Neurology diagnoses and treats disorders of the nervous system, including the brain, spinal cord, and nerves, as well as thought and memory.
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The symptoms of a stroke are dictated strictly by the anatomy of the occluded vessel. The Middle Cerebral Artery (MCA) is the most commonly affected vessel. An MCA stroke typically results in contralateral (opposite side) hemiparesis and hemisensory loss, predominantly affecting the face and arm more than the leg. If the dominant hemisphere (usually the left) is involved, the patient will have aphasia (loss of language).
Occlusion of the Anterior Cerebral Artery (ACA) presents differently. Because the ACA supplies the medial part of the brain, the weakness and sensory loss are greatest in the contralateral leg and foot. Patients may also exhibit profound frontal lobe signs, such as abulia (lack of will or initiative), urinary incontinence, and primitive reflexes.
Strokes in the vertebrobasilar system are notoriously difficult to diagnose because they lack the clear “face-arm-speech” pattern. These vessels supply the brainstem, cerebellum, and visual cortex. Symptoms often include the “D’s”: Dizziness, Diplopia (double vision), Dysarthria (slurred speech), Dysphagia (swallowing trouble), and Dystaxia (incoordination).
A specific and devastating manifestation is “Locked-In Syndrome,” caused by a thrombosis of the basilar artery. This infarcts the ventral pons, disconnecting the brain from the spinal cord. The patient remains fully conscious and cognitively intact but is completely paralyzed, able only to move their eyes vertically. Recognizing the subtle signs of posterior ischemia is a critical skill in vascular neurology.
Not all strokes involve large arteries. “Lacunar” strokes occur when the tiny, penetrating arteries deep in the brain clot off. These vessels are susceptible to lipohyalinosis, a thickening of the vessel wall caused by chronic hypertension. Because these strokes hit dense pathways, they cause pure motor or pure sensory deficits without “cortical” signs like aphasia or neglect.
While individually small, the accumulation of these strokes leads to a condition called vascular parkinsonism or vascular cognitive impairment. Patients develop a “magnetic gait” (feet stuck to the floor), urinary issues, and pseudobulbar affect (uncontrollable emotional outbursts). This represents the chronic, progressive side of vascular neurology.
A TIA involves the exact same pathophysiology as an ischemic stroke—a clot blocks a vessel—but the clot dissolves spontaneously before permanent tissue death occurs. By definition, symptoms last less than 24 hours, but most last less than one hour.
Vascular neurologists view TIA not as a benign event but as an unstable emergency. It indicates active pathology (e.g., a showering clot from the heart or a critical stenosis). The risk of a major stroke in the days following a TIA is exceptionally high. The ABCD2 score is used to stratify this risk and determine the need for hospital admission.
While hypertension and diabetes are the giants of stroke risk, vascular neurology also investigates rare etiologies. CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is a genetic disease affecting the small vessels, leading to migraines and strokes in younger adults. Fabry disease is a lysosomal storage disorder that can cause stroke.
In younger patients, Cervical Artery Dissection is a leading cause. This involves a tear in the inner lining of the carotid or vertebral artery, often after minor neck trauma or chiropractic manipulation. The blood enters the wall, creating a false lumen that can clot and embolize to the brain.
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This is the classic description of a Subarachnoid Hemorrhage (aneurysm rupture); it is a “thunderclap” headache that reaches maximum intensity instantly, unlike a migraine which builds up.
The brain is wired casually, meaning the right side of the brain controls the left side of the body and vice versa; therefore, a right-sided stroke paralyzes the left side.
Neglect is a bizarre symptom usually seen in right-sided strokes where the patient’s brain ignores the left side of reality; they may only eat food on the right side of the plate or shave the right side of their face.
Rarely, high-velocity neck adjustments can tear the vertebral arteries inside the neck (dissection), leading to a stroke, particularly in young people.
It is a simple calculator used by doctors to predict the risk of stroke in the 2 days after a TIA, based on Age, Blood pressure, Clinical features, Duration, and Diabetes.
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