What this article covers
- Why stroke is measured in minutes, not days
- The FAST test: the four signs to know by heart
- Other warning signs beyond FAST
- Why people wait, and why that costs them so much
- What happens at hospital: the treatment window
- What to do while waiting for the ambulance
- Prevention: the risk factors you can control
Why stroke is measured in minutes, not days
A stroke occurs when blood supply to part of the brain is cut off, either by a clot blocking an artery (ischaemic stroke, around 87% of cases) or by a blood vessel rupturing and bleeding into brain tissue (haemorrhagic stroke). In both cases, the brain cells that depended on that blood supply begin to die within minutes of the disruption.
The scale of the damage is enormous. Studies estimate that an untreated ischaemic stroke destroys approximately 1.9 million brain cells per minute. After three hours without treatment, the damage is in most cases irreversible. This is why the defining phrase in stroke medicine is: time is brain.
A 2024 analysis in The Lancet Neurology examining the global burden of stroke and its risk factors found that stroke is the second leading cause of death worldwide and the leading cause of acquired disability. High blood pressure that is not adequately controlled remains by far the largest single modifiable risk factor, accounting for nearly half of all stroke cases in large international studies. This matters in the Arab world because hypertension is extremely common and often undertreated.
The INTERSTROKE study, published in The Lancet in 2016 and covering 32 countries including countries in the region, found that ten modifiable risk factors together explain more than 90% of stroke cases globally. This means the vast majority of strokes are preventable with sustained management of treatable conditions.
The FAST test: the four signs to know by heart
The FAST test was developed to give anyone, not just medical professionals, a reliable framework for recognising stroke. Each letter corresponds to a sign that can appear in a stroke, either together or alone. You can run the whole test in under a minute with no equipment.
Face: Ask the person to smile. Does one side of the face droop or fail to move? Does the corner of the mouth hang lower on one side? Even a slight asymmetry in the smile deserves immediate attention. Arm: Ask them to hold both arms straight out in front of them with palms facing up. Does one arm drift downward involuntarily within 30 seconds? Do they struggle to raise one arm at all? Speech: Ask them to repeat a simple sentence such as their name and address. Is their speech slurred, garbled or entirely absent? Do they seem unable to understand what you are saying to them? Time: If any of these signs are present, call emergency services immediately without hesitation or delay.
The crucial characteristic of stroke symptoms is that they appear suddenly rather than gradually. A person who was speaking normally ten minutes ago and is now unable to form a sentence is a stroke emergency. The abruptness of onset is the most important clue, and it distinguishes stroke from conditions like a fainting episode or a severe migraine attack.
Teach the FAST test to your family, particularly to anyone who lives with or cares for a person with high blood pressure, diabetes or a history of heart disease. Most strokes happen at home and are first witnessed by a family member. The person having the stroke usually cannot accurately assess their own condition because it is their brain that is affected. The person who sees the signs is the one who needs to act.
The FAST stroke test
| Letter | What it means | How to check |
|---|---|---|
| F - Face | Facial drooping on one side | Ask for a smile and watch for one-sided droop |
| A - Arm | Arm weakness on one side | Ask them to hold both arms out; watch for one drifting down |
| S - Speech | Slurred or lost speech | Ask a simple sentence and listen for clarity |
| T - Time | Call emergency services now | Every minute without treatment costs brain cells |
Other warning signs beyond FAST
FAST covers the most common symptoms, but several others should be treated with equal urgency. A sudden severe headache that the person describes as the worst of their life, with no obvious cause, is a classic warning sign of a subarachnoid haemorrhage, a bleed around the surface of the brain. This headache typically reaches maximum intensity within seconds.
Sudden loss of vision in one eye or loss of half the visual field in both eyes can be a stroke affecting the blood supply to the visual cortex or the optic artery. Sudden severe dizziness with loss of balance and difficulty walking, when it appears abruptly and is different from any previous dizziness, may indicate a stroke affecting the cerebellum. Sudden numbness or tingling on one entire side of the body is another warning sign.
Any of these symptoms, even if they completely resolve within minutes to an hour, must be evaluated urgently at a hospital the same day. What resolves quickly is called a transient ischaemic attack, or TIA, and it is not a near-miss to be relieved about. A TIA is the clearest warning the body can give that a larger stroke may follow within hours, days or weeks. The risk of a major stroke in the days immediately following a TIA is substantial, and urgent evaluation and treatment can prevent it.
