Supplement issue

Diagnosis of Ischemic Stroke

Dara G. Jamieson, MD
Department of Neurology, Weill Medical College of Cornell University, New York, New York, USA.

ABSTRACT

Early stroke management, and early initiation of secondary stroke prevention, may improve outcomes in
patients with acute ischemic stroke. However, ⬍10% of patients with acute ischemic stroke arrive at the
receiving hospital within 3 hours of symptom onset. Factors such as poor public awareness of symptoms,
lack of rapid detection by emergency medical services (EMS), poor coordination between EMS and the
hospital emergency department, or delay of diagnosis on arrival at the emergency department are all
contributing factors in the failure to provide prompt diagnosis and treatment of acute ischemic stroke. This
article focuses on the critical steps in diagnosing ischemic stroke, starting at the initial patient evaluation
by emergency personnel. Stroke mimics and different imaging techniques that may be used in the
differential diagnosis and evaluation of acute ischemic stroke are also discussed.
© 2009 Published by Elsevier Inc. • The American Journal of Medicine (2009) 122, S14 –S20

KEYWORDS: Imaging techniques; Ischemic stroke; Secondary stroke prevention

Early management of ischemic stroke, including initiation of
secondary stroke prevention measures, may improve outcomes
in patients with acute ischemic stroke.1,2 Therapeutic measures
for early ischemic stroke care include thrombolytic therapy and
oral aspirin. The only thrombolytic therapy approved for treat-
ment of acute ischemic stroke (intravenous tissue-type plas-
minogen activator [tPA]) has a therapeutic window of 3 hours
from when the patient was last without neurological symp-
toms. However, ⬍10% of patients with acute ischemic stroke
are eligible for tPA thrombolytic therapy because they do not
arrive at the receiving hospital within 3 hours of symptom
onset3 or they have neurologic deficits or medical conditions
that preclude thrombolytic therapy.
The reasons for delay in seeking medical treatment are
manifold. Because a diagnosis of ischemic stroke almost
always begins with recognition of stroke by the patient or
others present at the time of onset, it is not surprising that
limited awareness of signs and symptoms is a major factor
in delaying arrival at the emergency department. According
to a 2003 survey, only 17.2% of respondents correctly
classified stroke symptoms; however, there were differences
in the age, ethnicity, and level of education of the respon-
Statement of author disclosure: Please see the Author Disclosures
section at the end of this article.
Requests for reprints should be addressed to Dara G. Jamieson, MD,
Department of Neurology, Weill Medical College of Cornell University,
428 East 72nd Street, Suite 400, New York, New York 10021.
E-mail address: dgj2001@med.cornell.edu
dents.4 Another survey found that knowledge about stroke
was suboptimal among women, for whom stroke is a major
cause of death.5
Even after neurologic symptoms are recognized, other
factors still contribute to treatment delay. Median delay
from symptom onset to arrival at the emergency department
has been reported to be 3 to 6 hours.6 In one study, 45% of
individuals with acute stroke delayed ⬎6 hours before go-
ing to the hospital. Women delayed more often than men,
but patient delays were shorter if someone other than the
patient took the patient to the hospital, or when patients
judged their own symptoms as serious.7 In a similar study
that analyzed time between stroke symptom onset and ar-
rival at the emergency department, ⬍50% of calls for an
ambulance were made within the first hour after symptom
onset, and stroke was reported as the problem in only 43%
of calls to an ambulance.8
As a result of poor public awareness of the symptoms and
treatment for stroke, precious time has already been lost by the
time an individual is seen by a healthcare provider. This article
presents key factors in the diagnosis of ischemic stroke, be-
ginning with time of symptom onset. It will also discuss the
steps that must be taken once a patient thought to have expe-
rienced acute stroke is seen by a healthcare provider.
EMERGENCY RESPONSE
Emergency medical services (EMS) are usually the first
medical contact for persons who have experienced stroke.

