MBBS Year
1st Year
Subject
What Is Usually Asked
Circle of Willis, blood supply of the brain, internal capsule
ReferenceAll Years (1st-Final)All UniversitiesStroke
Stroke: Notes, PPT and PYQs for MBBS
Stroke (cerebrovascular accident) is a sudden neurological deficit of vascular origin, caused either by blocked blood flow to the brain (ischaemic stroke) or by bleeding into or around the brain (haemorrhagic stroke). It is a leading cause of death and disability. It is examined in Anatomy in 1st Year, Pathology and Pharmacology in 2nd Year, Community Medicine in 3rd Year, and General Medicine in Final Year.
SME-reviewed. Updated 2026.
Open in GeckoMed for PPT slides and notes.Quick Summary: What You Need to Know for University Exams
- Stroke is either ischaemic (most cases) or haemorrhagic (intracerebral or subarachnoid).
- Hypertension is the most important modifiable risk factor.
- The clinical picture depends on the arterial territory involved.
- Non-contrast CT of the brain is the first investigation, mainly to exclude haemorrhage.
- In eligible ischaemic stroke, intravenous thrombolysis is given within 4.5 hours of onset; mechanical thrombectomy is used for large vessel occlusion.
- "Time is brain": earlier treatment saves more brain tissue.
- Secondary prevention includes antiplatelets or anticoagulation, statins and blood pressure control.
Stroke Across MBBS Subjects
| MBBS Year | Subject | What Is Usually Asked |
|---|---|---|
| 1st Year | Anatomy | Circle of Willis, blood supply of the brain, internal capsule |
| 2nd Year | Pathology | Infarction, atherosclerosis, cerebral haemorrhage, berry aneurysm |
| 2nd Year | Pharmacology | Antiplatelets, anticoagulants, thrombolytics, statins |
| 3rd Year | Community Medicine | Risk factors, prevention, national NCD programme |
| Final Year | General Medicine | Clinical features, localisation, investigations, acute management, secondary prevention |
MBBS Year
2nd Year
Subject
What Is Usually Asked
Infarction, atherosclerosis, cerebral haemorrhage, berry aneurysm
MBBS Year
2nd Year
Subject
What Is Usually Asked
Antiplatelets, anticoagulants, thrombolytics, statins
MBBS Year
3rd Year
Subject
What Is Usually Asked
Risk factors, prevention, national NCD programme
MBBS Year
Final Year
Subject
What Is Usually Asked
Clinical features, localisation, investigations, acute management, secondary prevention
Definition and Classification
Definition (WHO): Rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than vascular origin.
Transient ischaemic attack (TIA): A brief episode of neurological dysfunction caused by focal brain or retinal ischaemia, without evidence of acute infarction. It is a warning sign of future stroke.
Classification
| Type | Subtypes and Key Causes |
|---|---|
| Ischaemic stroke (majority) | Large artery atherosclerosis (thrombotic), cardioembolism (for example atrial fibrillation), small vessel (lacunar) disease, other determined causes, undetermined cause (TOAST classification) |
| Intracerebral haemorrhage | Hypertension (commonly in the basal ganglia, especially the putamen, thalamus, pons and cerebellum), amyloid angiopathy, anticoagulants, vascular malformations |
| Subarachnoid haemorrhage | Rupture of a berry aneurysm (most common non-traumatic cause), arteriovenous malformation |
| Cerebral venous thrombosis | Less common; associated with pregnancy, the puerperium, dehydration and prothrombotic states |
Type
Ischaemic stroke (majority)
Subtypes and Key Causes
Large artery atherosclerosis (thrombotic), cardioembolism (for example atrial fibrillation), small vessel (lacunar) disease, other determined causes, undetermined cause (TOAST classification)
Type
Intracerebral haemorrhage
Subtypes and Key Causes
Hypertension (commonly in the basal ganglia, especially the putamen, thalamus, pons and cerebellum), amyloid angiopathy, anticoagulants, vascular malformations
Type
Subarachnoid haemorrhage
