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Neurology Last reviewed:

Stroke

Also known as: Cerebrovascular Accident, CVA, Brain Attack

Reviewed by the Black Health editorial team Last reviewed

2x

first-stroke risk in non-Hispanic Black adults vs. white adults (CDC, 2024)

Overview

Stroke is both preventable and time-critical. For Black adults in the United States, both of those facts carry extra weight. The risk of having a first stroke is nearly twice as high for non-Hispanic Black adults as for white adults, and Black adults have the highest stroke death rates of any racial group in the country. (CDC, Stroke Data and Statistics) Between ages 45 and 64, the disparity is even sharper: stroke mortality among Black adults in that age range runs three to four times higher than for white adults of the same age. (PMC: Racial Disparities in Stroke Affecting Black Americans)

This page explains the warning signs, the biology driving the gap, and what to do right now if you suspect a stroke is happening.

How Stroke affects Black patients

Black Americans carry the heaviest stroke burden in the United States. The CDC reports the risk of a first stroke is roughly twice as high for non-Hispanic Black adults as for non-Hispanic white adults, and Black adults have the highest stroke death rates of any racial group. The disparity is sharpest in middle age. In the REGARDS cohort (Reasons for Geographic and Racial Differences in Stroke), Black adults ages 45 to 54 had about three times the stroke incidence of white adults the same age, with the gap narrowing only modestly into the late 50s and 60s.

Geography compounds the risk. The Stroke Belt, Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, and Tennessee, has had elevated stroke mortality since at least 1940. Inside that region, the coastal plain of the Carolinas and Georgia is sometimes called the Stroke Buckle, where rates run higher still. CDC data show Black men in the South died of stroke at 65.7 per 100,000, the highest regional rate in the country.

Hypertension is the engine. The REGARDS investigators found that traditional risk factors, with systolic blood pressure doing most of the work, explained roughly half of the Black-white stroke disparity. Both hypertension and diabetes start earlier in life in Black patients and are more often poorly controlled. CDC mortality data through 2021 showed the Black-white stroke gap widening during COVID-19, with absolute differences in stroke death rates climbing 21.7 percent above the prepandemic period.

Sickle cell disease is a separate, child-specific pathway to stroke that overwhelmingly affects Black families. Without screening, an estimated 11 percent of children with sickle cell anemia had an overt stroke before age 20 in older cohorts; the Stroke Prevention Trial in Sickle Cell Anemia (STOP, NEJM 1998) showed that annual transcranial Doppler (TCD) screening with chronic transfusion for children with abnormal velocities cut first-stroke risk by 92 percent. Silent infarcts, strokes visible on MRI without obvious symptoms, reach 39 percent of children with sickle cell anemia by age 18, and each silent infarct raises the risk of an overt stroke.

Symptoms

The standard teaching tool is BE-FAST. Any one sign is enough to call 911.

  • B, Balance: sudden loss of balance, coordination, or trouble walking.
  • E, Eyes: sudden blurred, double, or lost vision in one or both eyes.
  • F, Face: one side of the face drooping, numb, or uneven when smiling.
  • A, Arms: one arm weak, numb, or drifting down when both are raised.
  • S, Speech: slurred speech, trouble finding words, or inability to repeat a simple sentence.
  • T, Time: note the time symptoms started and call 911 immediately.

Less-recognized presentations that still warrant 911: sudden severe headache with no known cause (can signal hemorrhagic stroke); sudden confusion; sudden numbness on one side of the body; sudden dizziness or vertigo with nausea, especially with any other BE-FAST sign.

When to see a doctor

Call 911 for any BE-FAST sign, even if it goes away. A TIA that resolves in five minutes is a medical emergency, not a false alarm, the clot that caused it can re-form. Do not drive to the hospital. Do not wait to see if it passes. Paramedics route to certified stroke centers and start pre-arrival workup; private cars do not.

The clot-busting drug tPA works within 4.5 hours of when symptoms started, and mechanical thrombectomy is now indicated up to 24 hours after onset in selected patients with large-vessel occlusion. Every minute of delay kills roughly 1.9 million neurons. If you wake up with symptoms, the clock starts when you were last known well, not when you woke up, go anyway, because newer imaging-guided protocols can still extend treatment to many wake-up strokes.

Screening

There is no single screening test for stroke. Prevention is about controlling the conditions that cause it.

  • Blood pressure: the highest-yield screen. The AHA recommends a goal under 130/80 for most adults at elevated cardiovascular risk; controlling hypertension is the single largest lever for closing the Black-white stroke gap, per REGARDS analyses.
  • Atrial fibrillation: ask about pulse checks at primary care visits; an irregular pulse warrants an EKG. A-Fib raises stroke risk roughly fivefold and is often silent.
  • Diabetes and cholesterol: routine screening per USPSTF age and risk-based guidance.
  • Carotid imaging: not recommended for the general population, but reasonable when a clinician hears a carotid bruit or after a TIA.
  • Sleep apnea: if you snore loudly, wake gasping, or have daytime sleepiness, ask for a sleep study. A 2024 Neurology analysis of REGARDS found CPAP use was associated with reduced incident stroke risk among Black adults with diagnosed sleep apnea.
  • Sickle cell, ages 2 to 16: annual transcranial Doppler (TCD) screening is standard of care for children with sickle cell anemia. Abnormal velocities trigger chronic transfusion or hydroxyurea per ASH 2020 guidelines.