0002-9343/$ -see front matter © 2009 Published by Elsevier Inc.

doi:10.1016/j.amjmed.2009.02.006
Jamieson Diagnosis of Ischemic Stroke
Figure 1 Face arm speech test training. (Reprinted with permission from Stroke.10)
The American Stroke Association (ASA) describes a
“stroke chain of survival,” which includes rapid assessment
by EMS, followed by hospital notification and priority
transport to appropriate stroke centers.9 One tool used to
improve detection and diagnosis of stroke by EMS workers
is the face arm speech test (FAST), which is a rapid ambu-
lance protocol developed to allow ambulance staff to
quickly recognize acute stroke (Figure 1).10 Emergency
responders should also try to extract key information during
transport, such as time of symptom onset, medications taken
by the patient, and pertinent medical history (e.g., head
trauma, prior history of stroke, presence of diabetes melli-
tus, hypertension, or atrial fibrillation) during transport to
hospital.
EMERGENCY DEPARTMENT CARE
Patients presenting to the emergency department after
symptom onset may be candidates for thrombolytic therapy
and, therefore, need to be evaluated immediately, followed
by immediate initiation of appropriate treatment. Figure 2
S15
shows a sample stroke emergency department algorithm, de-
signed to show how hospitals could quickly identify patients
with stroke who are eligible for tPA therapy (Figure 2).11
CAUSES OF SUDDEN ONSET OF NEUROLOGIC
SYMPTOMS
Many neurologic conditions present with the sudden onset
of symptoms that are initially indistinguishable from symp-
toms of ischemic stroke. Neurologic conditions that mimic
stroke include brain mass lesions (tumor, abscess, hemor-
rhage), meningitis, demyelination, migraine, seizures with
postictal symptoms, toxic/metabolic encephalopathies, pos-
terior reversible encephalopathy syndrome, and psycho-
genic symptoms. Noncerebrovascular diseases may also be
confused with ischemic stroke, and include conditions such
as cardiac syncope, vestibular dysfunction, epilepsy, and
transient global amnesia.12 In a study by Libman and co-
workers,13 stroke team physicians correctly diagnosed
stroke in 81% of cases before imaging procedures were
performed. The remaining 19% of cases diagnosed as stroke
S16 The American Journal of Medicine, Vol 122, No 4B, April 2009

Figure 2 Southcoast Hospital Group sample stroke emergency department algorithm. CT ⫽ computed tomog-
raphy; CXR ⫽ chest x-ray; ECG ⫽ electrocardiogram; ED ⫽ emergency department; EMS ⫽ emergency medical
services; EMTALA ⫽ Emergency Medical Treatment and Active Labor Act; inc/exc ⫽ inclusion/exclusion; IV ⫽
intravenous; NIH ⫽ National Institutes of Health; NIHSS ⫽ NIH Stroke Scale; NPO ⫽ nothing by mouth; S/S ⫽
signs/symptoms; tPA ⫽ tissue-type plasminogen activator. (Reprinted with permission from the American Heart
Association.11)

were ultimately determined to be conditions that mimic
stroke. The 4 most common stroke mimics were seizures
with postictal deficits, systemic infections, brain tumor, and
toxic-metabolic disturbances.14
A study by Hand and associates,14 evaluated the symp-
toms of patients admitted to the emergency department with
a diagnosis of “possible ischemic stroke.” Using logistic
regression, 8 items were found to be predictive in distin-
guishing stroke from a mimic (Table 1).14 Clinical features
at initial bedside assessment by the emergency department
that suggest acute stroke include presence of an exact time
of onset, definite focal symptoms, abnormal vascular find-
ings, a high National Institutes of Health Stroke Scale
(NIHSS) score, and lateralization of symptoms. The pres-
ence of a mimic was suspected because of cognitive im-
pairment and abnormal signs in other systems.14 The diag-
nostic model previously described is based on bedside
assessment of patients before brain imaging and laboratory
analysis. Imaging procedures would subsequently be used
to confirm a diagnosis of stroke. As the imaging techniques
Jamieson Diagnosis of Ischemic Stroke
Table 1 Logistic regression model for predicting the
diagnosis of brain attack*
Variable Odds Ratio (95% CI)
Known cognitive impairment 0.33 (0.14–0.76)
An exact onset could be determined 2.59 (1.30–5.15)
Definite history of focal neurologic 7.21 (2.48–20.93)
symptoms
Any abnormal vascular findings† 2.54 (1.28–5.07)
Abnormal findings in any other system‡ 0.44 (0.23–0.85)
NIHSS score
0§
1–4 1.92 (0.70–5.23)
5–10 3.14 (1.03–9.65)
⬎10 7.23 (2.18–24.05)
The signs could be lateralized to the left 2.03 (0.92–4.46)
or right side of the brain
OCSP classification was possible 5.09 (2.42–10.70)
CI ⫽ confidence interval; NIHSS ⫽ National Institutes of Health
Stroke Scale; OCSP ⫽ Oxfordshire Community Stroke Project; OR ⫽ odds
ratio.