Subtypes and Key Causes
Rupture of a berry aneurysm (most common non-traumatic cause), arteriovenous malformation
Type
Cerebral venous thrombosis
Subtypes and Key Causes
Less common; associated with pregnancy, the puerperium, dehydration and prothrombotic states
Aetiology (Risk Factors)
| Non-Modifiable | Modifiable |
|---|---|
| Increasing age | Hypertension (most important) |
| Male sex | Diabetes mellitus |
| Family history | Smoking |
| Previous stroke or TIA | Dyslipidaemia |
| - | Atrial fibrillation and other heart disease |
| - | Obesity, physical inactivity, unhealthy diet |
| - | Excess alcohol |
| - | Carotid artery stenosis |
Non-Modifiable
Increasing age
Modifiable
Hypertension (most important)
Non-Modifiable
Male sex
Modifiable
Diabetes mellitus
Non-Modifiable
Family history
Modifiable
Smoking
Non-Modifiable
Previous stroke or TIA
Modifiable
Dyslipidaemia
Non-Modifiable
-
Modifiable
Atrial fibrillation and other heart disease
Non-Modifiable
-
Modifiable
Obesity, physical inactivity, unhealthy diet
Non-Modifiable
-
Modifiable
Excess alcohol
Non-Modifiable
-
Modifiable
Carotid artery stenosis
Pathophysiology
Ischaemic Stroke (Flowchart)
- An artery is blocked by thrombosis or embolism
- Blood flow to a region of brain falls sharply
- The ischaemic core dies quickly from energy failure
- The surrounding penumbra is underperfused but still salvageable for a limited time
- Energy failure leads to loss of ion pumps, glutamate release (excitotoxicity), calcium influx and cell death
- Without reperfusion, the penumbra becomes part of the infarct
Haemorrhagic Stroke
- Intracerebral haemorrhage: Rupture of small penetrating arteries damaged by long-standing hypertension; the haematoma raises intracranial pressure and compresses surrounding brain.
- Subarachnoid haemorrhage: Blood enters the subarachnoid space, causing sudden severe headache, meningeal irritation and a risk of delayed vasospasm.
(Examiner may ask you to draw the circle of Willis and the arterial territories of the brain.)
Clinical Features
Recognise stroke quickly (BE-FAST): Balance loss, Eyes (vision loss), Face drooping, Arm weakness, Speech difficulty, Time to call for help.
Features by Arterial Territory
| Artery | Main Features |
|---|---|
| Middle cerebral artery | Contralateral weakness and sensory loss of face and arm more than leg; homonymous hemianopia; aphasia if the dominant hemisphere is affected; neglect if the non-dominant hemisphere is affected |
| Anterior cerebral artery | Contralateral weakness of the leg more than the arm; urinary incontinence; behavioural change |
| Posterior cerebral artery | Contralateral homonymous hemianopia, often with macular sparing |
| Vertebrobasilar system | Vertigo, double vision, slurred speech, unsteadiness, difficulty swallowing, "crossed" signs (cranial nerve signs on one side with limb signs on the other) |
| Posterior inferior cerebellar or vertebral artery | Lateral medullary (Wallenberg) syndrome: ipsilateral facial sensory loss, Horner's syndrome and ataxia, with contralateral loss of pain and temperature in the body |
| Lenticulostriate arteries | Internal capsule infarct: dense contralateral hemiplegia |
Artery
Middle cerebral artery
Main Features
Contralateral weakness and sensory loss of face and arm more than leg; homonymous hemianopia; aphasia if the dominant hemisphere is affected; neglect if the non-dominant hemisphere is affected
Artery
Anterior cerebral artery
Main Features
Contralateral weakness of the leg more than the arm; urinary incontinence; behavioural change
Artery
Posterior cerebral artery
Main Features
Contralateral homonymous hemianopia, often with macular sparing
Artery
Vertebrobasilar system
Main Features
Vertigo, double vision, slurred speech, unsteadiness, difficulty swallowing, "crossed" signs (cranial nerve signs on one side with limb signs on the other)
Artery
Posterior inferior cerebellar or vertebral artery
