Stroke

A stroke happens when blood flow to part of the brain is cut off. The two main kinds are ischemic stroke (a clot blocking an artery, about 87 percent of strokes) and hemorrhagic stroke (a vessel rupturing inside or around the brain). A transient ischemic attack, or TIA, is a temporary blockage that resolves on its own. The symptoms look identical to a stroke and a TIA is a warning shot: roughly 1 in 3 people who have one go on to have a full stroke, often within days.

Stroke is time-critical in a way few conditions are. Brain tissue starts dying within minutes of losing blood flow, and the treatments that save function, clot-busting drugs and mechanical clot removal, only work inside narrow time windows from when symptoms started. Getting to an emergency room by ambulance, not by car, is the single biggest decision a family makes during a stroke. Paramedics can route to a certified stroke center and start the clock on treatment before arrival.

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.

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.

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.