*The model gives a predicted probability of stroke (ranging from 0 to 1).
The mathematical equation uses the coefficient for each variable plus a
constant (not shown) to calculate the probability. The ORs provide a
“weighting” for the importance of each variable (i.e., NIHSS score ⬎10
and definite history of focal neurologic symptoms are the most powerful
predictive factors).
†Systolic blood pressure ⬎150 mm Hg, atrial fibrillation, valvular
heart disease, or absent peripheral pulses.
‡Respiratory, abdominal, or other abnormal signs.
§NIHSS ⫽ 0 was entered as the reference group (therefore, it does
not have a coefficient).
Reprinted with permission from Stroke.14
are used, stroke mimics will be ruled out. By using com-
puted tomography (CT) and routine laboratory evaluation,
the incidence of stroke mimics decreased to 4%. With the
additional use of magnetic resonance imaging (MRI) tech-
niques, the incidence of mimics decreased to 1% to 2%.15
At the patient’s presentation to the emergency depart-
ment, it may not be possible to distinguish immediately
between an acute stroke and an ongoing transient ischemic
attack (TIA). The symptoms of a TIA are similar to those of
stroke, yet they usually resolve ⬍1 hour after onset.16 The
diagnosis of a TIA is difficult, and there are many nonva-
scular mimics.17 The most common are glucose derange-
ment, migraine, seizure, postictal states, and tumors.18 His-
torically, a TIA was believed to be a somewhat benign event
that ended without permanent damage. Today, a TIA is
recognized as a serious event that indicates a high risk for a
secondary cerebrovascular event because a TIA indicates
the presence of conditions that can lead to ischemic stroke.
In one study, the estimated stroke risks after a TIA were
8.0% at 7 days, 11.5% at 30 days, and 17.3% at 90 days.19
An earlier study showed that of all recurrent strokes after
TIAs diagnosed in the emergency department, 50% oc-
curred within the first 48 hours after the initial event.20
Early diagnosis of a TIA and immediate treatment to try to
S17
prevent a secondary cerebrovascular event is essential be-
cause a TIA may herald an impending ischemic stroke.
RADIOLOGIC DIAGNOSIS OF ISCHEMIC STROKE
CT
Patients who have experienced stroke symptoms for ⬍3
hours may be candidates for tPA treatment at arrival at the
emergency department. However, tPA cannot be given to
patients with intracerebral hemorrhage (ICH). The only
reliable method of distinguishing ischemic stroke and hem-
orrhagic stroke is through brain imaging techniques. Non-
contrast CT (NCCT) is the standard imaging procedure used
to detect acute ICH.21 NCCT is faster, more widely avail-
able, and less expensive than MRI. However, changes due
to hyperacute ischemic stroke may not be visible on early
NCCT scans and brainstem stroke may be particularly hard
to image on CT scans. Also, NCCT does not provide infor-
mation about the extent and severity of the perfusion deficit.
