aphasia
  • Decreased level of consciousness
  • NIHSS score: 22

This is a large left MCA territory cardioembolic stroke. 2, 1

Teaching Section: Logical Deduction of Infarct Location

Step 1: Identify the Primary Deficit Pattern

Motor deficits tell you about the motor pathway:

  • Face + Arm > Leg weakness = MCA territory (lateral cortex and corona radiata) 1
  • Leg > Arm weakness = ACA territory (medial cortex) 2
  • Face = Arm = Leg weakness (equal) = Lacunar stroke in internal capsule or corona radiata 2, 1
  • Crossed signs (ipsilateral cranial nerve + contralateral body) = Brainstem stroke 1

Step 2: Look for Cortical Signs

Cortical signs indicate large vessel/cortical stroke, NOT lacunar: 1

Language dysfunction:

  • Aphasia (especially Broca's or Wernicke's) = Dominant hemisphere (usually left) MCA territory 1
  • Dysarthria alone (slurred speech with intact comprehension) = Can be lacunar or brainstem 2

Neglect/Inattention:

  • Left-sided neglect = Non-dominant (usually right) MCA territory 1

Visual field defects:

  • Homonymous hemianopsia = Optic tract, optic radiations, or occipital cortex (MCA or PCA territory) 1
  • Macular sparing = PCA/occipital cortex (collateral blood supply) 2

Gaze deviation:

  • Eyes deviate toward the lesion = Cortical stroke (frontal eye fields) 1

Step 3: Recognize Classic Lacunar Syndromes

Lacunar strokes are small (≤1.5 cm), subcortical, and have NO cortical signs: 2, 1

  1. Pure motor hemiparesis = Internal capsule, corona radiata, or basis pontis 2, 1
  2. Pure sensory stroke = Thalamus (VPL nucleus) 2, 1
  3. Ataxic hemiparesis = Basis pontis or posterior limb of internal capsule 2, 1
  4. Dysarthria-clumsy hand = Basis pontis or genu of internal capsule 2, 1
  5. Sensorimotor stroke = Thalamus and adjacent internal capsule 2

Key distinguishing features of lacunar strokes: 2, 1

  • No aphasia, neglect, or visual field defects
  • Associated with hypertension and diabetes
  • Small vessel disease mechanism

Step 4: Identify Posterior Circulation Strokes

Brainstem strokes present with crossed signs and cranial nerve involvement: 1

Vertigo + ataxia + cranial nerve signs = Posterior circulation (vertebrobasilar) 1

Specific patterns:

  • Diplopia, dysarthria, dysphagia, ataxia = Basilar artery/brainstem 1
  • Decreased consciousness or coma = Basilar artery occlusion (especially basilar tip) 1
  • Nausea and vomiting = Common in posterior circulation strokes 1

Cerebellar strokes: 1

  • Severe truncal ataxia, limb ataxia, nystagmus
  • Risk of brainstem compression from edema
  • May require neurosurgical decompression

Step 5: Use Vascular Territory Anatomy

Anterior Circulation (Carotid System):

MCA (most common stroke location): 1

  • Superior division = Face and arm weakness, Broca's aphasia (if dominant)
  • Inferior division = Wernicke's aphasia (if dominant), hemianopsia, neglect (if non-dominant)
  • Entire MCA = Face + arm > leg weakness, aphasia or neglect, hemianopsia, gaze deviation

ACA: 2

  • Leg > arm weakness
  • Abulia, grasp reflex
  • Urinary incontinence

Posterior Circulation (Vertebrobasilar System):

PCA: 2

  • Homonymous hemianopsia (often with macular sparing)
  • Memory impairment (if medial temporal lobe involved)
  • Alexia without agraphia (if dominant occipital + splenium of corpus callosum)

Basilar artery: 1

  • Bilateral motor/sensory deficits
  • Cranial nerve palsies
  • Decreased consciousness
  • "Locked-in syndrome" if ventral pons affected

Step 6: Consider Stroke Mechanism Based on Pattern

Large-artery atherosclerosis: 2

  • Cortical infarcts
  • Often preceded by TIA in same territory
  • Carotid stenosis or intracranial stenosis on imaging

Cardioembolic: 2

  • Large cortical infarcts
  • Sudden onset with maximal deficit at onset
  • Atrial fibrillation, valvular disease, or recent MI
  • Multiple vascular territories may be involved

Small-vessel disease (lacunar): 2, 1

  • Small subcortical infarcts
  • Classic lacunar syndromes
  • Hypertension and diabetes as risk factors
  • No cortical signs

Step 7: Critical Pitfalls to Avoid

Don't assume all strokes present dramatically: 3

  • Some patients describe subtle, complex symptoms
  • All stroke symptoms are sudden, persistent, and never experienced before
  • Even subtle symptoms require urgent evaluation

Don't delay imaging waiting for "classic" presentation: 2

  • Clinical presentation alone cannot reliably differentiate ischemic from hemorrhagic stroke 2
  • Immediate CT or MRI is mandatory 2

Don't miss posterior circulation strokes: 1

  • HINTS exam (Head Impulse, Nystagmus, Test of Skew) is more sensitive than early MRI for cerebellar stroke 4
  • Vertigo with any focal neurological sign = stroke until proven otherwise

Don't forget stroke mimics: 5, 4, 6

  • Hypoglycemia (check glucose immediately)
  • Seizure with Todd's paralysis
  • Migraine with aura
  • Conversion disorder
  • Brain tumor

Don't miss the time window: 2, 5

  • Establish when patient was last known well (not when symptoms were discovered)
  • Creative questioning with time anchors (phone calls, TV programs) can help 2
  • "Wake-up strokes" use last time patient was known normal 2

Step 8: Systematic Approach to Any Stroke Patient

1. Establish time last known well 2, 5

2. Perform NIHSS (quantifies severity and guides treatment) 2, 5

3. Check blood pressure (common in acute stroke, but don't treat aggressively unless >220/120 mmHg) 5

4. Immediate glucose testing (rule out hypoglycemia) 5, 4

5. Identify the deficit pattern:

  • Motor: Face/arm/leg distribution
  • Sensory: Pattern and distribution
  • Language: Aphasia vs dysarthria
  • Visual: Field defects
  • Coordination: Ataxia
  • Cranial nerves: Brainstem involvement
  • Level of consciousness

6. Look for cortical signs (aphasia, neglect, hemianopsia, gaze deviation) 1

7. Determine vascular territory:

  • Anterior circulation (MCA, ACA)
  • Posterior circulation (PCA, basilar, cerebellar)
  • Lacunar (small vessel)

8. Consider mechanism:

  • Large-artery atherosclerosis
  • Cardioembolic
  • Small-vessel disease
  • Other (dissection, hypercoagulable state)

9. Immediate CT/MRI (differentiate ischemic from hemorrhagic) 2

10. Assess for thrombolysis eligibility (if within 4.5 hours) 4

References

1
Guideline

Middle Cerebral Artery Stroke and Lacunar vs Cortical Stroke Differences

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Research

Acute Stroke Diagnosis.

American family physician, 2022

5
Guideline

Approach to a Patient with Past History of Stroke

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

6
Research

Diagnosis of acute stroke.

American family physician, 2015

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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