Stroke: Symptoms, Causes & Emergency Treatment

What Is the FAST Test for Stroke?

The FAST test is a simple way to recognize stroke symptoms and remember to act quickly. F stands for Face drooping, A for Arm weakness, S for Speech difficulty, and T for Time to call emergency services. If any of these signs are present, call for emergency help immediately.

The FAST test was developed to help people quickly identify the most common warning signs of stroke. It has become the standard method used by healthcare organizations worldwide because it is easy to remember and can be performed by anyone, anywhere. Research shows that public awareness of FAST significantly reduces the time between stroke onset and hospital arrival, which directly improves outcomes.

When a stroke occurs, different parts of the brain may be affected depending on where blood flow is interrupted. The FAST test targets the most common and easily observable symptoms, which relate to the brain areas controlling facial muscles, arm movement, and speech. While not all strokes present with these exact symptoms, the FAST test identifies the majority of cases and serves as an essential first step in recognizing a potential stroke emergency.

Understanding why each component of the test matters helps you perform it effectively. The brain's motor cortex, which controls movement, is often affected during stroke, leading to weakness on one side of the body. Similarly, the areas responsible for speech production and language comprehension can be damaged, resulting in difficulty speaking or understanding words. Facial drooping occurs because the nerves controlling facial muscles originate in the brain, and stroke can disrupt these signals.

How to Perform the FAST Test

Performing the FAST test takes only a few seconds but could save a life. Each step is designed to quickly assess a different brain function that is commonly affected during stroke. Here is how to perform each component:

• F - Face: Ask the person to smile and show their teeth. Look carefully at both sides of the face. If one side droops, appears numb, or doesn't move as well as the other side, this is a warning sign of stroke.
• A - Arms: Ask the person to close their eyes and raise both arms out in front of them, palms facing up. Ask them to hold this position for 10 seconds. If one arm drifts downward or cannot be raised to the same height as the other, this indicates possible stroke.
• S - Speech: Ask the person to repeat a simple sentence such as "The sky is blue today" or "No ifs, ands, or buts." Listen carefully for slurred words, difficulty forming words, using wrong words, or inability to speak at all.
• T - Time: If you observe any of these signs, call emergency services immediately. Note the time when symptoms first appeared – this information is crucial for treatment decisions. Do not wait to see if symptoms improve.

What Are the Symptoms of a Stroke?

Stroke symptoms appear suddenly and include facial drooping, arm or leg weakness on one side, difficulty speaking or understanding speech, vision problems, severe headache without known cause, dizziness, and loss of balance. Symptoms depend on which part of the brain is affected.

Stroke symptoms develop rapidly because the brain is extremely sensitive to interruptions in blood supply. Unlike other organs that can tolerate brief periods without oxygen, brain cells begin dying within minutes when blood flow stops. This is why stroke symptoms appear so suddenly – one moment a person may be fine, and the next moment they experience dramatic changes in function.

The specific symptoms a person experiences depend entirely on which area of the brain is affected and how extensive the damage is. The brain is organized into regions that control different functions: the left hemisphere typically controls language and the right side of the body, while the right hemisphere controls spatial awareness and the left side of the body. The brainstem controls vital functions like breathing and consciousness, while the cerebellum coordinates movement and balance.

It is important to understand that stroke symptoms can vary significantly between individuals. Some people experience multiple symptoms simultaneously, while others may have only one or two. The severity can also range from mild to severe. What makes stroke different from other conditions is the sudden onset – symptoms typically reach their maximum intensity within seconds to minutes, rather than gradually worsening over hours or days.

Common Stroke Symptoms

While the FAST test covers the most frequent symptoms, there are additional warning signs that everyone should know. Recognizing the full range of possible symptoms increases the chances of identifying a stroke quickly:

• Numbness or weakness: Sudden numbness, weakness, or paralysis in the face, arm, or leg, especially on one side of the body. The person may be unable to lift their arm or their leg may give way when standing.
• Confusion: Sudden confusion, trouble understanding what others are saying, or difficulty thinking clearly. The person may seem disoriented or unable to follow simple instructions.
• Vision problems: Sudden trouble seeing in one or both eyes, including blurred vision, double vision, or complete loss of vision. Some people describe it as a "curtain" coming down over their vision.
• Severe headache: A sudden, severe headache with no known cause, often described as "the worst headache of my life." This is especially common in hemorrhagic stroke caused by bleeding in the brain.
• Dizziness and balance problems: Sudden dizziness, loss of balance or coordination, or trouble walking. The person may stagger, veer to one side, or be unable to stand.
• Difficulty swallowing: Trouble swallowing food or liquids, which can lead to choking or aspiration.