Because of the shortcomings of NCCT, newer methods of
CT stroke imaging are being investigated. These methods
include CT angiography (CTA) and perfusion CT (PCT).22
CTA may aid in the selection of treatment, especially if a
large vessel occlusion indicates consideration of intra-arte-
rial thrombolysis or mechanical clot retrieval. These CT
techniques are not always available in the acute setting, but
they may provide information about vessel patency or oc-
clusion (site of occlusion and length of occluded segment),
capacity of the collateral circulation, and presence of critical
cortical hypoperfusion, although estimates of the size of the
perfusion deficit may be inaccurate.23 PCT is potentially
useful for detecting areas of cerebral perfusion deficits be-
fore morphologic changes are observable on NCCT scans
and may therefore aid in lesion localization. In a study by
Murphy and colleagues,24 PCT parameters were used to
distinguish between infarcted and penumbral tissue in a
small sample of patients. The penumbra may persist for
⬎12 hours; this suggests that some tissue is still salvageable
after the accepted 3-hour window for administration of tPA.
In this case, defining areas of viable tissue using PCT-
derived parameters could extend the treatment window of
tPA.24 CTA/PCT imaging significantly improves the overall
accuracy of stroke assessment compared with NCCT and
provides valuable information about the extent of infarct/
penumbra, collateral circulation, and other pathophysio-
logy.22 These promising CT techniques should help physi-
cians in the future to determine the appropriate therapeutic
intervention for the patient with an acute ischemic stroke.
MRI
Interest is growing in the use of multimodal MRI for acute
stroke evaluation, instead of CT. Although MRI is more
costly and less widely available, it may be a better method
of early evaluation for treatment of patients with stroke.
Another limitation of MRI is the increased scanning time
required which may delay time-constrained treatment and
may be inappropriate for unstable patients. Aside from its
S18
high cost and limited availability, MRI is not recommended
for patients with pacemakers or metallic implants, although
one study indicated that MRI might be performed at 1.5 T
in patients with pacemakers.25 Another concern about the
use of MRI was whether it is as effective as CT in diagnosis
of ICH. A study comparing NCCT and MRI (with diffusion-
weighted images and susceptibility-weighted images) in pa-
tients with suspected acute stroke showed that MRI detected
acute stroke (all types), acute ischemic stroke, and chronic
hemorrhage more frequently than did NCCT (P ⬍0.0001),
and was similar to NCCT in detection of acute intracranial
hemorrhage. Overall, MRI had a sensitivity of 83% and CT
had a sensitivity of 26% for the diagnosis of any acute
stroke.26 Because MRI can detect acute and chronic hem-
orrhage, as well as acute ischemic stroke, some physicians
believe that MRI should be the preferred imaging technique
for the diagnosis of patients with suspected stroke.26,27 The
use of MRI may have significant advantages over the use of
CT to identify patients eligible for tPA in early acute stroke.
MRI may also be a better method than CT in determining
which patients with stroke could benefit from tPA admin-
istered after the 3-hour window.28 The techniques used for
evaluation include diffusion-weighted imaging, perfusion-
weighted MRI, and magnetic resonance angiography (MRA).
Diffusion-weighted images provide information about early
brain ischemia and the evolution of ischemic brain tissue in
early stroke. Perfusion-weighted imaging uses a contrast
agent to identify hypoperfused brain regions; perfusion-
weighted imaging lesions are apparent immediately after
occlusion occurs and resolve soon after recanalization.
