Stroke warning signs: Neurologist explains symptoms and why every minute matters

Stroke can strike without warning, and the difference between timely treatment and permanent disability may come down to minutes. In an interview with THE WEEK, Dr Syamlal S, Senior Consultant in Neurology at KIMSHEALTH, Thiruvananthapuram, explains how to recognise the early signs of a stroke, what bystanders should do immediately, and how advances in treatment can limit brain damage.

He also addresses common myths about stroke and explains why recording the exact time symptoms began—or when the patient was last known to be well—is critical to determining eligibility for life-saving treatment.

Excerpts:

Q: What are the early warning signs of a stroke, and can the body show symptoms hours or days before a major stroke occurs?

A: Stroke usually occurs suddenly, but some patients may experience warning symptoms hours or even days before a major stroke. These warning episodes are called Transient Ischaemic Attacks (TIAs), often referred to as mini-strokes. They occur when blood supply to a part of the brain is temporarily interrupted.

The most important warning signs include sudden weakness or numbness of the face, arm or leg, particularly on one side of the body; difficulty speaking or understanding speech; sudden loss of vision; unexplained dizziness or loss of balance; and a sudden, unusually severe headache.

The internationally recognised BE-FAST acronym helps identify stroke symptoms:

- B – Balance: Sudden loss of balance or coordination.

- E – Eyes: Sudden loss of vision or double vision.

- F – Face: Facial drooping or asymmetry.

- A – Arms: Weakness or numbness of an arm.

- S – Speech: Slurred speech or difficulty speaking.

- T – Time: Seek emergency medical attention immediately.

Even if these symptoms disappear within minutes, they should never be ignored. A TIA can be a warning of an impending major stroke, with the risk being particularly high during the first 48 hours. However, many strokes occur without any preceding warning symptoms.

Q: What should a person or bystander do immediately when stroke symptoms appear, and what are the critical first few minutes in reducing brain damage?

A: Stroke is a medical emergency where every minute matters. During an ischaemic stroke, approximately 1.9 million neurons may be lost every minute when a major brain artery remains blocked. This explains the internationally accepted principle, "Time is Brain."

The first and most important step is to recognise the symptoms and immediately activate emergency medical services. In India, the national emergency number is 112, while ambulance services are also accessible through 108 in many states.

The patient should be transported to the nearest appropriate stroke-ready hospital, preferably one equipped with CT scanning, thrombolysis facilities and access to mechanical thrombectomy.

Family members should note the exact time symptoms began or when the patient was last known to be normal. This information is crucial for deciding treatment eligibility.

While waiting for medical assistance, the patient should be kept comfortable and monitored for changes in consciousness or breathing. Nothing should be given orally until swallowing safety is assessed.

The first few minutes are critical because rapid recognition, ambulance activation and hospital notification can significantly reduce treatment delays. Early restoration of blood circulation can prevent irreversible brain damage and improve the chances of recovery.

Q: What are the common mistakes people make when responding to a suspected stroke, and what should they never do while waiting for medical help?

A: One of the most dangerous mistakes is waiting for symptoms to improve spontaneously. Many patients and relatives mistakenly assume that weakness, speech difficulty or dizziness will disappear after rest.

Another common mistake is attempting home remedies, massage or traditional treatments instead of seeking immediate medical care. Patients should never be given food, water or oral medications because stroke can impair swallowing and increase the risk of choking or aspiration. Aspirin or other blood-thinning medications should not be administered before brain imaging, because the stroke may be caused by bleeding rather than a blocked blood vessel. Unnecessary attempts to reduce blood pressure at home should also be avoided, as sudden lowering of blood pressure can worsen brain ischaemia in certain situations. Patients should not be encouraged to walk, drive themselves or sleep off their symptoms. The safest approach is immediate ambulance transportation to a stroke-capable hospital. Even when symptoms resolve completely, urgent medical evaluation remains essential.

