Overview

A stroke is a serious, life-threatening medical condition that occurs when the blood supply to part of the brain is cut off.

Strokes are a medical emergency and urgent treatment is essential.

The sooner a person receives treatment for a stroke, the less damage is likely to happen.

If you suspect that you or someone else is having a stroke, phone 999 immediately and ask for an ambulance.

Symptoms of a stroke

The main symptoms of stroke can be remembered with the word FAST:

• Face – the face may have dropped on 1 side, the person may not be able to smile or their mouth or eye may have dropped.
• Arms – the person with suspected stroke may not be able to lift both arms and keep them there because of arm weakness or numbness in 1 arm.
• Speech – their speech may be slurred or garbled, or the person may not be able to talk at all despite appearing to be awake; they may also have problems understanding what you're saying to them.
• Time – it's time to dial 999 immediately if you see any of these signs or symptoms.

Causes of a stroke

Like all organs, the brain needs the oxygen and nutrients provided by blood to function properly.

If the supply of blood is restricted or stopped, brain cells begin to die. This can lead to brain injury, disability and possibly death.

There are 2 main causes of strokes:

• ischaemic – where the blood supply is stopped because of a blood clot (this accounts for 85% of all cases)
• haemorrhagic – where a weakened blood vessel supplying the brain bursts

There is also a related condition known as a transient ischaemic attack (TIA), where the supply of blood to the brain is temporarily interrupted.

This causes what's known as a mini-stroke. It can last a few minutes or persist up to 24 hours.

TIAs should be treated urgently, as they're often a warning sign you're at risk of having a full stroke in the near future.

Seek medical advice as soon as possible, even if your symptoms get better.

Certain conditions increase the risk of having a stroke, including:

• high blood pressure (hypertension)
• high cholesterol
• atrial fibrillation
• diabetes

Symptoms

If you suspect you or someone else is having a stroke, phone 999 immediately and ask for an ambulance.

Even if the symptoms disappear while you're waiting for the ambulance, it's still important to go to hospital for an assessment.

After an initial assessment,  you will be referred to a specialist for further tests to help determine the cause of the stroke. You should be referred to see a specialist within 24 hours of the start of your symptoms. Treatment can also begin if necessary.

Symptoms of a stroke that disappear quickly and in less than 24 hours may mean you have had a transient ischaemic attack (TIA).

These symptoms should also be treated as a medical emergency to reduce the chances of having another stroke.

Recognising the signs of a stroke

The signs and symptoms of a stroke vary from person to person but usually begin suddenly.

As different parts of your brain control different parts of your body, your symptoms will depend upon the part of your brain affected and the extent of the damage.

The main stroke symptoms can be remembered with the word FAST: Face-Arms-Speech-Time.

• Face – the face may have dropped on 1 side, the person may not be able to smile or their mouth or eye may have drooped
• Arms – the person may not be able to lift both arms and keep them there because of weakness or numbness in 1 arm
• Speech – their speech may be slurred or garbled, or the person may not be able to talk at all despite appearing to be awake; they may also have problems understanding what you're saying to them
• Time – it's time to dial 999 immediately if you notice any of these signs or symptoms

It is important for everyone to be aware of these signs and symptoms, particularly if you live with or care for a person who is in a high-risk group, such as someone who is elderly or has diabetes or high blood pressure.

Other possible symptoms

Symptoms in the FAST test identify most strokes, but occasionally a stroke can cause different symptoms.

Other signs and symptoms may include:

• complete paralysis of 1 side of the body
• sudden loss or blurring of vision
• dizziness
• confusion
• difficulty understanding what others are saying
• problems with balance and coordination
• difficulty swallowing (dysphagia)
• a sudden and very severe headache resulting in a blinding pain unlike anything experienced before
• loss of consciousness

However, there are usually other causes for these symptoms.

Transient ischaemic attack (TIA)

The symptoms of a transient ischaemic attack (TIA), also known as a mini-stroke, are the same as a stroke, but tend to only last between a few minutes and a few hours before disappearing completely.