Symptoms in Women vs Men

While both men and women can experience the classic FAST symptoms, research has shown that women sometimes present with additional or different symptoms that may be overlooked. Women are more likely to report general weakness, fatigue, confusion, nausea, and disorientation. They may also experience sudden behavioral changes, agitation, or hallucinations. Because these symptoms can seem vague or be attributed to other conditions, women may delay seeking emergency care, leading to worse outcomes.

When Should You Call Emergency Services for Stroke?

Call emergency services immediately if you or anyone shows ANY signs of stroke, even if symptoms seem mild or go away. Do not drive yourself to the hospital – paramedics can begin assessment and notify the hospital to prepare. Every minute matters because brain-saving treatments must be given within hours.

The decision to call emergency services for suspected stroke should never involve hesitation or "waiting to see" if symptoms improve. Stroke is a medical emergency where time directly translates to brain tissue – the phrase "time is brain" reflects the reality that approximately 1.9 million brain cells die every minute during an ischemic stroke. The treatments that can reverse stroke damage have strict time windows, and every minute of delay reduces the chances of full recovery.

Many people make the mistake of waiting because their symptoms seem "not that bad" or because they don't want to "make a fuss." This is dangerous thinking. Mild symptoms can rapidly progress to severe stroke, and even if symptoms resolve completely (suggesting a TIA), the person remains at extremely high risk for a more serious stroke in the coming hours and days. Emergency medical evaluation is essential regardless of symptom severity.

Another common mistake is having a family member drive the patient to the hospital. While the intention is good, this delays care in several important ways. Emergency medical services (EMS) can begin assessing the patient immediately, start treatment en route, and most importantly, alert the receiving hospital so the stroke team is assembled and ready when the patient arrives. This "prehospital notification" can save 20-30 minutes of in-hospital delay – time that directly impacts outcome.

What Causes a Stroke?

Stroke is caused by interrupted blood flow to the brain. Ischemic stroke (87% of cases) occurs when a blood clot blocks an artery. Hemorrhagic stroke (13%) occurs when a blood vessel ruptures and bleeds into the brain. Both types cause brain cells to die due to lack of oxygen and nutrients.

Understanding what causes stroke helps explain why time-critical treatment is so important and why prevention focuses on certain risk factors. The brain requires a constant supply of oxygen and glucose delivered through the bloodstream. When this supply is interrupted – whether by a blockage or bleeding – brain cells begin dying within minutes. The longer the interruption continues, the more brain tissue is permanently damaged.

The two main types of stroke – ischemic and hemorrhagic – have fundamentally different causes and require different treatments. This is why imaging tests (CT or MRI) are performed immediately when a patient arrives at the hospital with stroke symptoms. Giving clot-busting medication to someone with a hemorrhagic stroke would be catastrophic, as it would worsen the bleeding. Conversely, failing to dissolve a clot in an ischemic stroke means brain tissue continues dying unnecessarily.

Ischemic Stroke (Blood Clot)

Ischemic stroke accounts for approximately 87% of all strokes and occurs when blood flow through an artery supplying the brain is blocked. This blockage is almost always caused by a blood clot, but the clot can form in different ways:

Thrombotic stroke occurs when a blood clot (thrombus) forms directly in an artery leading to or within the brain. This typically happens in arteries that have been narrowed by atherosclerosis – the buildup of fatty deposits (plaque) on artery walls over years. The narrowed area creates turbulent blood flow that promotes clot formation. This type is often associated with high cholesterol, high blood pressure, smoking, and diabetes, which all accelerate atherosclerosis.

Embolic stroke occurs when a blood clot forms elsewhere in the body – usually the heart or large arteries in the neck – and travels through the bloodstream until it lodges in a brain artery too small to let it pass. The most common source is the heart, particularly in people with atrial fibrillation (an irregular heartbeat that allows blood to pool and clot in the heart chambers). Embolic strokes often affect larger brain areas because the clots can be quite large.