Main Features
Lateral medullary (Wallenberg) syndrome: ipsilateral facial sensory loss, Horner's syndrome and ataxia, with contralateral loss of pain and temperature in the body
Artery
Lenticulostriate arteries
Main Features
Internal capsule infarct: dense contralateral hemiplegia
Lacunar Syndromes
- Pure motor stroke
- Pure sensory stroke
- Sensorimotor stroke
- Ataxic hemiparesis
- Dysarthria-clumsy hand syndrome
Features Suggesting Haemorrhage
- Sudden severe headache, vomiting and reduced consciousness
- Subarachnoid haemorrhage: "thunderclap" headache, often described as the worst headache ever, with neck stiffness
Diagnosis
| Investigation | Purpose |
|---|---|
| Blood glucose | Excludes hypoglycaemia, a common stroke mimic |
| Non-contrast CT of the brain | First investigation; distinguishes haemorrhage from ischaemia |
| MRI with diffusion-weighted imaging | Most sensitive for early ischaemic changes |
| CT angiography or MR angiography | Detects large vessel occlusion and aneurysms |
| ECG and cardiac monitoring | Atrial fibrillation |
| Echocardiography | Cardiac sources of embolism |
| Carotid Doppler | Carotid stenosis |
| Blood tests | Complete blood count, coagulation profile, renal function, lipids, HbA1c |
| Lumbar puncture | Suspected subarachnoid haemorrhage with a normal CT (xanthochromia) |
Investigation
Blood glucose
Purpose
Excludes hypoglycaemia, a common stroke mimic
Investigation
Non-contrast CT of the brain
Purpose
First investigation; distinguishes haemorrhage from ischaemia
Investigation
MRI with diffusion-weighted imaging
Purpose
Most sensitive for early ischaemic changes
Investigation
CT angiography or MR angiography
Purpose
Detects large vessel occlusion and aneurysms
Investigation
ECG and cardiac monitoring
Purpose
Atrial fibrillation
Investigation
Echocardiography
Purpose
Cardiac sources of embolism
Investigation
Carotid Doppler
Purpose
Carotid stenosis
Investigation
Blood tests
Purpose
Complete blood count, coagulation profile, renal function, lipids, HbA1c
Investigation
Lumbar puncture
Purpose
Suspected subarachnoid haemorrhage with a normal CT (xanthochromia)
Management
Acute Ischaemic Stroke
| Treatment | Key Points |
|---|---|
| Intravenous thrombolysis | Alteplase or tenecteplase in eligible patients within 4.5 hours of onset, after excluding haemorrhage |
| Mechanical thrombectomy | For large vessel occlusion in the anterior circulation; within 6 hours, and up to 24 hours in selected patients on advanced imaging |
| Antiplatelet therapy | Aspirin early after haemorrhage is excluded (delayed for 24 hours after thrombolysis) |
| Blood pressure | Lowered before thrombolysis to below 185/110 mmHg; otherwise, very high levels are lowered cautiously |
| Stroke unit care | Monitoring, swallowing assessment, positioning, early mobilisation |
| Prevent complications | Deep vein thrombosis prophylaxis, pressure care, infection control |
Treatment
Intravenous thrombolysis
Key Points
Alteplase or tenecteplase in eligible patients within 4.5 hours of onset, after excluding haemorrhage
Treatment
Mechanical thrombectomy
Key Points
For large vessel occlusion in the anterior circulation; within 6 hours, and up to 24 hours in selected patients on advanced imaging
Treatment
Antiplatelet therapy
Key Points
Aspirin early after haemorrhage is excluded (delayed for 24 hours after thrombolysis)
Treatment
Blood pressure
Key Points
Lowered before thrombolysis to below 185/110 mmHg; otherwise, very high levels are lowered cautiously
Treatment
Stroke unit care
Key Points
Monitoring, swallowing assessment, positioning, early mobilisation
Treatment
Prevent complications
Key Points
Deep vein thrombosis prophylaxis, pressure care, infection control
Examples of contraindications to thrombolysis: intracranial haemorrhage on imaging, recent major surgery or head injury, active bleeding, and very high blood pressure that cannot be controlled.