Although the symptoms do improve, a TIA should never be ignored as it's a serious warning sign of a problem with the blood supply to your brain.

It means you're at an increased risk of having a stroke in the near future.

It's important to phone 999 immediately and ask for an ambulance if you or someone else have TIA or stroke symptoms.

If a TIA is suspected, you will be offered aspirin to take straightaway. This helps to prevent a stroke.

Even if the symptoms disappear while you're waiting for the ambulance to arrive, an assessment in a hospital should still be done. You should be referred to see a specialist within 24 hours of the start of your symptoms.

If you think you have had a TIA before, but the symptoms have since passed and you did not seek medical advice at the time, make an urgent appointment with a GP.

They can refer you for a hospital assessment, if appropriate.

Who can get it

There are 2 main types of stroke – ischaemic strokes and haemorrhagic strokes. They affect the brain in different ways and can have different causes.

Ischaemic strokes

Ischaemic strokes are the most common type of stroke. They occur when a blood clot blocks the flow of blood and oxygen to the brain.

These blood clots typically form in areas where the arteries have been narrowed or blocked over time by fatty deposits known as plaques. This process is known as atherosclerosis.

As you get older, the arteries can naturally narrow, but there are some things that dangerously speed up this process.

These include:

• smoking
• high blood pressure (hypertension)
• obesity
• high cholesterol levels
• diabetes
• excessive alcohol intake

Another possible cause of ischaemic stroke is a type of irregular heartbeat called atrial fibrillation.

This can cause blood clots in the heart that break apart and end up in the blood vessels that supply the brain.

Haemorrhagic strokes

Haemorrhagic strokes (also known as cerebral haemorrhages or intracranial haemorrhages) are less common than ischaemic strokes.

They occur when a blood vessel within the skull bursts and bleeds into and around the brain.

The main cause of haemorrhagic stroke is high blood pressure, which can weaken the arteries in the brain and make them more likely to split or rupture.

Things that increase the risk of high blood pressure include:

• being overweight
• drinking excessive amounts of alcohol
• smoking
• a lack of exercise
• stress

Haemorrhagic strokes can also occur as the result of the rupture of a balloon-like expansion of a blood vessel (brain aneurysm) or abnormally formed blood vessels in the brain.

Reducing the risk of a stroke

It's not possible to completely prevent strokes because some things that increase your risk of the condition cannot be changed.

These include:

• age – you're more likely to have a stroke if you are over 55,  although about 1 in 4 strokes happen in younger people
• family history – if a close relative (parent, grandparent, brother or sister) has had a stroke, your risk is likely to be higher
• ethnicity – if you're south Asian, African or Caribbean, your risk of stroke is higher, partly because rates of diabetes and high blood pressure are higher in these groups
• your medical history – if you have previously had a stroke, transient ischaemic attack (TIA) or heart attack, your risk of stroke is higher

But it's possible to significantly reduce your risk of having a stroke by making lifestyle changes to avoid problems such as atherosclerosis and high blood pressure.

You should also seek medical advice if you think you may have an irregular heartbeat.

This can be a sign of atrial fibrillation, which increases the risk of a stroke.

Diagnosis

Strokes are usually diagnosed by doing physical tests and studying images of the brain produced during a scan.

When you first arrive at hospital with a suspected stroke, a doctor will usually want to find out as much as they can about your symptoms.

A number of tests can then be carried out to help confirm the diagnosis and determine the cause of the stroke.

This may include:

• A blood test to find out your cholesterol and blood sugar levels
• checking your pulse for an irregular heartbeat
• taking a blood pressure measurement.

Brain scans

Even if the physical symptoms of a stroke are obvious, brain scans should also be done to determine:

• if the stroke has been caused by a blocked artery (ischaemic stroke) or burst blood vessel (haemorrhagic stroke)
• which part of the brain has been affected
• how severe the stroke is

Everyone with suspected stroke should receive a brain scan within 1 hour of arriving at hospital.