Hemorrhagic Stroke (Brain Bleeding)

Hemorrhagic stroke occurs when a blood vessel in the brain ruptures, causing bleeding into or around brain tissue. Although less common than ischemic stroke, hemorrhagic strokes are often more severe and have higher mortality rates. The damage comes not only from the lack of blood flow beyond the rupture but also from the direct pressure of accumulated blood on brain tissue.

Intracerebral hemorrhage is bleeding directly into brain tissue. The most common cause is chronic high blood pressure, which weakens small artery walls over time until they eventually rupture. This type typically occurs during activity when blood pressure is elevated. Risk factors include uncontrolled hypertension, excessive alcohol use, and use of blood-thinning medications.

Subarachnoid hemorrhage is bleeding into the space between the brain and the thin tissues covering it. This is most commonly caused by a ruptured aneurysm – a weak, bulging spot in an artery wall that eventually bursts. This type often presents with a sudden, severe "thunderclap" headache and can occur in younger people who may not have typical stroke risk factors.

TIA – A Serious Warning Sign

A transient ischemic attack (TIA), sometimes called a "mini-stroke," occurs when blood flow to the brain is temporarily blocked. The symptoms are identical to stroke but resolve completely within 24 hours (usually within minutes). TIA is caused by the same mechanisms as ischemic stroke – typically a small clot that either dissolves on its own or passes through the blockage.

Despite the temporary nature of symptoms, TIA is a medical emergency that requires immediate evaluation. It is a powerful warning sign that a full stroke may be imminent. Studies show that approximately 10-15% of TIA patients will have a full stroke within 3 months, with half of those occurring within 48 hours. Urgent evaluation allows doctors to identify the cause and begin preventive treatment before a major stroke occurs.

How Is Stroke Diagnosed?

Stroke is diagnosed through physical examination, brain imaging (CT scan or MRI), and blood tests. CT scan is usually performed first to determine whether the stroke is caused by a clot or bleeding – this is critical because treatments differ. Additional tests identify the stroke's cause and guide prevention of future strokes.

When a patient arrives at the emergency department with suspected stroke, every minute counts. Modern stroke centers have protocols to ensure that evaluation and treatment begin immediately – the goal is "door-to-needle time" of less than 60 minutes for eligible patients to receive clot-busting medication. The diagnostic process is designed to quickly answer the most critical questions: Is this a stroke? If so, what type? And is the patient eligible for emergency treatment?

The first priority is brain imaging – typically a CT (computed tomography) scan – which can be completed in minutes and immediately distinguishes between ischemic and hemorrhagic stroke. This distinction is absolutely critical because the treatments are completely different. A CT scan can rule out bleeding within seconds, allowing doctors to consider clot-busting therapy. MRI (magnetic resonance imaging) provides more detailed images and is sometimes used, but CT remains the standard for initial emergency evaluation due to speed and availability.

Diagnostic Tests and Examinations

Beyond the initial CT scan, several other tests are typically performed to understand the stroke's cause and guide treatment:

• CT angiography (CTA): Uses contrast dye to visualize blood vessels in the brain and neck, identifying blockages or narrowing that may have caused the stroke or could cause future strokes
• MRI: Provides detailed images of brain tissue and can detect strokes that may not appear on CT, particularly smaller or very recent strokes
• Electrocardiogram (ECG): Records heart rhythm to detect atrial fibrillation or other heart rhythm abnormalities that can cause blood clots
• Echocardiogram: Ultrasound of the heart to look for clot sources, valve problems, or other heart conditions
• Carotid ultrasound: Examines the carotid arteries in the neck for narrowing (stenosis) that may require treatment
• Blood tests: Check blood sugar, cholesterol levels, clotting function, and other factors that affect stroke risk and treatment decisions

How Is Stroke Treated?

Ischemic stroke can be treated with clot-busting medication (tPA) within 4.5 hours or mechanical thrombectomy to physically remove large clots. Hemorrhagic stroke requires controlling bleeding and reducing brain pressure, sometimes requiring surgery. Immediate treatment is followed by rehabilitation to maximize recovery.

Stroke treatment has undergone revolutionary advances in recent decades. Whereas stroke was once considered largely untreatable – leading to the fatalistic view that little could be done – we now have highly effective treatments that can reverse stroke damage and dramatically improve outcomes. However, these treatments are time-sensitive, which is why rapid recognition and emergency response remain the most critical factors in stroke care.

