Stroke: The Warning Signs and Why Every Minute Counts
A stroke happens when the blood supply to part of the brain is suddenly cut off, either by a clot blocking an artery or by a burst vessel bleeding into the brain, and brain cells begin dying within minutes. The warning signs come on suddenly and are usually painless: the face drooping on one side, weakness or numbness in one arm or leg, speech that is slurred or makes no sense, sudden loss of vision, sudden severe imbalance, or a sudden worst-ever headache. Any one of these is enough — call Rescue 1122 immediately, ask for a hospital with a working CT scanner, and note the exact time the symptoms began, because the treatment that dissolves or removes the clot can only be given within the first hours. Do not give food, water or any medicine by mouth, do not let the person sleep it off, and do not wait to see whether it passes. Symptoms that clear within an hour are a transient ischaemic attack, which is not a false alarm but a warning that a full stroke may follow within days and needs assessment the same day.
Health writers · Aslam Clinic
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What a stroke is
The brain has no store of oxygen or sugar. It depends entirely on a continuous blood supply, and when that supply to one area stops, the cells in that area begin to die within minutes. A is exactly that event, and it happens in two ways.
About four in five strokes are ischaemic: an artery is blocked, either by a clot that formed on a fatty plaque in the vessel itself, or by a clot that travelled up from the heart — most often from an irregular rhythm called atrial fibrillation. The remaining one in five are haemorrhagic: a vessel bursts and bleeds into or around the brain, usually because of years of uncontrolled high , sometimes from a weakened vessel wall. The symptoms of the two look identical from outside. Only a scan can tell them apart, and that distinction decides the treatment completely, which is why nothing can be given until the scan is done.
Which abilities are lost depends entirely on which part of the brain is affected. Because the nerve pathways cross over, damage on the left side of the brain causes weakness on the right side of the body, and in most people it also affects language. Damage on the right side causes left-sided weakness and often a difficulty in recognising that anything is wrong — which is one reason the person having the stroke is frequently the last to accept that they need help.
Recognising it: the FAST test
| Sign | How to check it | What you are looking for |
|---|---|---|
| F — Face | Ask the person to smile, or to show their teeth | One side of the mouth or one eyelid droops; the smile is uneven; the face looks fallen on one side |
| A — Arms | Ask them to raise both arms and hold them there for ten seconds | One arm drifts downwards, or cannot be lifted at all, or feels heavy and numb |
| S — Speech | Ask them to repeat a simple sentence back to you | Slurred, jumbled, the wrong words, or no words at all — or they cannot understand what you are saying |
| T — Time | Look at the clock the moment you notice any sign, then call 1122 | The exact start time, or the last time they were definitely normal. This is the number the hospital needs |
The signs FAST does not cover
FAST is deliberately simple, and it catches most strokes but not all. Around one stroke in seven affects the back of the brain and produces none of the three classic signs. Treat any of the following as a stroke if it comes on suddenly:
- Sudden loss or blurring of vision in one or both eyes, or a curtain coming down across the vision.
- Sudden severe or loss of balance, particularly if the person cannot stand or walk without falling to one side.
- Sudden double vision, or a squint that was not there an hour ago.
- Sudden difficulty swallowing, or a sudden change in the voice.
- Sudden numbness down one side of the body, even without weakness.
- A sudden worst-ever headache, especially with vomiting, neck stiffness or drowsiness, which may mean bleeding around the brain.
- Sudden confusion in someone who was normal minutes earlier.
Why the time matters so much
In a large ischaemic stroke, the brain loses on the order of two million nerve cells every minute that the artery stays blocked. That is the entire reason for the urgency. Two treatments can reopen the artery, and both are governed by the clock.
- Clot-dissolving treatment (thrombolysis) — a drug given into a vein that breaks down the clot. It can be given up to 4.5 hours after symptoms started in suitable patients, but the benefit is largest in the first ninety minutes and falls steeply after that. It cannot be given at all if the scan shows a bleed, which is why the scan comes first.
- Clot retrieval (thrombectomy) — a fine tube passed up an artery to physically pull out the clot, for large blockages in a main vessel. In carefully selected patients it can help up to 24 hours after onset, but this is a ceiling for a minority, not a window to rely on, and it is performed only at specialist centres.
