Stroke warning signs and symptoms

This post discusses stroke warning signs and symptoms, the F.A.S.T. campaign, the concept of the “golden hour”, and delays in seeking hospital care.

Stroke warning signs and symptoms

According to the National Institute of Neurological Disorders and Stroke1, the following are a list of stroke warning signs and symptoms.

  • Sudden numbness or weakness of one side of the face, an arm, or a leg
  • Sudden confusion
  • Difficulty in understanding or trouble in speech
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance and coordination
  • Sudden severe headache with no known cause
  • Seeing two images (double vision)
  • Vomiting

If you re-visit Module 2: The brain basics, you can appreciate how these problems occur as a result of interruption to the blood supply routes; anterior, middle, and posterior cerebral arteries.

As soon as the signs and symptoms begin to unfold, no one can be sure whether it is going to be either a stroke or mini-stroke. Hence the safest strategy in this scenario is to suspect a stroke and take the individual to the nearest hospital with a minimum delay. Even if it is a mini-stroke, the patient needs to be assessed as early as possible to prevent a full-blown stroke.

The F.A.S.T. campaign

F.A.S.T. is an acronym of popular stroke warning signs and symptoms awareness campaign in the world. Each of the first three letters denotes one common sign or a symptom of stroke, which can easily be detected by anyone. The last letter, T, emphasizes the urgency of taking action – call emergency – as soon as possible. Those are;

  • F : face,
  • A :arms,
  • S : speech,
  • T : time.

The following poster (Figure 1) is from such a campaign carried out by the University College London Hospitals in the NHS. It summarises what F.A.S.T. means.

How should we use the F.A.S.T.?

Knowing what these letters represent is not enough. We need to ask its associated specific questions. The following questions assist you in the effective use of the acronym.

How to suspect a stroke

  1. Look at the face

    Ask: can you smile?
    Observe: whether one side of the mouth or an eye is drooping

  2. Compare both arms

    Ask: Raise your both arms
    Observe: Whether the person is having any difficulty of raising one or both arms

  3. Observe the speech

    Observe: whether the person cannot speak or understand as before

  4. Check the time

    Call an ambulance of you observe any one of the above

However, research reveals that the F.A.S.T. campaign, although it raises the awareness of stroke signs and symptoms, may not significantly improve our response to the situation, particularly when the signs and symptoms are not severe such as in the case of mini-stroke2.

The concept of the “golden hour”

In the event of a stroke, the first hour is the most critical to save brain cells as many as possible. As you already know every passing minute costa about 2 million neurons3. The affected person should be on the bed of a hospital with adequate facilities to manage a stroke emergency. This hour is described as the golden hour4.

However, the elapse of the first hour does not mean that we should lose our hope of salvaging still-alive but affected brain tissues. The Canadian best practice guidelines keep from the “witnessed symptom onset” to hospital arrival time as “four and a half hours”5.

The following video clip from the US CDC summarizes the stroke signs and symptoms except for its reference to the time frame.

Stroke warning signs and symptoms (source: US CDC)

Delays in seeking hospital care

Saving still-alive brain cells is a race against time. However, delays happen. The delays can be conceptualized as pre-hospital delays and in-hospital delays. This section discusses the reasons for prehospital delays.

The “family member” effect

Interestingly, research shows that if a stroke occurs at home and in front of family members and loved ones, the delaying time to seek hospital care is longer than if it occurs at the workplace or in front of unknown bystanders6.

This is important because the majority of strokes occur at home and they arrive late at the hospital. For example, in the US, 70 percent of stroke events occur at home and 70 percent of patients with a suspected stroke arrive at a hospital six hours after the event6.

Knowledge and perceived seriousness

Lack of knowledge about stroke warning signs and symptoms is a major problem in spite of awareness campaigns. This is especially relevant to low-middle income countries where the majority of strokes occur. Very few studies exist about awareness levels of stroke warning signs and symptoms from those countries.

However, the knowledge of warning signs alone is inadequate to shorten the delay. It is not the knowledge but, research shows, the perceived seriousness of the observed signs and symptoms triggers action8.

Communicating suspected stroke signs and symptoms

The delay also occurs after taking the decision either to call an ambulance or taking to a hospital depending on the services available. This occurs when describing the event via telephone because most of the time people use vague descriptions. Most of the time we tend to use vague terms to describe the events of a stroke9.


Lack of transport facilities is a major cause for delay in places where community ambulance services either do not exist or not accessible due to geographic and economic reasons, particularly in low-middle income countries.

What to do when we encounter a suspected patient

  • Decision making is the key; Follow the F.A.S.T.
  • First aid and CPR if necessary
  • Remind the reasons for the delays
  • Act fast; call an ambulance; if that facility does not exist, take the person to the nearest hospital as soon as possible.
  1. National Institute of Neurological Disorders and Stroke (NINDS): Basic facts: preventing stroke; NIH; 2020. Accessed on September 16, 2020.
  2. Wolters FJ, Li L, Gutnikov SA, Mehta Z, Rothwell PM. Medical Attention Seeking After Transient Ischemic Attack and Minor Stroke Before and After the UK Face, Arm, Speech, Time (FAST) Public Education Campaign: Results From the Oxford Vascular Study. JAMA Neurol. 2018;75(10):1225–1233. doi:10.1001/jamaneurol.2018.1603
  3. Jeffrey L. Saver (2006): “Time is Brain”: Quantified; Stroke Journal. 2006;37(1): 263-266.
  4. Advani R, Naess H. & Kurz M.W. (2017). The golden hour of acute ischemic stroke.Scand J Trauma Resusc Emerg Med. 2017 May 22;25(1):54. doi: 10.1186/s13049-017-0398-5.
  5. Canadian Stroke Best Practices (2018): Emergency Medical Services Management of Acute Stroke Patients Recommendations.
  6. Dhand, A., Luke, D., Lang, C. et al. Social networks and risk of delayed hospital arrival after acute stroke. Nat Commun 10, 1206 (2019).
  7. Eric S. Donkor (2018): Stroke in the 21st Century; Stroke Res Treat.: published online.
  8. Teusch I Y, Brainin M. Stroke Education: Discrepancies among Factors Influencing Prehospital Delay and Stroke Knowledge. International Journal of Stroke. 2010;5(3):187-208. doi:10.1111/j.1747-4949.2010.00428.x
  9. Christopher T. Richards, Baiyang Wang, Eddie Markul, Frank Albarran, Doreen Rottman, Neelum T. Aggarwal, Patricia Lindeman, Leslee Stein-Spencer, Joseph M. Weber, Kenneth S. Pearlman, Katie L. Tataris, Jane L. Holl, Diego Klabjan & Shyam Prabhakaran (2017) Identifying Key Words in 9-1-1 Calls for Stroke: A Mixed Methods Approach, Prehospital Emergency Care, 21:6, 761-766, DOI: 10.1080/10903127.2017.1332124


Author: Prasantha De Silva

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