Why people wait, and why that costs them so much
The most common preventable harm in stroke is not lack of treatment but delay in seeking it. Across the region, a recognisable pattern emerges: when stroke symptoms appear, the first action is often to call a family member, then to wait for someone to arrive with a car, then to drive to the nearest clinic rather than the nearest hospital with stroke facilities. In each step, irreplaceable brain tissue is being lost.
Several factors drive this delay. Many people do not recognise the symptoms as urgent. In conditions like facial drooping or slurred speech, people sometimes assume the person is confused or drunk. Some worry about the cost of an emergency department visit. Others feel it is disrespectful to call an ambulance before consulting an elder. Understanding that none of these considerations matter against the minutes counting down is the message this article exists to carry.
Calling an ambulance is better than driving to hospital yourself for two reasons. The ambulance crew can begin assessment immediately, alert the receiving hospital to prepare the stroke team, and potentially begin some interventions on the way. And driving a person who may deteriorate rapidly in a private car means the driver is managing a medical emergency at the wheel. Neither is safe or fast enough.
What happens at hospital: the treatment window
When a stroke patient arrives at an emergency department equipped for stroke care, a CT scan of the brain is the first priority. It distinguishes an ischaemic stroke from a haemorrhagic one, because the treatment for each is completely different. Thrombolysis, intravenous administration of a clot-dissolving drug called alteplase, is the primary treatment for ischaemic stroke and must be given within 4.5 hours of symptom onset.
A 2025 review in Annual Review of Medicine described how mechanical thrombectomy, a catheter procedure that physically retrieves the clot from inside the brain artery, has extended the treatment window to up to 24 hours in carefully selected patients with evidence of salvageable brain tissue on advanced imaging. This procedure is available in major stroke centres in Saudi Arabia, Egypt, Jordan and the UAE, though access varies considerably across the region.
The clock starts from the moment symptoms were first noticed, not from the moment of hospital arrival. A person who wakes up with stroke symptoms must be treated as if the clock started at the last time they were seen well, typically the night before. This is especially important because many strokes occur during sleep.
The stroke treatment window for ischaemic stroke
- 0 minutes Symptoms begin suddenly: facial droop, arm weakness, speech difficulty
- Under 10 minutes Call emergency services immediately, note the exact time
- Under 60 minutes Arriving early maximises chances of full recovery
- 4.5 hours Last window for intravenous thrombolysis in ischaemic stroke
- Up to 24 hours Mechanical thrombectomy possible in selected cases at specialist centres
What to do while waiting for the ambulance
Keep the person calm and seated or lying with their head and shoulders slightly elevated. Do not give them anything to eat or drink, because swallowing is frequently impaired after stroke and food or liquid can enter the lungs. Do not give aspirin before a doctor has confirmed the type of stroke: aspirin is appropriate for ischaemic stroke but dangerous in haemorrhagic stroke, where it would worsen the bleeding.
Stay with the person and talk to them in a calm, reassuring way. Even if they cannot respond, they are often aware and frightened. If they lose consciousness and stop breathing and you are trained in CPR, begin resuscitation. If they lose consciousness but are still breathing, place them in the recovery position on their side to protect the airway.
Record the exact time when you first noticed the symptoms. Write it down, photograph it, do whatever helps you remember accurately. When you arrive at the emergency department, this single piece of information is one of the first things the stroke team will ask for, because it determines whether the thrombolysis window is still open.
Prevention: the risk factors you can control
High blood pressure is the single most important modifiable stroke risk factor. Controlling it consistently reduces stroke risk by roughly 35 to 40%. This means checking your blood pressure regularly, taking prescribed medicines reliably every day, and targeting a reading below 130/80 mmHg if your doctor has recommended that. In a region where hypertension is extremely common and often remains undiagnosed or untreated until a complication occurs, regular blood pressure screening is genuinely life-saving. A blood pressure check takes less than two minutes and can be done at most pharmacies.
Atrial fibrillation, an irregular heart rhythm, increases stroke risk by roughly five times because it allows clots to form in the heart and travel to the brain. Many people with atrial fibrillation have no symptoms and do not know they have it. A routine pulse check or ECG can detect it. If you have been told you have an irregular heartbeat, talk urgently to your doctor about anticoagulation treatment, because this is one of the most effective stroke-prevention interventions available.
