Stroke

Recognize a stroke: BE FAST

• Balance: sudden loss of balance or coordination
• Eyes: sudden loss of vision or double vision
• Face: ask the person to smile. Does one side droop?
• Arms: ask them to raise both arms. Does one drift down?
• Speech: is speech slurred or strange, or can they not understand you?
• Time: call 911 immediately and note the time symptoms started

Do not drive the person to hospital yourself if an ambulance is available: paramedics can alert the stroke team and take them to a stroke center. Do not give food, drink or aspirin, because aspirin can worsen a bleeding stroke.

Types of stroke

Transient ischemic attack (mini stroke)

A transient ischemic attack (TIA) causes stroke symptoms that resolve, usually within minutes, without lasting brain damage on scans. It is a major warning sign: the risk of a full stroke is highest in the next 48 hours. Treat it as an emergency.

Symptoms by affected area

• left side of the brain: weakness on the right, language difficulties (aphasia)
• right side of the brain: weakness on the left, neglect of the left side, poor judgment
• brainstem and cerebellum: vertigo, double vision, slurred speech, difficulty swallowing, unsteadiness and weakness on both sides

Risk factors

Modifiable

• high blood pressure: the single most important risk factor
• atrial fibrillation: raises stroke risk about fivefold
• smoking and vaping
• diabetes
• high LDL cholesterol
• obesity and physical inactivity
• heavy alcohol use and drug use (cocaine, amphetamines)
• carotid artery stenosis
• obstructive sleep apnea
• poor diet high in salt and processed foods

Not modifiable

• age, with risk doubling each decade after 55
• family history and previous stroke or TIA
• Black, Hispanic and American Indian people in the US have higher stroke rates
• sickle cell disease
• pregnancy and the postpartum period, migraine with aura, and estrogen use in some women

Diagnosis in the emergency room

• rapid assessment with a stroke scale
• blood sugar check, because low sugar can mimic stroke
• CT scan of the head immediately to rule out bleeding
• CT angiography to find a large blocked artery suitable for thrombectomy
• CT perfusion or MRI to identify salvageable brain tissue, especially when the onset time is unknown
• ECG, blood tests, and later heart monitoring and echocardiography to find the cause

Emergency treatment

Ischemic stroke

• Thrombolysis: clot-busting medicine (alteplase or tenecteplase) given intravenously within 4.5 hours of symptom onset in eligible patients. The earlier, the better.
• Mechanical thrombectomy: a catheter removes the clot from a large artery. It is effective up to 6 hours, and up to 24 hours in selected patients based on imaging.
• Antiplatelet medicine such as aspirin, often started within 24 to 48 hours, and short-term dual antiplatelet therapy after minor stroke or high-risk TIA.

Hemorrhagic stroke

• lowering blood pressure
• reversing blood thinners
• surgery or endovascular treatment for aneurysms and some bleeds
• managing brain pressure in intensive care

Recovery and rehabilitation

Rehabilitation begins as soon as the person is stable. The brain can rewire itself (neuroplasticity), and the greatest gains usually happen in the first 3 to 6 months, though improvement can continue for years.

• physical therapy: strength, balance and walking
• occupational therapy: daily activities such as dressing and cooking
• speech and language therapy: communication and swallowing
• psychological support: depression affects about 1 in 3 stroke survivors and is treatable
• managing fatigue, spasticity and pain

Common lasting effects include weakness, speech and language problems, memory and thinking problems (vascular dementia), vision loss and emotional changes.

Preventing another stroke

• blood pressure control, usually to under 130/80 mm Hg
• antiplatelet medicines (aspirin, clopidogrel) for most ischemic strokes
• anticoagulants for atrial fibrillation
• statins to lower LDL cholesterol
• carotid surgery or stenting for significant narrowing
• lifestyle: stop smoking, exercise regularly, eat a Mediterranean-style or DASH diet, limit salt and alcohol, maintain a healthy weight
• diabetes and sleep apnea treatment

About 1 in 4 strokes happen in people who have had a previous stroke, so secondary prevention matters.

Frequently asked questions

What are the warning signs of a stroke?

Use BE FAST: sudden loss of Balance, Eye or vision changes, Face drooping, Arm or leg weakness, Speech difficulty, and Time to call 911. Other signs include sudden confusion, numbness and a sudden severe headache. Act immediately, even if symptoms go away.

What is the difference between ischemic and hemorrhagic stroke?

An ischemic stroke is caused by a clot blocking blood flow to the brain and accounts for most strokes. A hemorrhagic stroke is caused by a blood vessel bursting and bleeding into or around the brain. A CT scan tells them apart, and the treatments are different.

What is a mini stroke?

A mini stroke, or transient ischemic attack (TIA), causes temporary stroke symptoms that usually resolve within minutes. It does not leave lasting damage, but it signals a high risk of a full stroke in the following days. It needs emergency evaluation.

How long do you have to treat a stroke?

Clot-busting medicine must be given within 4.5 hours of symptom onset, and clot removal can help up to 24 hours in selected patients. Every minute counts, because millions of brain cells die each minute without blood flow. Call 911 at the first sign.

Can you fully recover from a stroke?

Some people recover fully, especially after small strokes treated quickly. Many have some lasting effects, but rehabilitation can greatly improve function, with most gains in the first 3 to 6 months and continued progress afterward.

How can I reduce my risk of stroke?

Control blood pressure, do not smoke, treat atrial fibrillation, manage diabetes and cholesterol, exercise regularly, eat a healthy diet low in salt, limit alcohol and maintain a healthy weight. Up to 80% of strokes are considered preventable.