Stroke: Symptoms, First Aid, and Treatment

Stroke is damage to brain tissue caused by sudden interruption of cerebral blood flow or rupture of a cerebral artery. Millions of neurons are lost every minute; early diagnosis and treatment are lifesaving. This guide covers types of stroke, the FAST test, emergency treatment, risk factors, prevention, and rehabilitation.

Thrombotic stroke: Occlusion of a cerebral artery by a thrombus that forms locally on an atherosclerotic plaque. It typically involves large vessels (carotid or middle cerebral artery) and more often begins at night or in the early morning hours.
Embolic stroke: Occlusion of a cerebral artery by a clot fragment (embolus) that originates elsewhere — usually the heart or large vessels. Atrial fibrillation (AF) is the most common source of cardioembolic stroke. Onset is abrupt, and symptoms are maximal from the start.
Lacunar stroke: Occlusion of small perforating arteries (40–400 micrometers in diameter) deep within the brain due to lipohyalinosis or microatheroma. Hypertension is the most important risk factor. Lacunar strokes cause small, deep infarcts and present with specific lacunar syndromes such as pure motor hemiparesis or pure sensory loss.

Intracerebral hemorrhage (ICH): Bleeding into the brain parenchyma. Chronic hypertension is the most common cause. Hypertensive hemorrhages most often occur in the basal ganglia, thalamus, pons, and cerebellum. The bleeding damages brain tissue both directly and by exerting pressure on surrounding structures.
Subarachnoid hemorrhage (SAH): Bleeding into the subarachnoid space between the meninges. The most common cause is rupture of a cerebral aneurysm. It characteristically begins with a sudden, explosive headache ("thunderclap headache") described as "the worst headache of my life." Meningismus (neck stiffness), nausea and vomiting, and altered consciousness may accompany it. Mortality is high, and urgent neurosurgical evaluation is required.

F – Face: Ask the person to smile. Is one side of the face drooping? Is the mouth pulling to one side? An asymmetric smile is an important sign of stroke.
A – Arms: Ask the person to raise both arms. Does one arm drift downward or fail to lift? Unilateral arm weakness or numbness suggests stroke.
S – Speech: Ask the person to say a simple sentence. Is the speech slurred, are the words confused, or is the person unable to speak? Dysarthria (slurred speech) or aphasia (loss of speech) is a sign of stroke.
T – Time: If you notice any of these signs, call 112 immediately. Every minute counts!

Sudden weakness or numbness: in the face, arm, or leg — usually on one side of the body (hemiparesis/hemiplegia)
Sudden vision loss: loss of vision in one or both eyes, double vision (diplopia), or visual field defect
Sudden severe headache: an unexplained, unprecedented headache — particularly suggestive of hemorrhagic stroke or SAH
Balance and coordination disturbance: sudden gait difficulty, vertigo, unsteadiness
Altered consciousness: confusion, drowsiness, coma
Difficulty swallowing (dysphagia)

Ischemic core: the central region where blood flow has stopped completely and brain cells die irreversibly within minutes
Penumbra: the surrounding region where blood flow is reduced but brain tissue is still viable. This region is salvageable — saving the penumbra is the goal of treatment.

Brain CT (Computed Tomography): The first imaging study performed in every patient with suspected stroke. Its primary purpose is to rule out hemorrhagic stroke (bleeding), because the treatment of ischemic and hemorrhagic stroke is completely different. CT can show bleeding within minutes; however, it has low sensitivity for early ischemic changes.
Brain MRI (Magnetic Resonance Imaging): Diffusion-weighted MRI (DWI) shows ischemic stroke far earlier and more sensitively than CT, but it may not always be quickly available in the emergency setting.
CT angiography (CTA): Visualizes the cerebral and cervical arteries. It localizes the occluded vessel and is critical for thrombectomy decisions, rapidly identifying large-vessel occlusion.
CT perfusion: Distinguishes the ischemic core from the penumbra and is used for patient selection in thrombectomy.