An early brain scan is especially important for people who:

• might benefit from medicine to clear blot clots (thrombolysis), such as alteplase or early anticoagulant treatment
• are already taking anticoagulant treatments
• have a lower level of consciousness

This is why a stroke is a medical emergency and you should call 999 when a stroke is suspected – there's no time to wait for a GP appointment.

The 2 main types of scan used to assess the brain in people who have had a suspected stroke are:

• a CT scan 
• an MRI scan

CT scans

A CT scan is like an X-ray, but uses multiple images to build up a more detailed, 3-dimensional picture of your brain to help your doctor identify any problem areas.

During the scan, you may be given an injection of a special dye into one of the veins in your arm to help improve the clarity of the CT image and look at the blood vessels that supply the brain.

If it's suspected you're experiencing a stroke, a CT scan is usually able to show whether you have had an ischaemic stroke or a haemorrhagic stroke.

It's generally quicker than an MRI scan and can mean you're able to receive appropriate treatment sooner.

MRI scans

An MRI scan uses a strong magnetic field and radio waves to produce a detailed picture of the inside of your body.

It's usually used in people with complex symptoms, where the extent or location of the damage is unknown. 

It's also used in people who have recovered from a transient ischaemic attack (TIA).

This type of scan shows brain tissue in greater detail, allowing smaller, or more unusually located, areas affected by a stroke to be identified.

As with a CT scan, special dye can be used to improve MRI scan images.

Swallow tests

A swallow test is essential for anybody who has had a stroke, as swallowing ability is commonly affected soon after having a stroke.

When a person cannot swallow properly, there's a risk that food and drink may get into the windpipe and lungs, which can lead to chest infections such as pneumonia. This is called aspiration.

The test is simple. The person is given a few teaspoons of water to drink. If they can swallow this without choking and coughing they'll be asked to swallow half a glass of water.

If they have any difficulty swallowing, they will be referred to the speech and language therapist for a more detailed assessment.

They usually will not be allowed to eat or drink normally until they have seen the therapist.

Fluids or nutrients may need to be given directly into a vein in the arm (intravenously) or through a tube inserted into their stomach via their nose.

Heart and blood vessel tests 

Further tests on the heart and blood vessels might be done later to confirm what caused your stroke.

Some of the tests that may be performed are described below.

Carotid ultrasound

A carotid ultrasound scan can help show if there is any narrowing or blockages in the neck arteries leading to your brain.

An ultrasound scan involves using a small probe (transducer) to send high-frequency sound waves into your body.

When these sound waves bounce back, they can be used to create an image of the inside of your body.

When carotid ultrasonography is needed, it should happen within 48 hours.

Echocardiography

An echocardiogram makes images of your heart to check for any problems that could be related to your stroke.

This usually involves moving an ultrasound probe across your chest (transthoracic echocardiogram).

An alternative type of echocardiogram called transoesophageal echocardiography (TOE) may sometimes be used.

An ultrasound probe is passed down your gullet (oesophagus), usually under sedation.

As this allows the probe to be placed directly behind the heart, it produces a clear image of blood clots and other abnormalities that may not get picked up by a transthoracic echocardiogram.

Treatment

Effective treatment of stroke can prevent long-term disability and save lives.

The specific treatments recommended depend on whether a stroke is caused by

• a blood clot obstructing the flow of blood to the brain (ischaemic stroke)
• bleeding in or around the brain (haemorrhagic stroke).

Treatment will usually involve taking 1vor more different medicines, although some people may also need surgery.

Treating ischaemic strokes

If you have had an ischaemic stroke, a combination of medicines to treat the condition and prevent it from happening again is usually recommended.

Some of these medicines need to be taken immediately and only for a short time, while others may only be started once the stroke has been treated and may need to be taken long-term.

Thrombolysis - "clot buster" medicine

Ischaemic strokes can often be treated using injections of a medicine called alteplase that dissolves blood clots and restores blood flow to the brain.