Haemorrhagic Stroke
- Stabilise airway, breathing and circulation
- Lower blood pressure carefully
- Reverse anticoagulation if relevant
- Neurosurgical referral for selected haematomas, especially cerebellar haemorrhage or hydrocephalus
- Subarachnoid haemorrhage: nimodipine to reduce vasospasm-related injury; secure the aneurysm by endovascular coiling or surgical clipping
Secondary Prevention
| Measure | Examples |
|---|---|
| Antiplatelets | Aspirin or clopidogrel; short-term dual therapy after minor stroke or high-risk TIA |
| Anticoagulation | For atrial fibrillation |
| Statins | Lipid lowering |
| Blood pressure control | Long-term antihypertensive treatment |
| Carotid endarterectomy or stenting | Symptomatic significant carotid stenosis |
| Lifestyle | Stop smoking, healthy diet, exercise, control diabetes |
Measure
Antiplatelets
Examples
Aspirin or clopidogrel; short-term dual therapy after minor stroke or high-risk TIA
Measure
Anticoagulation
Examples
For atrial fibrillation
Measure
Statins
Examples
Lipid lowering
Measure
Blood pressure control
Examples
Long-term antihypertensive treatment
Measure
Carotid endarterectomy or stenting
Examples
Symptomatic significant carotid stenosis
Measure
Lifestyle
Examples
Stop smoking, healthy diet, exercise, control diabetes
Rehabilitation
- Physiotherapy, occupational therapy and speech therapy
- Management of swallowing problems and nutrition
- Screening for and treatment of depression
- Family support and education
Complications
- Raised intracranial pressure and brain herniation
- Haemorrhagic transformation of an infarct
- Aspiration pneumonia
- Deep vein thrombosis and pulmonary embolism
- Seizures
- Urinary infection and pressure sores
- Post-stroke depression, spasticity and contractures
- Recurrent stroke
Prevention (Community Medicine Angle)
- Stroke is covered under India's national programme for prevention and control of non-communicable diseases, which focuses on screening and control of risk factors such as hypertension and diabetes.
- Primary prevention: blood pressure control, stopping smoking, diabetes control, healthy diet and physical activity.
- Public awareness of warning signs (BE-FAST) helps patients reach hospital within the treatment window.
Prognosis
Outcomes depend on stroke type, size and location, age, and how quickly treatment starts. Early reperfusion, stroke unit care and rehabilitation improve recovery. Large haemorrhages and brainstem strokes carry a higher risk of death.
Quick Viva Questions
Q: What is the time window for intravenous thrombolysis in ischaemic stroke? A: Within 4.5 hours of symptom onset in eligible patients.
Q: What is the first investigation in suspected stroke? A: Non-contrast CT of the brain, to exclude haemorrhage; blood glucose is checked immediately to exclude hypoglycaemia.
Q: What is the most common cause of non-traumatic subarachnoid haemorrhage? A: Rupture of a berry aneurysm.
Q: Which drug reduces the risk of ischaemic damage from vasospasm after subarachnoid haemorrhage? A: Nimodipine.
Q: What is the ischaemic penumbra? A: Underperfused but still viable brain tissue around the infarct core, which can be saved by early reperfusion.
How Stroke Appears in MBBS University Exams
Typical question styles (not attributed to specific papers or years):
- "Classify cerebrovascular accidents. Discuss the aetiology, clinical features, investigations and management of ischaemic stroke." (Long essay, Medicine)
- "Describe the blood supply of the brain. Add a note on the circle of Willis." (Long essay, Anatomy)
- "Write a short note on subarachnoid haemorrhage." (Short note)
- "Write a short note on thrombolytic therapy in stroke." (Short note, Medicine or Pharmacology)
- "Write a short note on lateral medullary syndrome." (Short note)
Frequently Asked Questions
What is the difference between a stroke and a TIA?
A TIA is a brief episode of neurological dysfunction without evidence of brain infarction, while a stroke causes lasting damage. A TIA is a warning sign that needs urgent evaluation.
Why is a CT scan done before thrombolysis?
To exclude bleeding, because thrombolytic drugs would worsen a haemorrhagic stroke.
Can I download the stroke PPT for my presentation?
Yes. Use the Download PPT button at the top of this page. The GeckoMed app also gives offline access to the slides and notes.
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