In a stroke, roughly two million brain cells die every minute that blood flow is not restored. Treatment that dissolves or removes the clot works only within a few hours of symptom onset.
That makes stroke one of the very few conditions where what a bystander does in the first ten minutes genuinely determines whether someone walks again.
The FAST Test
This identifies the majority of strokes in under a minute, and it is worth memorising.
- F for Face: ask the person to smile. Does one side droop?
- A for Arms: ask them to raise both arms. Does one drift down?
- S for Speech: ask them to repeat a simple sentence. Is it slurred or muddled?
- T for Time: if any of these is abnormal, go to hospital immediately and note the time symptoms began
The time of onset is critical information. If the person woke with symptoms, the relevant time is when they were last seen normal. Treatment decisions depend entirely on this, so establish it before you leave the house and tell the emergency team.
Symptoms FAST Can Miss
Around one in five strokes does not produce face, arm or speech signs. These presentations are frequently missed.
- Sudden severe dizziness with inability to walk or stand
- Sudden loss of vision in one eye, or loss of half the visual field in both eyes
- Sudden double vision
- The worst headache of your life, of sudden onset
- Sudden numbness on one side of the body
- Sudden confusion or difficulty understanding speech
- Sudden difficulty swallowing
The common thread is sudden onset of a neurological symptom. Gradual onset over days is far less likely to be stroke. Strokes affecting the back of the brain often present with dizziness and imbalance and are frequently misattributed to inner ear problems.
What to Do Immediately
The actions in the first minutes matter, and several common instincts are wrong.
- Call for an ambulance, or arrange the fastest transport to a hospital with stroke facilities
- Note the exact time symptoms started
- Lay the person down with the head slightly raised
- If unconscious but breathing, place them on their side
- Loosen tight clothing
- Stay with them and keep them calm
- Bring their medication list to hospital
Do not give food, water or medicines by mouth, since swallowing is often impaired and aspiration into the lungs is a serious complication. Do not give aspirin, because if the stroke is a bleed rather than a clot, aspirin makes it worse. Do not wait to see whether symptoms improve. Do not take them to a small clinic without a CT scanner, since that wastes the window.
Why the Type of Stroke Matters
There are two fundamentally different types, and they look identical from outside.
Ischaemic stroke, around eighty five percent, occurs when a clot blocks an artery. Treatment involves dissolving or removing the clot.
Haemorrhagic stroke, around fifteen percent, occurs when a vessel bursts and bleeds into the brain. Treatment involves controlling blood pressure and sometimes surgery, and clot dissolving drugs would be catastrophic.
Only a CT scan distinguishes them, which is why the first step in hospital is imaging and why bringing the patient to a facility with scanning available matters so much.
The Treatment Window
Two treatments can restore blood flow in ischaemic stroke, and both are time limited.
Thrombolysis, a clot dissolving drug given intravenously, is generally given within four and a half hours of symptom onset. Benefit reduces with every passing hour within that window.
Mechanical thrombectomy, removing a large clot with a catheter, can be performed up to twenty four hours in selected patients with specific imaging findings, and is used for large vessel blockages.
Most patients arrive too late for either. In India the average delay from onset to hospital arrival is many hours, largely because symptoms are not recognised or people wait to see if they resolve. Our stroke service assesses these patients on arrival.
Transient Ischaemic Attack Is a Warning
A TIA produces stroke symptoms that resolve completely, usually within minutes to an hour. Because everything returns to normal, people assume it was nothing.
It is not nothing. A TIA indicates a high risk of a full stroke, and that risk is highest in the days immediately afterwards. Prompt assessment and treatment substantially reduce it.
Anyone who has had transient weakness, speech difficulty or visual loss, even lasting only ten minutes, should be assessed urgently rather than at a routine appointment. This is an opportunity to prevent a disabling stroke, and it is repeatedly missed.
Reducing Your Risk
The large majority of strokes are preventable through control of identifiable risk factors.
- Blood pressure: the single largest modifiable risk factor by a wide margin
- Atrial fibrillation: an irregular pulse should be investigated, since appropriate blood thinning reduces stroke risk by around two thirds
- Diabetes control
- Cholesterol
- Stopping smoking, after which risk falls substantially within a few years
- Physical activity and weight
- Reducing salt and alcohol
- Treating obstructive sleep apnoea
Atrial fibrillation deserves emphasis because it is often silent. If a doctor has ever told you your pulse is irregular, get an arrhythmia evaluation, even if you feel entirely well.
Recovery and Rehabilitation
Recovery continues for months and is heavily influenced by how early and how intensively rehabilitation begins.
Rehabilitation should start within days of the stroke, not weeks. It involves physiotherapy for movement and balance, occupational therapy for daily activities, speech and language therapy for communication and swallowing, and psychological support.
The fastest improvement occurs in the first three months, though gains continue well beyond that with continued therapy. The belief that recovery stops at six months is outdated and discourages people unnecessarily.
Depression after stroke is very common and is associated with worse functional recovery. It should be looked for actively rather than assumed to be an understandable reaction. Our physiotherapy and neurology departments coordinate rehabilitation.
Learn FAST and teach it to your family, particularly if someone at home has high blood pressure, diabetes or an irregular pulse. If you see any sudden neurological symptom, note the time and go straight to a hospital with a CT scanner. Do not give anything by mouth, and do not wait.
Our emergency department at T. Nagar operates around the clock with imaging and critical care support.
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