Treatment overview

Acute treatment is dictated by stroke type and time from onset.

  • Ischemic stroke: intravenous thrombolysis with alteplase (tPA) or tenecteplase within 4.5 hours of symptom onset for eligible patients. Endovascular mechanical thrombectomy for large-vessel occlusions is now indicated up to 24 hours from last-known-well in selected patients (AHA/ASA 2019 guideline update and subsequent trials).
  • Hemorrhagic stroke: blood pressure control, reversal of any blood thinners, neurosurgical evaluation. Some bleeds need surgery to evacuate the clot or clip an aneurysm; many are managed in a neuro-ICU.
  • Stroke-unit care: admission to a dedicated stroke unit independently reduces death and disability. Ask whether the hospital is a Primary Stroke Center, Thrombectomy-Capable Stroke Center, or Comprehensive Stroke Center.
  • Secondary prevention: antiplatelet therapy (aspirin or clopidogrel) or anticoagulation if A-Fib is found, statin therapy, aggressive BP control, diabetes management, smoking cessation. Cardiac rhythm monitoring after a cryptogenic stroke often uncovers paroxysmal A-Fib that changes the prevention plan.
  • Rehabilitation: physical, occupational, and speech therapy starting in the hospital and continuing for months. Recovery curves are steepest in the first 90 days but gains continue well beyond.

Questions to ask your doctor

Bring this list to your next appointment.

  • What is my current stroke risk, and which of my risk factors are most important to target?
  • Is my blood pressure at goal given my history?
  • Should my lipid panel include lipoprotein(a)?
  • Do I have atrial fibrillation, and should I be on anticoagulation?
  • What is my target blood pressure, and what combination of medications gets me there?
  • If I have TIA symptoms that resolved, how quickly do I need to be evaluated?

Find care for stroke

Not sure where to start? Describe what you're experiencing and we'll help you find the right kind of care, including a neurology.

Find care

The numbers

  • Non-Hispanic Black adults and Pacific Islander adults have the highest rates of death from stroke of any racial or ethnic group. (CDC, Stroke Data and Statistics)

What it is

A stroke occurs when blood supply to part of the brain is cut off. Brain cells begin to die within minutes of losing oxygen. There are two main types:

Ischemic stroke (about 87% of all strokes): A blood clot blocks an artery supplying the brain. The clot may form locally (thrombotic stroke) or travel from elsewhere in the body (embolic stroke, often from the heart in atrial fibrillation). Ischemic strokes are treatable with clot-dissolving medication (tPA/alteplase) if the patient arrives at an emergency department within 4.5 hours of symptom onset, and with mechanical thrombectomy (clot removal) up to 24 hours in some patients.

Hemorrhagic stroke (about 13% of strokes): A blood vessel in or around the brain ruptures. Less common but more often fatal. High blood pressure is the leading cause.

TIA (transient ischemic attack): Often called a "mini-stroke." Symptoms are identical to stroke but resolve within minutes to an hour. A TIA is a medical emergency: roughly 10 to 15 percent of TIA patients have a full stroke within three months, with the highest risk in the first 48 hours. Do not wait and see. Call 911.

Every stroke is a medical emergency. Brain cells die at a rate of approximately 1.9 million per minute during an untreated ischemic stroke. Time from symptom onset to treatment is the most critical variable in outcome.

Warning signs: BE FAST

The BE FAST mnemonic covers the most important stroke warning signs. If you see any of these, call 911 immediately. Do not drive yourself. Do not wait to see if symptoms improve.

B: Balance. Sudden loss of balance or coordination, difficulty walking, unexplained dizziness.

E: Eyes. Sudden change in vision in one or both eyes, blurred vision, double vision, or loss of sight.

F: Face. Facial drooping, especially on one side. Ask the person to smile. An uneven smile is a warning sign.

A: Arms. Weakness or numbness in one arm. Ask the person to raise both arms. Does one drift downward?

S: Speech. Slurred speech, inability to find words, difficulty understanding others. Ask the person to repeat a simple sentence.

T: Time to call 911. If any of the above symptoms are present, call 911 now. Note the time symptoms started. This information determines treatment eligibility.

BE FAST was developed to add balance and eye symptoms to the older FAST acronym, capturing posterior circulation strokes that FAST alone misses. (Aroor et al., Stroke, 2017; DOI: 10.1161/strokeaha.116.015169)

Call 911 even if symptoms resolve. A TIA that clears in minutes still requires emergency evaluation within hours.

