Causes of Stroke
Related Subjects:
|Acute Stroke Assessment (ROSIER&NIHSS)
|Atrial Fibrillation
|Atrial Myxoma
|Causes of Stroke
|Ischaemic Stroke
|Cancer and Stroke
|Cardioembolic stroke
|CT Basics for Stroke
|Endocarditis and Stroke
|Haemorrhagic Stroke
|Stroke Thrombolysis
|Brain Herniation syndromes
|Haemorrhagic stroke
|Traumatic Head/Brain Injury
|Acute Hydrocephalus
|Epidural Haematoma
|Subdural haematoma
|Basic Neuroscience
|Basal Ganglia
|Apraxia
|Cerebral Angiography and Perfusion
🧠 Introduction
- Diagnosing the cause of a stroke is like detective work 🕵️ - a stroke physician must not only identify stroke but also investigate its cause to prevent recurrence.
- Clues come from careful history and examination: a carotid bruit ➝ stenosis, atrial fibrillation ➝ cardioembolism, Horner’s syndrome ➝ carotid dissection, or a murmur ➝ endocarditis.
- Each case requires critical thinking and Bayesian reasoning - avoid blaming “innocent bystanders” like a patent foramen ovale (PFO) without clear evidence.
- When no clear cause is found, the term cryptogenic stroke is used - it is safer to accept uncertainty than to treat wrongly.
⚠️ Challenges for a Stroke Physician
- Distinguish stroke from mimics (e.g. seizure, migraine, hypoglycaemia).
- Determine the likely cause in each patient and tailor prevention accordingly.
- Balance overlapping risks (e.g. AF + carotid stenosis ➝ anticoagulation vs surgery).
- Communicate the plan clearly to patients and families.
- Focus investigations on high-yield tests, avoid unnecessary or harmful ones.
🧩 Mechanisms of Ischaemic Stroke
- 🩸 In situ arterial thrombosis (atherosclerosis of large vessels).
- 🩸 Small vessel occlusion (lipohyalinosis, hypertension, CADASIL).
- ⚡ Embolism: artery-to-artery (ruptured plaque) or cardioembolic (AF, thrombus, endocarditis, tumour).
- 🫀 Paradoxical embolism (e.g. PFO, right-to-left shunt).
- 💧 Low flow states: hypotension, shock ➝ watershed infarcts.
🧬 Pathological Causes of Ischaemic Stroke
- 🌉 Large vessel atherosclerosis: cervical (carotid, vertebral) and intracranial (MCA, ACA, PCA).
- 🫀 Cardioembolism: AF, mitral stenosis, left atrial thrombus, endocarditis, cardiac tumours.
- 🧩 Small vessel disease: hypertension, CADASIL, Fabry’s disease, diabetes.
- 🩺 Cervical dissections: carotid or vertebral arteries.
- 🔥 Vasculitis: primary (e.g. giant cell arteritis) or secondary (autoimmune/infective).
- 🌪️ Angiopathies: migraine-related, postpartum, drug-induced, RCVS.
- 🧬 Monogenic syndromes: CADASIL, CARASIL, MELAS, Fabry’s.
- 🧪 Haematological causes: polycythaemia, thrombocytosis, sickle cell disease, thrombophilias.
🩸 Aetiologies of Haemorrhagic Stroke
- ⚡ Hypertension: deep bleeds (basal ganglia, pons, thalamus).
- 🧠 Cerebral amyloid angiopathy (CAA): lobar bleeds in older adults.
- 🔗 Vascular anomalies: AVMs, cavernomas, dural AV fistula, aneurysms.
- 🩺 Coagulopathy: anticoagulants (warfarin, DOACs), platelet disorders, thrombolysis.
- 🩸 Cerebral venous thrombosis: venous back-pressure ➝ secondary haemorrhage.
- 🎭 Other: brain tumours (primary/metastatic) bleeding into lesion.
💥 Mechanisms of Haemorrhage
- 🔎 Structural weaknesses: aneurysms, AVMs, Charcot-Bouchard microaneurysms.
- ↔️ Venous back pressure: e.g. cerebral venous sinus thrombosis.
- 🩺 Coagulopathy: anticoagulants, bleeding disorders, DOACs.
💥 Causes of Subarachnoid Haemorrhage
- 🎈 Saccular (berry) aneurysm rupture.
- 🔗 AV malformation.
- ❓ Idiopathic/perimesencephalic.
- 🤕 Trauma.
- 💊 Anticoagulants or thrombolysis.
- 🌪️ Reversible cerebral vasoconstriction syndrome (RCVS).
- 🩸 Intracranial artery dissection.
🧬 Monogenic Causes of Stroke
- CADASIL / CARASIL.
- MELAS (mitochondrial encephalopathy).
- Fabry’s disease.
- Sickle cell disease.