A perfusion-weighted imaging/diffusion-weighted imag-
ing mismatch detects tissue at risk of infarction; this tissue
is the target of tPA.29 Mismatch values may be used to
identify patients who are likely to respond well to tPA even
3 hours after symptom onset. MRA may also be used to
predict which patients should receive tPA. For example,
when MRA detects complete occlusion of the distal internal
carotid artery, recanalization is unlikely to occur with use of
tPA.28 The use of MRI, MRA, or magnetic resonance per-
fusion may extend the time window for tPA to be useful in
acute stroke and allow for successful reperfusion therapy in
more patients with stroke. For now, however, CT scanning
is the most commonly used initial imaging modality to
evaluate a patient presenting with the sudden onset of a
neurologic deficit.
Doppler Ultrasound
As endovascular intervention becomes increasingly avail-
able, visualization of the entire circulation by noninvasive
techniques is important to identify a treatable lesion. Trans-
cranial Doppler (TCD) imaging is a noninvasive screening
technique that measures blood flow velocity and direction in
segments of large intracranial arteries to assess intracranial
artery disease.30 A battery of TCD findings that can be
routinely measured reliably may identify patients with
ⱖ70% angiographic internal carotid artery stenosis with
high sensitivity31 and can also provide information about
The American Journal of Medicine, Vol 122, No 4B, April 2009
right-to-left cardiac shunts.30 One limitation of TCD is that
evaluation of the posterior cerebral arteries may be less
reliable than investigations of the anterior portions.32
Carotid duplex ultrasonography (CUS), which is a union
of Doppler analysis and real-time ultrasound, is a useful tool
for screening for cervical carotid artery disease. Conditions
such as intimal thickening, atherosclerotic plaque, and prox-
imal dissections may be apparent with ultrasound image
analysis of the area of the carotid artery bifurcation.33 One
study showed that CUS has a ⬎90% accuracy rate in diag-
nosing significant extracranial stenosis.34 However, CUS
assesses only a limited portion of the extracranial circula-
tion and gives little information about the vertebral arteries
compared with MRA or CTA, which are generally preferred
to TCD or CUS in evaluating the extracranial and intracra-
nial circulation of a patient with an ischemic stroke.
Catheter Angiography
In some cases, etiologic diagnoses cannot be made by use of
noninvasive imaging techniques. The measurement of lu-
minal diameter narrowing by angiography (catheter, CTA,
or MRA) is the most reliable method for identification of
candidates for surgical carotid endarterectomy (CEA). Al-
though CUS has been suggested as a relatively reliable,
noninvasive method of detecting carotid occlusion, infre-
quent false-positive results may result in unnecessary sur-
gery, and false-positive results suggestive of occlusion
should be confirmed by angiographic techniques.35 Catheter
angiography is widely used in patients who will undergo
stent placement in the extracranial or intracranial circulation
or for the diagnosis of cerebral vasculitis or malformations.
Cardiac Evaluation of Patients With
Ischemic Stroke
Studies have shown that patients with TIA or stroke have a
high prevalence (20% to 40%) of asymptomatic cardiovas-
cular disease.36 All patients with stroke should be evaluated
for unrecognized cardiovascular conditions. Noninvasive,
provocative tests include exercise electrocardiography
(ECG), exercise thallium-201 scintigraphy, and stress echo-
cardiography. In patients with stroke monitored in the hos-
pital, ECG changes were more frequent in patients with
ischemic stroke than in controls. The 6-month mortality
rate in the patients who showed ECG changes during this
time was 38.9%; the mortality rate in patients with stroke
with normal ECG parameters was 15.2% (P ⬍0.05).37
Continuous, ambulatory ECG may be performed for a du-
ration of up to 24 hours using a Holter monitor or for 7 to
14 days using mobile cardiac outpatient telemetry. Patients
hospitalized with ischemic stroke may be monitored in a
telemetry unit. Transthoracic echocardiography (TTE) is a
noninvasive technique used to diagnose heart abnormalities.
