Stroke

A stroke is a sudden catastrophe in the blood vessels of the brain: an area of brain tissue is cut off from its blood supply and starts to die. Most often a clot blocks an artery; less often a vessel bursts and blood spills into the brain. From the outside the two look identical — the person abruptly loses control of one side of the body, of speech or of vision — and telling them apart is only possible in hospital. The one thing worth taking from this page fits into a single sentence: in a stroke, what is being treated is time. Everything else here explains that sentence.

Face, arm, speech — and the clock

Three signs can be checked in seconds, and any one of them is enough to call an ambulance. Go through them in order.

• Face. Ask the person to smile or show their teeth. In a stroke one corner of the mouth does not lift, the face looks pulled to one side, and sometimes the eye on that side closes less well.
• Arm. Ask them to raise both arms in front of them and hold them there. One arm does not lift at all, or slowly drifts down on its own as if it were being pulled.
• Speech. Ask them to repeat a simple sentence. The words are slurred, jumbled or hard to find, the person cannot name an everyday object, or does not understand what is being said to them.

One sign out of the three is enough — call an ambulance. Across Europe the single emergency number is 112. You do not need to check all three, you do not need to wait and see whether things improve or worsen, and you do not need to be certain it is a stroke: sorting that out is the doctors' job, yours is not to lose time.

And a fourth thing, the one that goes unnoticed: look at the clock and remember the time. If the person woke up with the symptoms already there, remember when they were last seen well. It will be clear in a moment why that single minute is the most valuable thing on this page.

Why time is brain

When a clot blocks an artery, the brain behind it does not die instantly. At first the cells simply stop working — hence the arm that suddenly will not move — but for a while they are still alive and can recover if blood flow is restored. After that they die for good. The count runs in minutes: the longer the vessel stays shut, the more brain moves from the first category into the second.

This is why two treatments exist that change the outcome dramatically: a drug given to dissolve the clot, and removal of the clot through a catheter threaded into the vessel. Both work only inside a narrow window measured in hours from the moment the symptoms began, and the earlier within that window treatment starts, the more brain is saved. Past the window neither is done: there is no longer any benefit, while the risk of bleeding remains.

Two things follow from that. The time the symptoms started is medical information that determines which treatment is possible; the doctor will ask about it first, and an answer of "sometime this afternoon" can cost someone the treatment itself. And the second: "I'll lie down, it may pass" is the most expensive sentence in stroke. A stroke usually does not hurt, and that misleads both the person and everyone around them. Do not wait for morning, for the end of the working day, or for someone else to confirm your suspicion.

What to do while the ambulance is on its way

• Tell the call handler plainly that you suspect a stroke, list the signs and give the time they started. Where the person is taken depends on it: stroke is not treated in every hospital, but in a unit with round-the-clock scanning and specialists in the blood vessels of the brain.
• Give nothing to eat, nothing to drink and no tablets. Swallowing is often affected in a stroke, and the person can choke without noticing it.
• Do not give aspirin on your own initiative. Until there has been a scan, nobody knows whether this is a clot or a bleed; if it is a bleed, a drug that thins the blood makes everything worse.
• Lay the person down with the head slightly raised, loosen the collar and belt, open a window. If they are unconscious or vomiting, turn them onto their side so that nothing passes into the airway.
• Do not drive them to hospital yourself, and certainly do not get behind the wheel if the symptoms are yours. The ambulance crew begins treatment on the way and warns the hospital in advance, so the team is already waiting.
• Gather the list of medicines the person takes, especially anything that thins the blood. And do not leave them alone: their condition can change within minutes.

Signs the face-arm-speech check misses

That check picks up most strokes, but not all of them. When the circulation fails at the back of the brain — in the cerebellum and the brainstem — the face and the arm can be entirely normal and the person will simply seem odd. These are the strokes most often missed, and the ones put down to blood pressure, food poisoning or tiredness. All the signs below have one thing in common: they appear suddenly, over seconds or minutes, rather than building up over a week.

• Sudden loss of sight in one eye, or loss of half the field of vision as though a curtain had come down at one side; sudden double vision.
• Severe dizziness that makes it impossible to stand or walk, with unsteadiness and veering to one side. What separates it from ordinary dizziness is precisely the inability to keep your balance.
• A sudden, extremely severe headache unlike any before it, especially with vomiting, dislike of light or loss of consciousness.
• Sudden confusion, disorientation or strange behaviour, when the person does not grasp where they are or what is happening.
• Numbness or clumsiness down one side of the face, an arm or a leg; a hand that abruptly drops everything.
• Sudden difficulty swallowing, choking on food, or disturbed speech without any weakness in the arms.

Any of these, if it came on abruptly, is a reason to call an ambulance rather than to wait and watch.

If the symptoms have gone away on their own

It happens: the arm would not work for fifteen minutes and now it does, the speech is back, the vision has cleared. Relief arrives, and with it the decision not to go anywhere. This is the most dangerous trap on the whole page.

