Introduction

The approach to neurovascular disease has considerably changed over the last decade. With advances in neuroimaging, localization of the lesion has become easier. However, clinical recognition of stroke syndromes is still very important for several reasons.

First, in the acute phase, it enables diagnosis, exclusion of stroke imitators (migraine, epilepsy, PRES, anxiety, psychogenic, etc.), and recognition of rare manifestations of stroke, such as cognitive-behavioral presentations which are easily misdiagnosed.

Second, it contributes to the planning of acute interventions by localizing the stroke (anterior versus posterior circulation or cortical versus subcortical involvement) and by interpretation of imaging abnormalities. Each subtype of stroke may benefit from intravenous thrombolysis for example, but only some subtypes, such as proximal intracranial occlusion, may be appropriate candidates for acute endovascular recanalization.

Third, during hospitalization, localization helps to direct the subsequent work-up. If a cardioembolic etiology is suspected, for instance, it would lead to more intensive cardiac investigations, such as transesophageal echography or repeated 24-hour cardiac rhythm recording. In contrast, if a lacunar etiology is presumed, the cardiac investigation may remain limited.

Fourth, it also allows the clinician to anticipate, recognize and treat complications related to a specific stroke type, such as large fluctuations in the lacunar “capsular warning syndrome” or brainstem compression from cerebellar edema.

Finally, making the correct diagnosis means choosing the appropriate secondary prevention. In the presence of a significant carotid stenosis, endarterectomy may be very effective if the recent stroke occurred in the territory distal to the stenosis, but of limited effectiveness if another territory is involved.