Both of those numbers are ceilings and neither is a target. Every minute of delay costs brain that will not come back. In practice the delay that matters most in Pakistan is not the ambulance journey — it is the hour or more spent at home waiting for the symptoms to settle, calling relatives, or trying a home remedy. Nothing given at home helps a stroke, and the time it costs is measured in permanent disability.
It also has to be said plainly that not every hospital can treat a stroke. Thrombolysis requires a CT scanner, a doctor able to interpret it, and the drug on the shelf; thrombectomy requires a specialist centre. Saying the word "stroke" to the 1122 operator and asking for a hospital with a working CT scanner is the single most useful thing a caller can do. Even where clot-dissolving treatment is not available, getting to a hospital quickly still matters a great deal: controlling blood pressure, blood sugar and swallowing safety in the first days measurably changes how well someone recovers.
Mini-stroke: the warning you get in advance
A transient ischaemic attack, or TIA, is a stroke whose symptoms clear completely — usually within minutes, and by definition within twenty-four hours — because the blockage broke up on its own. People describe an arm that was dead for ten minutes, or an eye that went dark and came back, or half an hour of speech that would not work.
It is the most important warning in the whole of stroke medicine, and it is the one most often ignored, precisely because everything went back to normal. A significant proportion of people who have a TIA go on to have a full stroke, and much of that risk falls in the first few days. A TIA needs assessment the same day, not an appointment next week. Treatment started immediately — usually an antiplatelet medicine, blood pressure control, a , and treatment of an irregular rhythm if one is found — substantially reduces the chance of the stroke that would otherwise have followed.
What causes a stroke
The large international INTERSTROKE study, which included Pakistan, found that around nine strokes in ten are explained by risk factors that can be changed. That is an unusually hopeful finding for a condition this serious.
- High — by a wide margin the largest single cause, and the dominant one in South Asia. It is also the one most often untreated, because it has no symptoms.
- An irregular heart rhythm, particularly atrial fibrillation, which allows clots to form in the heart and travel to the brain. It may be felt as or found only on an .
- , which roughly doubles the risk.
- Tobacco in every form — cigarettes, huqqa, naswar, gutka.
- High and in the neck and brain arteries.
- Excess weight, inactivity, and a high-salt diet.
- A previous stroke or TIA, which is the strongest predictor of the next one.
- Age and family history, which cannot be changed but which raise the value of controlling everything above.
In hospital, and afterwards
The first step is an urgent of the brain to separate a clot from a bleed, alongside a blood sugar, an and blood tests. If it is a clot and the time window allows, thrombolysis or thrombectomy is considered. If it is a bleed, the priorities are controlling blood pressure, reversing any blood thinner, and deciding whether neurosurgery is needed. Over the following days: swallowing is assessed before anything is given by mouth, blood sugar and pressure are managed, the cause is investigated with an , prolonged rhythm monitoring and an of the neck arteries, and prevention of the next stroke is started.
Recovery is slow and real. The fastest improvement happens in the first three months, but gains continue for a year and beyond with work. Physiotherapy, speech and language therapy and occupational therapy are the treatments that make the difference at this stage, and the amount of practice matters more than any medicine. Depression after a stroke is common, under-recognised and treatable, and it interferes with rehabilitation — it is worth raising rather than waiting to be asked about. Families should also expect fatigue that is out of proportion to the physical deficit; it is part of the injury, not a lack of effort.
Preventing a stroke
- Know your blood pressure and treat it. This is the highest-value action available, and it works for both kinds of stroke.
- Have your pulse checked, or check it yourself: an irregular pulse may be atrial fibrillation, and treating it with an anticoagulant prevents most of the strokes it would otherwise cause.
- Stop all tobacco. The excess risk falls substantially within a few years of stopping.
- Control blood sugar if you have , and get tested if you have not been.
- Cut salt to under 5 g a day — one level teaspoon from all sources.
- Walk briskly for 30 minutes on most days.
- Take your prevention medicines every day, particularly after a TIA or a first stroke. This is where most preventable second strokes are lost.
When to see a doctor
Call Rescue 1122 immediately, never a clinic, for any sudden symptom described in this article — including one that has already gone away, which needs same-day assessment rather than reassurance. Book an appointment within days if you have been told you have an irregular pulse, if your blood pressure has been high on more than one reading, if you have diabetes that is not well controlled, or if a close relative has had a stroke young. And if you have already had a stroke or a TIA, keep every follow-up appointment and never stop a prevention medicine without asking — the second stroke is the one that most often could have been prevented.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