This use of 'clot-busting' medication is known as thrombolysis.

Alteplase is most effective if started as soon as possible after the stroke occurs - and certainly within 4.5 hours.

It's not generally recommended if more than 4.5 hours have passed, as it's not clear how beneficial it is when used after this time.

Before alteplase can be used, it's very important that a brain scan is done to confirm a diagnosis of an ischaemic stroke.

This is because the medicine can make the bleeding that occurs in haemorrhagic strokes worse.

Thrombectomy

A small number of severe ischaemic strokes can be treated by an emergency procedure called a thrombectomy.

This removes blood clots and helps restore blood flow to the brain.

Thrombectomy is only effective at treating ischaemic strokes caused by a blood clot in a large artery in the brain. 

It's most effective when started as soon as possible after a stroke.

The procedure involves inserting a catheter into an artery, often in the groin. A small device is passed through the catheter into the artery in the brain.

The blood clot can then be removed using the device, or through suction. The procedure can be carried out under local or general anaesthetic.

Aspirin and other antiplatelets

Most people will be offered a regular dose of aspirin. As well as being a painkiller, aspirin is an antiplatelet, which reduces the chances of another clot forming.

Other antiplatelet medicines may be used, such as clopidogrel and dipyridamole.

Anticoagulants

Some people may be offered an anticoagulant to help reduce their risk of developing new blood clots in the future.

Anticoagulants prevent blood clots by changing the chemical composition of the blood in a way that prevents clots from forming.

Warfarin, apixaban, dabigatran, edoxaban and rivaroxaban are examples of anticoagulants for long-term use.

There are also a number of anticoagulants called heparins that can only be given by injection and are used short term.

Anticoagulants may be offered if you:

• have a type of irregular heartbeat called atrial fibrillation that can cause blood clots
• have a history of blood clots
• develop a blood clot in your leg veins (deep vein thrombosis (DVT)) – because a stroke has left you unable to move one of your legs

Blood pressure medicines

If your blood pressure is too high, you may be offered medicines to lower it.

Medicines that are commonly used include:

• thiazide diuretics
• angiotensin-converting enzyme (ACE) inhibitors
• calcium channel blockers
• beta-blockers
• alpha-blockers

Find out more about treating high blood pressure.

Statins

If the level of cholesterol in your blood is too high, you will be advised to take a medicine known as a statin.

Statins reduce the level of cholesterol in your blood by blocking a chemical (enzyme) in the liver that produces cholesterol.

You may be offered a statin even if your cholesterol level is not particularly high, as it may help reduce your risk of stroke whatever your cholesterol level is.

Carotid endarterectomy

Some ischaemic strokes are caused by narrowing of an artery in the neck called the carotid artery, which carries blood to the brain.

The narrowing, known as carotid stenosis, is caused by a build-up of fatty plaques.

If the carotid stenosis is particularly severe, surgery may be used to unblock the artery. This is called a carotid endarterectomy.

It involves the surgeon making a cut (incision) in your neck to open up the carotid artery and remove the fatty deposits.

Treating haemorrhagic strokes

As with ischaemic strokes, some people who have had a haemorrhagic stroke will also be offered medcine to lower their blood pressure and prevent further strokes.

If you were taking anticoagulants before you had your stroke, you may also need treatment to reverse the effects of the medicine and reduce your risk of further bleeding.

Surgery

Occasionally, emergency surgery may be needed to remove any blood from the brain and repair any burst blood vessels. This is usually done using a surgical procedure known as a craniotomy.

During a craniotomy, a section of the skull is removed to allow the surgeon access to the source of the bleeding.

The surgeon will repair any damaged blood vessels and ensure there are no blood clots present that may restrict the blood flow to the brain.

After the bleeding has been stopped, the piece of bone removed from the skull is replaced, often by an artificial metal plate.

Surgery for hydrocephalus

Surgery can also be done to treat a complication of haemorrhagic strokes called hydrocephalus.