The treatment approach depends entirely on the type of stroke. For ischemic stroke, the goal is to restore blood flow as quickly as possible. For hemorrhagic stroke, the priorities are stopping the bleeding, reducing pressure on the brain, and preventing further damage. Both types require careful monitoring of vital signs, brain function, and potential complications in a stroke unit or intensive care setting.

Treatment for Ischemic Stroke

The primary treatments for ischemic stroke focus on restoring blood flow to the affected brain area:

Thrombolysis (clot-busting medication): Tissue plasminogen activator (tPA), also called alteplase, is a powerful medication that dissolves blood clots. When given within 4.5 hours of stroke onset (and ideally much sooner), tPA significantly improves the chances of recovery with minimal or no disability. The medication is given through an IV line and works by activating the body's clot-dissolving system. However, because it affects clotting throughout the body, there is a small risk of bleeding – which is why patients must meet strict eligibility criteria.

Mechanical thrombectomy: For strokes caused by large clots in major brain arteries, doctors can physically remove the clot using specialized devices. A catheter is threaded through an artery (usually starting at the groin) up to the blocked vessel, where a stent retriever or aspiration device captures and removes the clot. This procedure can be performed up to 24 hours after stroke onset in selected patients and has revolutionized treatment for large vessel occlusions, which previously had very poor outcomes.

Antiplatelet and anticoagulant therapy: After the acute phase, medications to prevent future clots are essential. Aspirin and other antiplatelet drugs reduce the stickiness of blood cells that form clots. Anticoagulants like warfarin or newer direct oral anticoagulants (DOACs) are prescribed when stroke is caused by heart-related conditions like atrial fibrillation.

Treatment for Hemorrhagic Stroke

Hemorrhagic stroke treatment focuses on stopping or controlling bleeding, reducing pressure within the skull, and preventing further damage:

Controlling blood pressure: High blood pressure can worsen bleeding, so it is carefully managed during the acute phase. Medications are given intravenously to rapidly but carefully lower blood pressure to target ranges.

Reversing blood thinners: If the patient was taking anticoagulant medications, these effects must be reversed quickly. Specific antidotes are available for different blood thinners.

Surgical intervention: Surgery may be needed to relieve pressure on the brain from accumulated blood, repair damaged blood vessels, or clip an aneurysm to prevent further bleeding. The decision to operate depends on the size and location of the hemorrhage, the patient's condition, and likelihood of benefit.

Draining excess fluid: If bleeding causes fluid buildup in the brain (hydrocephalus), a drain may be placed to relieve pressure.

What Is Recovery Like After a Stroke?

Stroke recovery varies greatly depending on stroke severity, location, and treatment timing. The brain can partially recover through neuroplasticity – forming new connections to compensate for damaged areas. Rehabilitation involving physical therapy, occupational therapy, and speech therapy is essential for maximizing recovery.

Recovery from stroke is a highly individual journey that depends on numerous factors: the size and location of the stroke, how quickly treatment was received, the person's age and overall health, and the intensity and quality of rehabilitation. Some people recover completely with minimal lasting effects, while others experience permanent disabilities that require ongoing support. Most fall somewhere between these extremes, with significant improvement possible through dedicated rehabilitation.

The brain possesses remarkable ability to adapt after injury – a property called neuroplasticity. Undamaged brain areas can sometimes take over functions that were lost when other areas were damaged. This process requires repeated practice and stimulation, which is why rehabilitation therapy is so important. The brain essentially needs to relearn tasks by forming new neural pathways, and this requires intensive, consistent practice.

Recovery typically follows a general pattern, with the most rapid improvement occurring in the first weeks to months after stroke. However, meaningful recovery can continue for years. Studies have shown that even patients who plateau in their recovery can make further gains with intensive therapy years after their stroke. This challenges the old belief that recovery stops after a certain point and emphasizes the importance of ongoing rehabilitation.

