Stroke and TIA: FAST Recognition and Urgent Referral
Recognise stroke symptoms, call 999 immediately, and never give aspirin before hospital assessment.
Why this matters
Stroke is one of the leading causes of death and disability in the UK, with around 100,000 strokes and 50,000 transient ischaemic attacks (TIAs) occurring each year in England. In both cases, speed is the single most important factor in outcome. For ischaemic stroke, which accounts for around 85% of all strokes, thrombolysis can be given within 4.5 hours of symptom onset and mechanical thrombectomy within 24 hours in selected patients. Every minute without treatment, approximately 1.9 million neurones are lost.
Community pharmacists are a trusted frontline point of contact. A patient or carer describing a "funny turn", sudden weakness, or slurred speech may not realise they are describing a stroke or TIA. Recognising the signs, acting without delay, and avoiding common pitfalls (particularly giving aspirin in the pharmacy before imaging) can determine whether a patient makes a full recovery or is left with permanent disability. A TIA with fully resolved symptoms is not a reason for reassurance: the risk of a full stroke within 48 hours can be as high as 10%, making same-day emergency assessment essential.
Red flags vs more likely benign
| Feature | More likely benign | Red flag ⚠ |
|---|---|---|
| Facial symmetry | Symmetrical smile, equal facial movement | Sudden facial drooping or asymmetry on smiling: possible stroke |
| Arm strength | Both arms raised equally, no drift over 10 seconds | One arm drifts down or cannot be raised when tested simultaneously |
| Speech | Clear articulation, coherent, appropriate words | Sudden slurring, garbled speech, wrong words, or inability to speak |
| Headache | Gradual-onset tension headache or known migraine pattern | Sudden thunderclap headache: worst ever, no warning; possible haemorrhagic stroke |
| Vision | Normal in both eyes, no new disturbance | Sudden loss of vision in one or both eyes, double vision, or loss of visual field |
| Balance | Steady gait, normal coordination | Sudden ataxia, loss of balance, or vertigo combined with any other FAST feature |
| Duration | Brief dizziness or lightheadedness with clear cause | Neurological symptoms that resolved fully: possible TIA; still a medical emergency |
| Consciousness | Alert, orientated, behaving normally | Sudden confusion, altered consciousness, or collapse of no apparent cause |
Key Clinical Points
Three points every pharmacist must understand when dealing with suspected stroke or TIA.
- Do not give aspirin in the pharmacy. Call 999 immediately and follow local stroke pathways.
- Record the time the patient was last known to be completely well, not just when symptoms were first noticed. This determines eligibility for thrombolysis and thrombectomy and is one of the most important pieces of information for the stroke team.
- Stroke mimics, including hypoglycaemia, migraine, and post-seizure weakness, are common. Do not delay calling 999 while considering alternatives: treating a mimic as a stroke is far safer than treating a stroke as a mimic.
Relay the time last known well to the ambulance crew immediately. Do not wait to calculate it: the crew can help if the exact time is uncertain.
🛑 BE-FAST: Stroke Recognition Framework
Use BE-FAST to assess any patient with suspected stroke or TIA.
Sudden loss of balance, ataxia, or inability to walk normally: a warning sign, particularly when combined with other features.
Sudden vision loss in one or both eyes, double vision, or loss of visual field: treat as a stroke sign.
Ask the patient to smile. Drooping or asymmetry on one side is a red flag.
Ask the patient to raise both arms. One arm drifting down or being unable to raise suggests motor weakness.
Sudden slurring, garbled speech, wrong words, or inability to speak: call 999 immediately.
Note the time last known well. Do not wait for improvement. Call 999 immediately if any BE-FAST feature is present.
Key Questions to Ask
Ask these questions to assess time-criticality, severity, and risk.
- When did symptoms start? If unclear: when was the patient last known to be completely well? This time, not when symptoms were noticed, determines treatment eligibility.
- Are symptoms still present, or have they fully resolved? Resolved symptoms still require urgent assessment.
- Work through BE-FAST: any problems with balance, vision, facial symmetry, arm strength, or speech?
- Is the patient taking any anticoagulants (apixaban, rivaroxaban, warfarin, dabigatran, edoxaban)? This is critical information for the stroke team.
- Any history of previous stroke or TIA? Any known atrial fibrillation?
- Any recent hypoglycaemia, seizure, or migraine? These are common stroke mimics but should not delay calling 999 if BE-FAST features are present.
- Any recent head injury or fall?
Relay the time last known well to the ambulance crew immediately. Do not delay calling 999 while gathering information.
What to do in pharmacy
Key takeaways
- Any BE-FAST feature requires immediate action: call 999 and note the time last known well. Do not wait to see if symptoms resolve.
- A TIA with fully resolved symptoms is a medical emergency. The risk of stroke within 48 hours is up to 10%. Any suspected TIA requires urgent same-day specialist assessment according to local stroke pathways.
- Do not give aspirin in the pharmacy. The stroke type cannot be determined without CT imaging, and aspirin worsens outcomes in haemorrhagic stroke. Call 999 and follow local stroke pathways.