An episode like that is called a transient ischaemic attack: a clot blocked the vessel and dissolved on its own, and the brain got away with it. But the cause that produced the clot is exactly where it was. A transient attack is not a lucky escape, it is a warning: the risk of a full stroke is highest in the days that follow, and the most dangerous stretch is the first forty-eight hours. It needs investigating urgently, not an appointment next week. If signs of a stroke were there and then went, call an ambulance just as you would if they had stayed.

What is looked for is the source of the clot and anything that can be corrected: the vessels in the neck are examined (a narrowed carotid artery is sometimes operated on), an ECG is recorded along with at least a day of heart rhythm monitoring to catch atrial fibrillation, and blood pressure, blood sugar and cholesterol are checked. Treatment that lowers the risk is started at the same visit. Worth a separate mention is brief blindness in one eye, as though a blind had been pulled down: same signal, same urgency.

What happens in hospital

The first thing done is a scan of the head. It is not there to "confirm it is a stroke" but to answer the one urgent question: clot or bleed. The treatments are opposites, and this is not a place to get it wrong. If needed, imaging of the vessels with contrast is added, to see exactly where the blockage sits and decide whether the clot can be pulled out.

After that, treatment follows the type. In an ischaemic stroke, if the person is inside the window, the clot is dissolved with the drug and, when a large artery is blocked, retrieved through a catheter. In a bleed the priorities are bringing the blood pressure down, stopping the bleeding and operating where necessary, either to remove pooled blood or to relieve the pressure inside the skull. In parallel there are blood tests, an ECG and imaging of the neck vessels and the heart, to work out where the clot came from.

From the first hours swallowing is tested — until that test the person is given nothing by mouth — blood pressure, sugar, temperature and oxygen are monitored, and sitting up and moving begins gradually. That early movement is part of the treatment.

When a stroke happens to someone young

Stroke is thought of as a condition of older people, and largely it is. But it also happens at thirty and at twenty, and in young people it is recognised latest of all: the person and everyone around them look for any other explanation — a bad night's sleep, a trapped nerve, a migraine. Age does not rule out a stroke, and the face-arm-speech check applies just the same at any age.

Younger people also have causes of their own. The main one is dissection of an artery in the neck: the inner lining of the vessel tears, blood tracks into the wall, narrows the channel, and a clot forms at that spot. It follows an injury, a sharp turn or overextension of the neck, a whiplash in a road accident, heavy exertion, and sometimes manipulation of the neck. The recognisable pattern is this: first pain in the neck, the back of the head or behind one ear, often with a smaller pupil and a drooping eyelid on that same side, and then, hours or days later, the signs of a stroke. Neck pain after an injury or a sudden movement, together with neurological symptoms, calls for urgent assessment.

Other causes in the young include a congenital opening between the upper chambers of the heart, through which a clot from the veins reaches the brain; clotting disorders; inflammation of the blood vessels; infection of the heart valves; sickle cell disease; cocaine and amphetamines. Separately, there is the combination of combined hormonal contraception with smoking and migraine with aura, and there is pregnancy and the first weeks after birth, particularly with high blood pressure and pre-eclampsia.

After a stroke: recovery and guarding against a second

How much someone recovers depends on which part of the brain was damaged and how much of it was lost. Most of what comes back does so in the first months, but improvement continues after that, so giving up at six months is premature. Working on it together are a physiotherapist, a speech and language therapist where speech or swallowing is affected, an occupational therapist and a psychologist. And it is worth knowing about something people are rarely warned of: the draining fatigue, the loss of memory and concentration, the low mood, the sudden crying or laughing for no reason. These are consequences of brain damage rather than weakness of character, and there is help for them too.

The second task is preventing another stroke, because after the first one the risk is raised. What genuinely makes a difference:

• blood pressure, the single biggest factor: treatment is adjusted until it reaches target and is not dropped once you feel better;
• atrial fibrillation, which calls for anticoagulants — the usual antiplatelet medicines are not a substitute for them;
• cholesterol-lowering medicines and medicines that stop platelets clumping, as prescribed and taken continuously;
• stopping smoking, moderation with alcohol, control of blood sugar in diabetes;
• movement to the extent cleared after assessment, and weight loss;
• treating pauses in breathing during sleep, where snoring comes with gaps in breathing and daytime sleepiness.

Driving is restricted after a stroke; the periods and conditions depend on the country and on which functions were affected, and that is discussed separately with the doctor. One last thing: whoever is caring for someone after a stroke also needs support and a break, otherwise they will not last.

Online consultation

An acute stroke is not something to sort out remotely: the signs in the first sections need an ambulance, and no message should take minutes away from that. But a remote appointment has its place in everything before and after. The doctor can go through your particular risk picture: the blood pressure that has been "a bit high" for years, the palpitations, the cholesterol, the family history, the combination of contraception with smoking and migraine with aura. They can help you read the discharge summary — what exactly happened, why these medicines were prescribed and what would follow from stopping one of them. They can talk through how to organise recovery at home, what to do about the fatigue and the low mood, which specialist to see first and how soon a face-to-face examination is needed. And they can answer the family's questions, which are usually the ones left unasked in hospital.

This material is for information only and does not replace medical advice.