Stroke and TIA: the symptoms, and why a warning that resolves is still an emergency

Stroke is the second leading cause of death worldwide and a leading cause of acquired disability. Roughly 85 per cent are ischaemic — a blocked artery — and the remainder haemorrhagic.

What has changed most in stroke medicine over three decades is that it became treatable, and treatable within a window measured in hours. Which makes recognition the single most consequential link in the chain.

Recognising it

The FAST acronym covers the majority of presentations:

• Face — has it drooped on one side? Can they smile?
• Arms — can they raise both and hold them? Does one drift down?
• Speech — is it slurred, or are they struggling to find words or understand you?
• Time — call emergency services immediately.

FAST misses some strokes, particularly posterior circulation events. Additional symptoms worth knowing: sudden severe dizziness or loss of balance, sudden loss or doubling of vision, sudden numbness on one side, and sudden severe headache with no obvious cause — the classic thunderclap headache of subarachnoid haemorrhage.

The common feature is sudden onset and focal deficit. Gradual, generalised symptoms are usually something else.

Why a TIA is an emergency

A transient ischaemic attack produces the same symptoms and resolves, typically within minutes and by definition within 24 hours, with no lasting infarction. Because it resolves, people wait, or mention it to their GP the following week, or do not mention it at all.

That is the dangerous part. The risk of stroke after a TIA is highest in the first 48 hours and remains elevated for weeks — historically quoted at around 5 per cent within two days and 10 per cent within a week, and reduced substantially by prompt assessment and treatment. The EXPRESS study showed that urgent evaluation and immediate initiation of secondary prevention reduced subsequent stroke risk by around 80 per cent.

So a TIA is not a false alarm. It is a warning that has been given in advance, and acting on it within hours is one of the highest-value interventions available in medicine.

What happens on assessment

Imaging first, because thrombolysis for an ischaemic stroke would be catastrophic in a haemorrhagic one. Non-contrast CT distinguishes the two quickly; CT angiography identifies large-vessel occlusion amenable to thrombectomy.

Then the search for a cause, because that determines prevention. Carotid imaging looks for stenosis that may warrant endarterectomy or stenting — and the benefit of that surgery is greatest when performed within two weeks of the event. Cardiac monitoring looks for atrial fibrillation, which changes prevention from antiplatelet to anticoagulant therapy; prolonged monitoring detects considerably more AF than a standard ECG, and finding it matters enormously.

Blood tests, echocardiography in selected cases, and in younger patients a search for less common causes such as arterial dissection or clotting disorders.

Secondary prevention

The measures that follow are unglamorous and collectively very effective.

Antiplatelet therapy — usually aspirin plus clopidogrel briefly, then single agent — for non-cardioembolic stroke. Anticoagulation if atrial fibrillation is found. Blood pressure lowering, which is the single most effective intervention for preventing recurrence. High-intensity statin therapy. Carotid intervention where indicated and timely. And the behavioural elements: stopping smoking, reducing alcohol, physical activity, and dietary change.

Recovery, and what it involves

Most functional recovery occurs in the first three to six months, though improvement can continue for years and the older idea of a hard plateau has been revised. Intensity and repetition of rehabilitation matter, and access to it varies enormously.

Several consequences are under-recognised. Post-stroke depression affects roughly a third of survivors and is both under-diagnosed and treatable. Fatigue is extremely common, poorly understood, and disproportionately disabling. Spasticity, shoulder pain in a weak arm, swallowing problems, and cognitive changes — particularly in attention and executive function — all need specific management.

Aphasia deserves particular mention because it is so easily mistaken for cognitive impairment. A person with expressive aphasia may understand everything said to them perfectly and be unable to produce the words. Speaking to them loudly, slowly, or as though to a child is a common and demoralising error.

The one thing to take from this

If symptoms come on suddenly and affect one side, or speech, or vision — call an ambulance, even if they have already gone away. Particularly if they have already gone away. The people who do best after a stroke are overwhelmingly the ones who arrived early enough for the treatment to still be possible.