This is where damage resulting from a stroke causes cerebrospinal fluid to build up in the cavities (ventricles) of the brain, causing symptoms such as headaches, sickness, drowsiness, vomiting and loss of balance.

Hydrocephalus can be treated by surgically placing a tube, called a shunt, into the brain to allow the fluid to drain.

Find out more about treating hydrocephalus.

Supportive treatments

You may need further short-term treatment to help manage some of the problems that can affect people who have had a stroke.

For example, you may require:

• a feeding tube inserted into your stomach through your nose (nasogastric tube) to provide nutrition if you have difficulty swallowing (dysphagia)
• nutritional supplements if you're malnourished
• fluids given directly into a vein (intravenously) if you are at risk of dehydration
• oxygen through a nasal tube or face mask if you have low levels of oxygen in your blood
• compression stockings to prevent blood clots in the leg (DVT)

Recovery

The injury to the brain caused by a stroke can lead to widespread and long-lasting problems.

Although some people may recover quickly, many people who have a stroke need long-term support to help them regain as much independence as possible.

This process of rehabilitation depends on the symptoms and their severity.

It often starts in hospital and continues at home or at a local clinic in your community.

A team of different specialists may help with your rehabilitation, including physiotherapists, psychologists, occupational therapists, speech and language therapists, dietitians and specialist nurses and doctors.

You will be encouraged to actively participate in the rehabilitation process and work with your care team to set goals you want to achieve during your recovery.

The different treatment and rehabilitation methods for some of the main problems caused by strokes are outlined below.

Further information:

• National Institute for Health and Care Excellence (NICE): stroke rehabilitation
• Stroke Association: effects of stroke

Psychological impact

2 of the most common psychological problems that can affect people after a stroke are:

• depression – many people experience intense bouts of crying, feel hopeless and withdraw from social activities
• anxiety – where people experience general feelings of fear and anxiety, sometimes punctuated by intense, uncontrolled feelings of anxiety (anxiety attacks)

Feelings of anger, frustration and bewilderment are also common.

You will receive a psychological assessment from a member of your healthcare team soon after your stroke to check if you're experiencing any emotional problems.

Advice should be given to help deal with the psychological impact of stroke. This includes the impact on relationships with other family members and any sexual relationship.

There should also be a regular review of any problems of depression and anxiety, and psychological and emotional symptoms generally.

These problems may settle down over time but if they are severe or last a long time, GPs can refer people for expert healthcare from a psychiatrist or clinical psychologist.

For some people, medicines and psychological therapies, such as counselling or cognitive behavioural therapy (CBT) may help.

CBT is a therapy that aims to change the way you think about things to produce a more positive state of mind.

Want to know more?

• Stroke Association: stroke helpline
• Stroke Association: emotional changes after a stroke

Cognitive impact

Cognitive is a term used by scientists to refer to the many processes and functions our brain uses to process information.

One or more cognitive functions can be disrupted by a stroke, including:

• communication – both verbal and written
• spatial awareness – having a natural awareness of where your body is in relation to your immediate environment
• memory
• concentration
• executive function – the ability to plan, solve problems and reason about situations
• praxis – the ability to carry out skilled physical activities, such as getting dressed or making a cup of tea

As part of your treatment, each one of your cognitive functions will be assessed and a treatment and rehabilitation plan will be created.

You can be taught a wide range of techniques that can help you relearn disrupted cognitive functions, such as recovering your communication skills through speech and language therapy.

There are many ways to compensate for any loss of cognitive function, such as using memory aids, diaries and routines to help plan daily tasks.

Most cognitive functions will return after time and rehabilitation but you may find that they do not return to the way they were before.

The damage a stroke causes to your brain also increases the risk of developing vascular dementia.

This may happen immediately after a stroke or may develop some time after the stroke happened.

Want to know more?

• Stroke Association: vascular dementia
• Stroke Association: memory and thinking after stroke

Movement problems

Strokes can cause weakness or paralysis on 1 side of the body and can result in problems with co-ordination and balance.

