Ischemic stroke: main symptoms and first signs

An ischemic stroke begins suddenly when a blood clot or embolus blocks a brain artery, cutting off blood flow to a section of nerve tissue. Symptoms vary depending on the affected area and develop over minutes, or, less commonly, gradually over hours. Classic signs include an asymmetrical smile, weakness or clumsiness in the hand, and slurred speech, but there are also "silent" variants with dizziness, unsteadiness, double vision, or sudden blindness in one eye. Time is critical: the sooner the symptoms are recognized and emergency medical attention is called, the better the chances of preserving viable brain tissue.

The expanded understanding of symptoms in recent years is driven by a better understanding of posterior circulation strokes—in the vertebrobasilar system, which supplies the brainstem, cerebellum, and occipital lobes. Balance, vision, and speech disturbances are often predominant here, without obvious limb weakness, so such cases are often recognized late. Awareness of "atypical" signs and public education help reduce delays in seeking help.

The first minutes: what the person himself and others around him should notice

A practical method for recognition is the "FASTER" rule, as defined by the international BE FAST guideline: balance, eyes, face, hand, speech, time. Sudden loss of balance, severe visual impairment, facial asymmetry, hand weakness, or speech impairment—any of these signs requires an immediate call to emergency services. The BE FAST approach supplements the classic "face, hand, speech" triad with balance and eye symptoms, increasing the chances of detecting posterior circulation strokes.

Research shows that using the BE FAST acronym increases the rate of correctly recognized strokes compared to the "face, hand, speech" approach alone. This is especially important for dizziness, double vision, blurred vision, and sudden unsteadiness. In everyday practice, these complaints are often mistaken for "fatigue," "cervical osteochondrosis," or "ear problems," leading to dangerous delays.

You should be wary if symptoms appear suddenly, while you're feeling relatively well, and don't resolve within a few minutes. Avoid driving, waiting for the symptoms to pass, or taking sedatives or painkillers in the hopes of "waiting it out." The only reliable course of action is to call an ambulance immediately and report the estimated time of onset of the symptoms.

Table 1. Signals requiring an immediate call to an ambulance

Sign	How does it manifest itself?	Why is it important?
Facial asymmetry	The smile "floats", the corner of the mouth drops	Often the first visible sign of hemispheric damage.
Weakness or numbness in the arm	The arm does not rise or “falls”	Indicates a focal deficit and requires urgent evaluation.
Speech impairment	Slurred speech, difficulty finding words	May be a sign of damage to the dominant hemisphere.
Loss of balance	Unsteadiness, falling on the side	Clue to posterior circulation stroke.
Sudden visual disturbances	Double vision, loss of half the visual field, blindness in one eye	Retinal artery occlusion or occipital lobe involvement is possible.

Picture of arterial basins: anterior and posterior circulation

When the anterior circulation supplying the frontal and parietal lobes is affected, motor and speech impairments predominate. Characteristic features include facial asymmetry, weakness in one arm and one leg, speech impairment, difficulty understanding, apraxia, and visual acuity. In severe cases, impaired consciousness may also occur. This condition is more likely to be noticed by others and is therefore more easily recognized.

Posterior circulation strokes may begin with sudden dizziness, unsteadiness, double vision, blurred vision, impaired coordination, a tendency to fall, dysphagia, and dysarthria. Nausea and vomiting sometimes accompany the symptoms, and the symptoms are then mistakenly interpreted as "gastritis" or "vestibular neuritis." The absence of obvious arm weakness does not rule out a stroke and should not be reassuring.

Occipital strokes often present with unilateral visual field loss or complete blindness in one eye if the retinal artery is affected. Brainstem strokes can result in a combination of dysarthria, dysphagia, diplopia, and severe unsteadiness. These symptoms are particularly dangerous because delayed treatment increases the risk of respiratory distress and coma.

Table 2. Predominant symptoms by blood supply basins

Pool	More commonly observed	Clinical clue
Anterior circulation	Weakness and numbness on one side of the body, speech and understanding impairment	The classic triad "face, hand, speech".
Posterior circulation	Dizziness, unsteadiness, diplopia, dysarthria, dysphagia, visual disturbances	Often "non-focal" complaints, high risk of missing.
Retinal artery	Sudden blindness in one eye, "curtain"	An emergency condition equivalent to a stroke.

"Atypical" and masked manifestations

Women are more likely than men to report less "focal" symptoms at the onset of stroke: sudden, unlocalized weakness, a feeling of confusion, nausea, vomiting, and fainting. This doesn't make stroke "less dangerous," but it does increase the risk of late recognition. It's important for healthcare providers and families to consider this gender-specific risk profile.

Old age, diabetes, and comorbidities can blur the picture: instead of severe weakness, sudden clumsiness, falls "for no reason," confusion, and a sharp deterioration in gait appear. In such patients, symptoms are often attributed to "age" or "fatigue," which is dangerous. Any sudden change in normal function requires calling an ambulance.

Cerebellar and brainstem strokes are particularly insidious. They are often accompanied by severe dizziness, vomiting, and nystagmus, leading them to be mistaken for a peripheral labyrinthine lesion. Assessing gait and stability at the start helps to suspect a central cause of dizziness and direct the patient on the correct route.