Rehabilitation After Stroke

Stroke rehabilitation is a team effort involving multiple specialists who work together to help the patient regain function and independence:

• Physical therapy: Focuses on restoring movement, strength, balance, and coordination. Therapists use exercises, stretching, and specialized techniques to help patients relearn how to walk, climb stairs, and perform physical activities.
• Occupational therapy: Helps patients regain ability to perform daily activities like dressing, bathing, eating, and writing. Therapists may recommend adaptive equipment or home modifications to increase independence.
• Speech-language therapy: Essential for patients with aphasia (difficulty with language) or dysarthria (difficulty with speech production). Therapists also address swallowing difficulties (dysphagia) which can be dangerous if food enters the airway.
• Cognitive rehabilitation: Addresses problems with memory, attention, problem-solving, and other thinking skills that may be affected by stroke.
• Psychological support: Depression and anxiety are common after stroke, affecting approximately one-third of survivors. Mental health support is an important component of comprehensive stroke care.

Long-Term Effects of Stroke

Stroke can cause lasting effects that depend on which brain areas were damaged:

• Weakness or paralysis: Often affects one side of the body (hemiparesis or hemiplegia). With therapy, many people regain significant function.
• Aphasia: Difficulty speaking, understanding speech, reading, or writing. Affects about one-third of stroke survivors.
• Dysphagia: Difficulty swallowing, which can affect nutrition and increase risk of aspiration pneumonia.
• Vision problems: Can include loss of vision in part of the visual field, double vision, or difficulty processing visual information.
• Cognitive changes: Memory problems, difficulty concentrating, slowed thinking, and challenges with planning and problem-solving.
• Emotional changes: Depression, anxiety, emotional lability (uncontrolled crying or laughing), and personality changes are common.
• Neglect: Difficulty perceiving or paying attention to one side of space, even without vision loss.

How Can You Prevent Stroke?

Up to 80% of strokes can be prevented. Key prevention strategies include controlling blood pressure (the most important modifiable risk factor), managing diabetes and cholesterol, quitting smoking, limiting alcohol, exercising regularly, eating a healthy diet, and treating atrial fibrillation if present.

Prevention is the most powerful weapon against stroke. While we cannot change certain risk factors like age, sex, or family history, the vast majority of strokes are caused by modifiable factors that can be addressed through lifestyle changes and medical treatment. Research consistently shows that addressing these risk factors can dramatically reduce stroke risk – making prevention far more effective than even our best emergency treatments.

The key to prevention is understanding your personal risk factors and working with healthcare providers to address them systematically. Risk factors often cluster together – someone with high blood pressure may also have diabetes, high cholesterol, and excess weight. Addressing all these factors together provides the greatest protection. Regular health screenings are important for detecting problems early, before they cause damage.

Key Steps to Reduce Your Stroke Risk

• Control blood pressure: High blood pressure is the single most important modifiable risk factor, contributing to more than half of all strokes. Target blood pressure for most adults is below 130/80 mmHg. This may require medication, reduced salt intake, weight loss, and regular exercise.
• Quit smoking: Smoking doubles the risk of stroke by damaging blood vessels, promoting atherosclerosis, raising blood pressure, and making blood more likely to clot. The risk begins decreasing immediately after quitting and returns to near-normal within 5-10 years.
• Manage diabetes: Diabetes accelerates atherosclerosis and damages blood vessels throughout the body. Maintaining good blood sugar control through diet, exercise, and medication significantly reduces stroke risk.
• Control cholesterol: High LDL ("bad") cholesterol contributes to plaque buildup in arteries. Diet, exercise, and statin medications can lower cholesterol and reduce stroke risk.
• Limit alcohol: Heavy alcohol use increases stroke risk through effects on blood pressure, heart rhythm, and blood clotting. If you drink, do so in moderation – up to one drink per day for women and two for men.
• Exercise regularly: Physical activity reduces multiple stroke risk factors including blood pressure, weight, diabetes risk, and cholesterol. Aim for at least 150 minutes of moderate aerobic activity per week.
• Maintain healthy weight: Obesity increases risk of high blood pressure, diabetes, and other stroke risk factors. Even modest weight loss can significantly reduce risk.
• Eat a healthy diet: Emphasize fruits, vegetables, whole grains, lean proteins, and healthy fats. Limit sodium, saturated fat, and processed foods. The Mediterranean diet has been shown to reduce stroke risk.
• Treat atrial fibrillation: This irregular heart rhythm increases stroke risk fivefold by allowing blood clots to form in the heart. Blood-thinning medications can reduce stroke risk by 60-70% in people with atrial fibrillation.