Why Black adults face higher risk

The disparity has multiple documented causes, most of them addressable:

Hypertension onset earlier and harder to control. Black adults develop high blood pressure at younger ages than white adults, and rates of treatment-resistant hypertension (requiring three or more medications) are higher. This means more cumulative years of elevated pressure damaging artery walls before a stroke event. (AHA Scientific Statement: Cardiovascular Health in African Americans)

Higher diabetes prevalence. Diabetes damages blood vessels and is a major independent stroke risk factor. Black adults carry higher diabetes rates than white adults.

Chronic stress and allostatic load. Sustained exposure to structural racism and discrimination raises blood pressure, promotes inflammation, and disrupts sleep. All of those contribute to vascular disease. The physiological impact of chronic stress is not speculative; it is measurable.

Geographic concentration in high-risk regions. The American South has historically had the highest stroke rates in the country (the "Stroke Belt"), and Black adults are disproportionately concentrated in those states. (PMC: Regional Differences in African Americans' High Risk for Stroke)

Less access to acute stroke care. Outcome after stroke depends heavily on how quickly tPA or thrombectomy is administered. Black patients are less likely to reach a certified stroke center quickly, and disparities in emergency triage have been documented.

Lipoprotein(a) elevation. A genetic variant more common in people of African descent raises lipoprotein(a) levels, an independent cardiovascular and stroke risk factor not captured by standard lipid panels.

Treatment, plainly

Acute treatment (emergency):

  • tPA/alteplase (clot buster): Administered intravenously within 4.5 hours of ischemic stroke onset. Requires ruling out hemorrhage by CT scan. This is why calling 911 and noting symptom onset time matters.
  • Mechanical thrombectomy: Catheter-based removal of the clot, effective up to 24 hours in eligible patients with large vessel occlusion. Requires a comprehensive stroke center.
  • Hemorrhagic stroke: Managed by controlling blood pressure, reversing any anticoagulants, and surgical intervention in some cases.

Secondary prevention (after a stroke or TIA):

  • Blood pressure control: The most important single intervention to prevent a second stroke. Target varies by clinical context; discuss with your neurologist.
  • Antiplatelet medications (aspirin, clopidogrel, aspirin-dipyridamole): For ischemic stroke not caused by atrial fibrillation.
  • Anticoagulants (warfarin, direct oral anticoagulants): For stroke caused by atrial fibrillation.
  • Statin therapy: Reduces LDL cholesterol and has independent anti-inflammatory effects on artery walls.
  • Diabetes management: Tight blood sugar control reduces vascular risk.
  • Lifestyle modification: Smoking cessation (reduces risk by up to 50% within two to five years), regular aerobic exercise, Mediterranean or DASH dietary patterns, alcohol moderation.

Rehabilitation: Stroke recovery involves physical, occupational, and speech therapy. Recovery is most rapid in the first three to six months but can continue for years. Early, intensive rehabilitation is associated with better outcomes.

When to seek emergency care

Call 911 immediately for any BE FAST symptom:

  • Sudden loss of balance or coordination
  • Sudden vision changes in one or both eyes
  • Facial drooping on one side
  • Arm weakness or drift
  • Slurred or garbled speech

Do not wait. Do not drive yourself to the hospital. Do not take aspirin without emergency guidance (it is contraindicated in hemorrhagic stroke). The single most important factor in stroke outcome is time.

For a TIA: symptoms that have resolved are still an emergency. Call 911 or go to the nearest emergency department that night.

How to find care

The American Stroke Association maintains a stroke support group finder and a toll-free helpline: 1-888-4-STROKE (1-888-478-7653).

Sources

  1. Centers for Disease Control and Prevention. Stroke Data and Statistics. https://www.cdc.gov/stroke/data-research/facts-stats/index.html
  1. CDC MMWR. Stroke Mortality Among Black and White Adults Aged 35 Years and Older Before and During the COVID-19 Pandemic, United States, 2015-2021. 2023. https://www.cdc.gov/mmwr/volumes/72/wr/mm7216a4.htm
  1. American Heart Association. Cardiovascular Health in African Americans: A Scientific Statement. Circulation. 2017. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000534
  1. PMC. Racial Disparities in Stroke Affecting Black Americans. 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC12323493/
  1. Aroor S, Singh R, Goldstein LB. BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): Reducing the Proportion of Strokes Missed Using the FAST Mnemonic. Stroke. 2017;48(2):479-481. https://www.ahajournals.org/doi/10.1161/strokeaha.116.015169
  1. Howard G, Cushman M, Kissela BM, et al. Traditional Risk Factors as the Underlying Cause of Racial Disparities in Stroke: Lessons from the Half-Full (Empty?) Glass. Stroke. 2011. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC3784978/
  1. PMC. Regional Differences in African Americans' High Risk for Stroke. https://pmc.ncbi.nlm.nih.gov/articles/PMC1995237/

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Medical disclaimer

This content is for informational and educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about a medical condition. If you are experiencing a medical emergency, call 911 or your local emergency number immediately.

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