Ischemic stroke physical examination

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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]

Overview

A complete physical examination may be suggestive of initial diagnostic clue about an ischemic stroke presenting as decreased motor strength, sensory loss or cranial nerve involvement. It may also help assess the degree of neurological deficit, identification of cause, localization of site of infarction, selection of patient for appropriate intervention, determination of prognosis and complications, and ruling out differential diagnosis.

Physical Examination

A complete physical examination in the patient of ischemic stroke is essential for the following reasons:[1]

  • Assess the degree of neurological deficit
  • Identify the cause
  • Locate the site of infarction
  • Selection of patient for appropriate intervention
  • Determine the prognosis and complications
  • Rule out differential diagnosis

Physical assessment may be divided into 1) GPA 2) Systemic examination 3) Neurological examination:

General physical assessment and Systemic Review

Organ System Findings Suggestive of
General Appearance Cachexia[2] Underlying carcinoma
Confused or disoriented Extensive neurological deficit
Vital Signs Fever May suggest concomittant infectious process
Tachycardia (irregularly irregular) Underlying atrial fibrillation[3]
Absent pulse (radial or carotid artery) Atherosclerosis
Tachypnea Congestive heart failure[4], concomittant lung disease
Skin Pallor Anemia of chronic disease from any inflammatory condition
Abnormal bruising Underlying coagulation disorder
Cyanosis Embolism
Wound infection
Diabetes mellitus
Migratory thrombophlebitis Underlying visceral carcinoma
Eyes Visual field defect Infarct involving posterior cerebral circulation
Absent light reflex Cranial nerve involvement
Speckled appearance of iris with ipsilateral pupil dilatation Carotid artery occlusion
Arteriolar constriction, arteriovenous nicking, yellow hard exudates, Hypertensive changes on fundoscopy [5]
Macular edema, microhemorrhages Diabetic eye disease[6]
Ears Deafness Brain stem infarction
Neck Carotid bruit Presence of occlusive extracranial disease[7][5]
Lungs Cough Congestive heart failure, underlying infection
Heart Arrhythmia Atrial fibrillation[7]
Displaced apical impulse Cardiac enlargement
Murmur Underlying valvular disease[8]
Abdomen Abdominal Tenderness Underlying visceral carcinoma
Palpable abdominal mass Underlying visceral carcinoma
Genitourinary Urinary incontinence Anterior circulation stroke
Erectile dysfunction [9] Anterior, middle or posterior cerebral infarction
Extremities Cyanosis Embolism
Neurological Dysarthria Suggestive of stroke
Muscle weakness Suggestive of stroke
Vertigo, deafness, nystagmus and hemiparesis Posterior circulation stroke
Gait abnormalities/Ataxia Cerebellar stroke
Cranial nerve abnormalities Brain stem infarct

Neurological examination

The physical examination findings in ischemic stroke may vary according to the blood vessel involved and site of infarction:

Vessel involved Physical examination
Anterior cerebral artery [10][11]
Middle cerebral artery[15]
  • Most common site of infarction
Posterior cerebral artery[22][23][24][25][24][26]
Vertebrobasilar artery[30] Midbrain
  • Contralateral decreased motor strength
  • Deviation of eye downwards and outwards-ipsilateral 3rd nerve palsy
Medulla
  • Impaired gag reflex
  • Uvula deviated to the opposite side of lesion
  • Ptosis
  • Miosis
  • Enophthalmos
  • Ipsilateral impaired pain, touch and temperature sensation on the upper half of the face
  • Contralateral decreased motor strength and sensory loss
  • Romberg's sign
  • Deviation of tongue to the side of lesion-hypoglossal nerve
  • Contralateral decreased motor strength
  • Contralateral loss of position sense, vibration and two point discrimination
Pons
  • Inability to close eyes
  • Deviation of angle of mouth
  • Facial muscle weakness-Facial ner ve
  • Loss of taste sensation on the anterior two thirds of tongue
  • Affected eye deviation inwardsand down-Abducent nerve
  • Locked-in syndrome[36][37]
Cerebellum

Neurological assessment with standardized scales

The neurological assessment of the patient with ischemic stroke may be done using standardized scoring system to assess patient prognosis and treatment strategy. Two types of scoring systems widely used are:


For more information about Glasgow coma scoring system, click here.
For information about NIHSS scoring system, click here

Glasgow coma score

Glasgow coma score helps determine the severity of infarction, extent of damage and prognosis in unconscious or semi conscious patients. The score is determined by adding score in each category with the maximum score of 15 and minimum score of 3.[38][39][40][41][42]

Parameter Patient response Glassgow coma score
Eye opening
  • Spontaneous
  • To speech
  • To pain
  • No response
  • 4
  • 3
  • 2
  • 1
Verbal response
  • Oriented to time, place and person
  • Confused
  • Inappropriate words
  • Incomprehensible words
  • No response
  • 5
  • 4
  • 3
  • 2
  • 1
Motor response
  • Obeys commands
  • Moves to localized pain
  • Flexion withdrawl from pain
  • Abnormal flexion to pain (decorticate posture)
  • Abnormal extension to pain (decerebrate posture)
  • No response
  • 6
  • 5
  • 4
  • 3
  • 2
  • 1

Interpretation of Glasgow coma scale:

The following interpretation of glasgow coma scale may help determine the prognostic outcome in patients with brain injury:

Mild brain injury

Glasgow coma scale of 13-15

Moderate brain injury

Glasgow coma scale of 9-12

Severe brain injury

Glasgow coma scale of 3-8

References

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