Diabetes and high cholesterol each damage artery walls over years in ways that greatly increase stroke risk. Both are very prevalent across the Arab world and are often uncontrolled. Smoking doubles stroke risk directly through its effects on blood vessel walls and clotting. Physical inactivity and obesity contribute independently. Addressing any combination of these through sustained lifestyle changes and appropriate medication produces compounding benefits over time.
After a TIA or a first stroke, the risk of a second stroke is highest in the days and weeks immediately following. This is not the time to wait for a routine appointment. Urgent assessment, antiplatelet medicines, blood pressure control and statin treatment started within days can reduce the risk of early recurrence substantially. The person who has just had a TIA and feels completely normal again is in a high-risk window that requires urgent medical attention, not reassurance that everything is fine.
Track your blood pressure readings, medication schedule and any brief neurological symptoms in the Sihtak app. This information helps your doctor assess your stroke risk and adjust prevention strategies at each visit.
Frequently asked questions
Can someone fully recover from a stroke?
Full recovery is possible, particularly for small strokes treated quickly. The extent of recovery depends on the size of the affected area, its location in the brain, and how fast treatment was received. Many people recover substantially with intensive rehabilitation over months. The brain has some capacity to reroute functions around damaged areas, which is why early and consistent rehabilitation matters.
Is stroke painful?
Ischaemic stroke usually causes no pain, which is part of why it is often not recognised immediately. The person may feel their arm is simply weak or that they are confused, not that something catastrophic is happening. Haemorrhagic stroke can cause a sudden severe headache. The absence of pain in the most common form of stroke makes learning the FAST signs especially important.
What is the difference between a stroke and a heart attack?
A heart attack occurs when a coronary artery supplying the heart muscle is blocked. A stroke occurs when an artery supplying the brain is blocked or bleeds. Both are emergencies with overlapping risk factors. A heart attack causes chest pain and shortness of breath. A stroke causes neurological symptoms: face drooping, arm weakness, speech problems. Both require immediate emergency care.
Should I give aspirin to someone having a stroke?
No, not before they reach hospital. Aspirin is beneficial in ischaemic stroke but would worsen a haemorrhagic stroke. Since you cannot tell which type someone is having without a brain scan, giving aspirin at home carries real risk. The right action is to call emergency services immediately and let the hospital team make the treatment decisions once the scan is done.
Does a TIA mean I will definitely have a real stroke?
Not definitely, but it means you are at substantially elevated risk and need urgent evaluation and treatment. The days immediately after a TIA carry the highest stroke risk. With prompt medical attention, the right medicines and risk factor control started immediately, the risk can be reduced dramatically. A TIA is not something to watch and wait on.
Does high blood pressure always cause stroke?
Not inevitably, but it is the strongest single modifiable risk factor. Chronically high blood pressure damages the walls of arteries in the brain over years, making them more likely to block or rupture. Many people live with high blood pressure for years without having a stroke, but their lifetime risk is substantially higher than someone with controlled pressure, and each passing year increases the cumulative damage.
What happens in stroke rehabilitation?
Rehabilitation starts as soon as the person is medically stable, sometimes within the first day or two in hospital. It includes speech and language therapy to recover communication, occupational therapy to regain the ability to perform daily activities, and physiotherapy to recover strength, balance and mobility. The process can continue for months after leaving hospital, and progress is often achievable well into the first year.
Sources
- Hilkens NA, Casolla B, Leung TW et al: Stroke, Lancet (London, England), 2024
- GBD 2021 Stroke Risk Factor Collaborators: Global, regional, and national burden of stroke and its risk factors, 1990-2021, The Lancet. Neurology, 2024
- Ho JP, Powers WJ: Contemporary Management of Acute Ischemic Stroke, Annual review of medicine, 2025
- O'Donnell MJ, Chin SL, Rangarajan S et al: Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study, Lancet (London, England), 2016
- Mensah GA, Fuster V, Murray CJL et al: Global Burden of Cardiovascular Diseases and Risks, 1990-2022, Journal of the American College of Cardiology, 2023
This content is for health education only and is not a substitute for medical advice. If you have symptoms that worry you, see your doctor.