Q: How can people recognise the difference between a stroke and other conditions that may cause similar symptoms, such as low blood sugar, migraine or vertigo?

A: Several medical conditions can mimic stroke, including hypoglycaemia, migraine, seizures and inner-ear disorders. Low blood sugar may produce weakness, confusion, sweating, abnormal behaviour or even one-sided neurological deficits. Checking blood glucose is therefore an important part of the initial assessment.

Migraine with aura can produce visual disturbances, tingling or speech difficulties. However, migraine symptoms often develop gradually and spread over several minutes, whereas stroke symptoms typically appear suddenly and reach maximum intensity quickly. Vertigo due to inner-ear disorders can cause severe dizziness, nausea and imbalance. However, strokes involving the cerebellum or brainstem can produce similar symptoms, sometimes without obvious weakness or speech disturbance.

Sudden persistent vertigo associated with inability to walk, severe imbalance, double vision, swallowing difficulty or limb incoordination should raise suspicion of a posterior circulation stroke. Importantly, no single symptom can reliably distinguish stroke from its mimics. Even experienced clinicians may require neurological examination and urgent brain imaging. Therefore, any sudden unexplained neurological symptom should be considered a possible stroke until proven otherwise.

Q: What treatments are available to minimise brain damage after a stroke, how quickly must they be administered, and what can families do to improve the chances of recovery?

A: Modern stroke treatment has undergone a remarkable transformation. Many patients who previously faced permanent disability can now achieve substantial neurological recovery if treated promptly.

For acute ischaemic stroke caused by a blocked artery, intravenous thrombolysis using clot-dissolving medications such as alteplase or tenecteplase may restore blood circulation. Thrombolysis is generally administered within 4.5 hours of symptom onset, although selected patients may benefit beyond this period based on advanced brain imaging and established treatment protocols.

Another major advancement is mechanical thrombectomy, a minimally invasive procedure in which specialists remove blood clots from large brain arteries using catheters. Mechanical thrombectomy is particularly effective for selected patients with large-vessel occlusion. It is generally performed within six hours, but carefully selected patients may benefit up to 24 hours after they were last known to be well.

For haemorrhagic stroke caused by bleeding into the brain, treatment focuses on controlling blood pressure, reversing anticoagulation when appropriate, managing intracranial pressure and performing neurosurgical interventions in selected cases.

Families play an important role by recognising symptoms early, ensuring rapid hospital transportation, providing accurate medical history and supporting rehabilitation. Early physiotherapy, speech therapy, occupational therapy and appropriate secondary prevention can significantly improve long-term outcomes.

Q: What are the most common myths about stroke and how can these misconceptions delay timely treatment and worsen outcomes?

A: Several misconceptions continue to contribute to delayed stroke treatment in India.

Myth 1: Stroke affects only elderly people.

Stroke can occur at any age, including among young adults. Increasing rates of hypertension, diabetes, obesity, smoking and sedentary lifestyles contribute to stroke risk even in younger populations.

Myth 2: Stroke always causes paralysis.

Not all strokes produce paralysis. Sudden visual loss, speech difficulty, imbalance, vertigo or altered consciousness may be the presenting symptoms.

Myth 3: If symptoms disappear, medical attention is unnecessary.

Temporary symptoms may indicate a TIA, which requires urgent evaluation because it can precede a disabling stroke.

Myth 4: Stroke cannot be treated effectively.

This is outdated. Modern treatments, including thrombolysis and mechanical thrombectomy, have dramatically improved outcomes when administered to eligible patients without delay.

Myth 5: Patients should rest or sleep and wait for improvement.

Waiting wastes valuable time and may allow irreversible brain injury to develop.

Myth 6: Stroke is always associated with severe headache.

Most ischaemic strokes occur without significant headache. Sudden weakness, speech difficulty or visual disturbances may be the only symptoms.

Myth 7: Complete recovery is impossible after stroke.

Many patients achieve meaningful recovery through timely treatment, structured rehabilitation and prevention of recurrent strokes.