Many people also experience extreme tiredness (fatigue) in the first few weeks after a stroke, and may also have difficulty sleeping, making them even more tired.

As part of your rehabilitation, you should be seen by a physiotherapist, who'll assess the extent of any physical disability before creating a treatment plan.

Physiotherapy will often involve several sessions a week, focusing on areas such as exercises to improve your muscle strength and overcome any walking difficulties.

The physiotherapist will work with you by setting goals. At first, these may be simple goals such as picking up an object.

As your condition improves, more demanding long-term goals, such as standing or walking, will be set.

A careworker or carer, such as a member of your family, will be encouraged to become involved in your physiotherapy.

The physiotherapist can teach you both simple exercises you can do at home.

If you have problems with movement and certain activities, such as getting washed and dressed, you may also receive help from an occupational therapist. They can find ways to manage any difficulties.

Occupational therapy may involve adapting your home or using equipment to make everyday activities easier, and finding alternative ways of achieving tasks you have problems with.

Want to know more?

• Stroke Association: occupational therapy after stroke
• Stroke Association: physiotherapy after stroke

Communication problems

Prevention

The best way to help prevent a stroke is to eat a healthy diet, exercise regularly, and avoid smoking and drinking too much alcohol.

These lifestyle changes can reduce your risk of problems like:

• atherosclerosis - where arteries become clogged up by fatty substances 
• high blood pressure 
• high cholesterol levels

If you have already had a stroke, making these changes can help reduce your risk of having another one in the future.

Diet

An unhealthy diet can increase your chances of having a stroke because it may lead to an increase in your blood pressure and cholesterol levels.

A low-fat, high-fibre diet is usually recommended, including plenty of fresh fruit and vegetables (5 a day) and wholegrains.

Ensuring a balance in your diet is important. Don’t eat too much of any single food, particularly foods that are high in salt and processed foods.

You should limit the amount of salt you eat to no more than 6g (0.2oz) a day as too much salt will increase your blood pressure. 6g of salt is about 1 teaspoonful.

Read more about healthy eating and losing weight.

Exercise

Combining a healthy diet with regular exercise is the best way to maintain a healthy weight.

Regular exercise can also help lower your cholesterol and keep your blood pressure healthy.

For most people, at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity, such as cycling or fast walking, every week is recommended.

If you are recovering from a stroke, you should discuss possible exercise plans with the members of your rehabilitation team.

Regular exercise may not be possible in the first weeks or months after a stroke but you should be able to begin exercising once your rehabilitation has progressed.

Stop smoking

Smoking significantly increases your risk of having a stroke. This is because it narrows your arteries and makes your blood more likely to clot.

You can reduce your risk of having a stroke by stopping smoking.

Not smoking will also improve your general health and reduce your risk of developing other serious conditions, such as lung cancer and heart disease.

You can call Help me Quit Wales on 0800 085 2219 for advice

Cut down on alcohol

Excessive alcohol consumption can lead to high blood pressure and trigger irregular heartbeat (atrial fibrillation), both of which can increase your risk of having a stroke.

Because alcoholic drinks are high in calories they also cause weight gain. Heavy drinking multiplies the risk of stroke by more than 3 times.

If you choose to drink alcohol and have fully recovered, you should aim not to exceed the recommended limits:

• men and women are advised not to regularly drink more than 14 units a week
• spread your drinking over 3 days or more if you drink as much as 14 units a week

If you have not fully recovered from your stroke, you may find that you  have become particularly sensitive to alcohol and even the recommended safe limits may be too much for you.

Find out more about drinking and alcohol.

Managing underlying conditions

If you have been diagnosed with a condition known to increase your risk of stroke – ensuring the condition is well controlled is also important for  helping prevent strokes.

The lifestyle changes mentioned above can help control these conditions to a large degree, but you may also need to take regular medication.

For more information, see:

• treating high cholesterol
• treating high blood pressure
• treating atrial fibrillation
• treating type 1 diabetes and treating type 2 diabetes
• treating TIAs