Intracerebral hemorrhage: Aggressive blood pressure control (systolic target <140 mmHg), urgent reversal of any anticoagulant medication, and intracranial pressure management. Neurosurgical intervention (hematoma evacuation, ventricular drainage) may be needed for large hematomas or developing hydrocephalus.
Subarachnoid hemorrhage: When caused by an aneurysm, urgent securing of the aneurysm (endovascular coiling or surgical clipping), vasospasm prophylaxis (nimodipine), hydrocephalus management, and intensive care monitoring are required.

Call 112 immediately: State that you suspect a "stroke." Note the time symptoms began — this information is critical for treatment decisions.
Place the patient in a safe position: Keep the head slightly elevated and the patient on their side (especially if consciousness is impaired) to reduce aspiration risk.
Do not give food or drink: Swallowing may be impaired, posing an aspiration risk.
Stay calm and reassure the patient.
Note the medications being taken: This is especially important with blood thinners and influences treatment.
Do not give aspirin: Unlike a heart attack, aspirin should not be given for stroke until hemorrhagic stroke has been ruled out.

Hypertension: the single most important risk factor for stroke. It increases the risk of both ischemic and hemorrhagic stroke. Every 20/10 mmHg reduction in blood pressure roughly halves stroke risk.
Atrial fibrillation (AF): An irregular heartbeat can lead to clot formation in the left atrium; the clot can travel to the brain and cause embolic stroke. AF increases the risk of ischemic stroke fivefold. Anticoagulant therapy can reduce stroke risk by 60–70%.
Diabetes mellitus: increases stroke risk 2–4 fold. It accelerates atherosclerosis and contributes to small-vessel disease.
Smoking: doubles stroke risk through endothelial damage, atherosclerosis, increased blood viscosity, and vasoconstriction. Quitting smoking brings risk back toward that of non-smokers within 2–5 years.
Dyslipidemia: High LDL cholesterol increases the risk of atherosclerotic stroke. Statin therapy reduces this risk by 25–30%.
Obesity and physical inactivity: Independent risk factors that contribute through hypertension, diabetes, and dyslipidemia.
Excessive alcohol use: Heavy alcohol consumption increases the risk of both ischemic and hemorrhagic stroke.
Sleep apnea: Untreated obstructive sleep apnea increases stroke risk.

Age: stroke risk doubles every decade after age 55
Sex: more common in men overall, but mortality is higher in women
Family history: a first-degree relative with a stroke history increases risk
Ethnicity: stroke risk is higher in people of African descent
Prior stroke or TIA (transient ischemic attack): the risk of recurrent stroke is markedly increased

Blood pressure control: target is generally <130/80 mmHg. Adherence to antihypertensive therapy is critical.
Anticoagulation in AF: Risk is assessed with the CHA2DS2-VASc score. In high-risk patients, anticoagulant therapy is started with warfarin or a direct oral anticoagulant (DOAC: dabigatran, rivaroxaban, apixaban, edoxaban).
Statin therapy: to reach LDL targets in patients at high atherosclerotic cardiovascular risk
Diabetes control: achieving HbA1c targets
Healthy lifestyle: smoking cessation, regular exercise, a Mediterranean-style diet, healthy weight, and moderate alcohol intake

Physiotherapy: regaining motor function, gait training, balance and coordination work, and spasticity management
Occupational therapy: regaining activities of daily living (eating, dressing, personal care) and improving upper-limb function
Speech and language therapy: treatment of aphasia (loss of speech), dysarthria (slurred speech), and dysphagia (swallowing difficulty)
Psychological support: post-stroke depression occurs in 30–50% of patients and worsens recovery. Antidepressant therapy and psychotherapy are important.
Neuropsychological assessment: evaluation and rehabilitation of cognitive functions (attention, memory, executive function)
Social work: reintegrating the patient into society, family education, and support resources

Adams & Victor's Principles of Neurology, 12th Edition — Chapter: Cerebrovascular Diseases
Harrison's Principles of Internal Medicine, 22nd Edition — Chapter: Cerebrovascular Diseases
Bradley and Daroff's Neurology in Clinical Practice, 8th Edition
AHA/ASA Guidelines for the Early Management of Patients with Acute Ischemic Stroke, 2019
AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage, 2022

Stroke: Symptoms, First Aid, and Treatment

Dr. Emre Gecer

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