However, transesophageal echocardiography (TEE), al-
though semi-invasive, may be a more sensitive method for
diagnosing cardiac disorders in patients with stroke without
cardiac symptoms. Such cardiac changes include aortic arch
Jamieson Diagnosis of Ischemic Stroke
atheromata, intracardiac thrombi or tumors, patent foramen
ovale (PFO), atrial septal aneurysm, slow left atrial flow,
and mitral or aortic valvular disease.38 A TTE or TEE with
intravenous injection of agitated saline or an ultrasound
contrast agent is used to determine the presence of a right-
to-left cardiac shunt.
Evaluation of Young Patients With
Ischemic Stroke
Ischemic stroke is rare in young adults (aged 18 to 45
years). Causes of ischemic stroke in 18- to 45-year-old
individuals were evaluated in a study by Lee and col-
leagues.34 Stroke subtype distribution was as follows:
small-vessel occlusion (20.5%), large-artery atherosclerosis
(7.2%), cardioembolism (17.8%), other determined etiology
(22.3%), and undetermined etiology (23.5%).34 Crypto-
genic stroke in young people is often associated with atrial
septal abnormalities such as PFO or atrial septal aneurysm.
In an ischemic stroke study conducted in Sweden in young
adults (18 to 44 years old), PFO or atrial septal aneurysm
was a possible cause of stroke in about 28% of cases,39
although studies have found that the prevalence of PFO in
younger patients who experience unexplained cerebrovas-
cular events could be as high as 75%.40 TEE is superior to
TTE in detecting PFO and ASA, mainly because TEE
shows the atrial septum in detail.41
In the general population, coagulation disorders causing
venous thrombosis are rarely associated with ischemic
stroke. However, an association may be stronger between
coagulopathy and stroke in younger patients.42 Therefore,
when an embolic event occurs in a younger patient, screen-
ing for hypercoagulable states is valid.43
Dissection involving the vertebral or internal carotid
arteries causes about 20% of occurrences of ischemic stroke
in young (aged ⬍45 years) patients.44 If arterial dissection
is suspected, MRA plus MRI of the head and neck, with fat
saturation, may be used for diagnosis.45
SUMMARY
Timely diagnosis of acute ischemic stroke is essential for
improving outcomes and initiation of secondary stroke pre-
vention, but most patients do not arrive at the hospital until
3 to 6 hours after onset of symptoms. Many patients do not
even recognize the major symptoms of stroke or may hes-
itate to call an ambulance even if symptoms are recognized.
By the time a patient is seen by EMS technicians or arrives
at the emergency department, the patient may be ineligible
for tPA if the symptoms of ischemic stroke have not been
recognized. Public education programs, EMS instruction to
increase the likelihood of rapid identification of stroke vic-
tims, and emergency department protocols to ensure imme-
diate evaluation and treatment of patients with stroke are
necessary to reduce the rates of morbidity and mortality
caused by acute ischemic stroke. Patients who are medically
eligible for tPA therapy should receive treatment. Ineligi-
bility for treatment should not be based on potentially mod-
S19
ifiable factors, such as delayed hospital arrival or delayed
time to diagnosis. The determination of the mechanism of
an acute ischemic stroke should focus on the detection of
cerebrovascular or cardiac disease for which there is a
specific treatment. The ultimate goal of the diagnostic eval-
uation is to try to prevent secondary events, which may
occur in the future, through medication (i.e., antiplatelet
agents, anticoagulation, 3-hydroxy-3-methylglutaryl coen-
zyme A reductase inhibitors [statins]) or revascularization
(i.e., carotid endarterectomy or intravascular stenting).
ACKNOWLEDGMENT
Editorial assistance for the development of this manuscript
was provided by Boehringer Ingelheim Pharmaceuticals,
Inc.
AUTHOR DISCLOSURES
The author of this article has disclosed the following indus-
try relationships:
Dara Jamieson, MD, is a member of the Speakers’
Bureau for Boehringer Ingelheim and Merck & Co., Inc.;
has worked as a consultant to Bayer, Boehringer Ingelheim,
and Merck & Co., Inc., and has received honoraria from
Bayer, Boehringer Ingelheim, and Merck & Co., Inc.
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