Table 3. Common signs of a stroke and how to avoid them

Mask state	What is similar?	What is alarming in favor of a stroke?
Vestibular neuritis	Dizziness and nausea	Sudden fall, severe unsteadiness, double vision, dysarthria.
Migraine with aura	Visual phenomena, numbness	Sudden, persistent deficit without a creeping aura.
Hypoglycemia	Confusion, weakness	The presence of focal deficiency and asymmetry with normal glucose.
Peripheral facial nerve paresis	Facial asymmetry	Preserved facial expressions of the forehead are more common in peripheral lesions, and in stroke - the cortical profile.

How to assess severity: screening and clinical scales

In the prehospital phase, paramedics and doctors use simple screenings. The Cincinnati Prehospital Scale assesses facial asymmetry, arm weakness, and speech, helping to quickly identify a probable stroke. The "face, arm, speech" and "FASTER" approaches are also widely used. These tools do not provide a diagnosis, but they save precious minutes.

In the emergency department, the severity of the deficit is measured using the National Institute of Health Stroke Scale, which includes 15 items: levels of consciousness, gaze, visual field, facial expression, limb strength, coordination, sensation, speech, comprehension, and attention. The overall score helps predict the outcome and determine treatment strategy.

To quickly triage patients with suspected major occlusions, modified severity scales are sometimes used prehospital to direct them to a center with thrombus extraction capabilities. This is an organizational tool and does not replace neuroimaging or clinical judgment in the hospital.

Table 4. What to assess according to the National Institute of Health Stroke Scale

Block	What to watch for	Why is it necessary?
Consciousness, gaze, visual fields	Contact, commands, eye movements, field dropouts	Detection of cortical and stem lesions.
Facial expressions and speech	Facial asymmetry, speech clarity and understanding	Evaluation of the dominant hemisphere and conductors.
Strength, coordination, sensitivity	Raising arms and legs, finger-nose test, tactile sensations	Quantization of focal deficit.
Attention and ignoring	Execution of bilateral stimuli	Detection of neglect.

Women, the elderly, and vulnerable groups: what to pay special attention to

Women are more likely to experience seemingly "non-specific" complaints, such as sudden nausea, vomiting, altered consciousness, and a general feeling of being "unusual." These symptoms are associated with delayed presentation and the risk of missing a stroke. Educational programs recommend considering gender differences when teaching stroke recognition.

Old age is associated with underlying cognitive and motor impairments, so a sudden fall, unexpected gait deterioration, new slurred speech, or sudden apathy should be considered a possible stroke until proven otherwise. Diabetes and chronic illnesses can blur the classic clinical picture.

Recent reviews highlight that differences extend not only to presentation but also to outcomes: women are more likely to have more severe strokes and greater functional limitations after discharge, necessitating early rehabilitation strategies and community support. This finding has implications for healthcare systems and family support.

Table 5. “Red flags” in women and the elderly

Situation	Example	Action
Sudden nausea and vomiting without abdominal pain	Against the background of dizziness and unsteadiness	Consider stroke, call an ambulance.
Unexplained fall	"My legs gave way," new instability	Rule out posterior circulation stroke.
Sudden confusion or unusual behavior	"He can't find the words," "he doesn't recognize"	Immediate assessment at a stroke center.

What to do immediately: a first response algorithm

The only correct action if you suspect a stroke is to immediately call an ambulance. It is important to inform the dispatcher of the estimated time of symptom onset and list the key signs. Avoid consuming food, water, or medications on your own, as this may interfere with swallowing and increase the risk of aspiration.

Until the emergency team arrives, ensure rest, place the person on their side if vomiting, and monitor breathing and consciousness. Avoid driving, putting off contacting the emergency department "until tomorrow," or waiting for it to pass. Time is crucial to the outcome of reperfusion therapy.

Table 6. Dos and Don'ts Before the Ambulance Arrives

Action	Can	It is forbidden
Call an ambulance	Yes, immediately at the first signs	-
Give water, food, pills	-	Not recommended due to risk of aspiration and confusion of symptoms.
Go to the hospital on your own	-	It’s impossible, it’s a waste of time and access to a specialized center.
Breathing and position control	Yes, if vomiting occurs, lay the patient on their side.	-

Why it's important to recognize a stroke quickly: The relationship between symptoms and treatment

Early recognition of symptoms enables reperfusion therapy: intravenous administration of thrombolytics within the first few hours and mechanical clot removal in suitable patients. These methods have been proven to improve functional outcomes, but are only effective with early admission. Therefore, training in symptom recognition is key to reducing disability.

Even if symptoms have diminished or disappeared, this is not a reason to skip an evaluation, as a transient ischemic attack (TIA) is a possible warning sign that often leads to a full-blown stroke. A professional assessment of the causes and risk factors allows for the initiation of preventative measures and the prevention of recurrence.

Table 7. Comparison of symptom and possible lesion

Symptom	Possible affected area	Clinical clue
Weakness and numbness of the right limbs	Left frontoparietal region	Often combined with speech impairment.
Double vision, unsteadiness, hoarse speech	Brainstem, cerebellum	Think about back circulation and don't wait for weakness in the hand.
Sudden blindness in one eye	Retina or optic tract	Emergency care as for a stroke.