Stroke Warning Signs: The BE FAST Checklist Explained
A stroke is a medical emergency in the same category as a heart attack, and the single biggest determinant of how well someone recovers is how quickly they reach a hospital that can treat them. Roughly two million brain cells die every minute an artery stays blocked.
BE FAST
The widely taught checklist is:
- B — Balance. Sudden loss of balance, coordination or unexplained dizziness
- E — Eyes. Sudden loss of vision in one or both eyes, double vision, or a visual field cut
- F — Face. Sudden drooping on one side. Ask the person to smile and look for asymmetry
- A — Arms. Sudden weakness or numbness, usually on one side. Ask them to raise both arms and see whether one drifts down
- S — Speech. Slurred speech, inability to find words, or inability to understand. Ask them to repeat a simple sentence
- T — Time. Call emergency services immediately and note the time symptoms began
The B and E were added because posterior circulation strokes, affecting the back of the brain, often present with balance and vision changes and were being missed by the older FAST version.
Other sudden symptoms that count
- Sudden severe headache described as the worst ever, which may indicate bleeding
- Sudden confusion
- Sudden numbness of the face, arm or leg on one side
- Sudden difficulty swallowing
- Sudden loss of consciousness
The common thread is sudden onset and one-sided involvement.
Why the time matters so much
Two treatments depend on arriving early.
Thrombolysis, a clot-dissolving drug given intravenously, is generally given within 4.5 hours of symptom onset. The earlier within that window, the better the outcome.
Mechanical thrombectomy, in which the clot is physically removed through a catheter, can be used up to 6 hours routinely and in selected patients up to 24 hours, guided by advanced imaging.
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Neither can be given until a CT scan has excluded bleeding, because the two kinds of stroke need opposite treatment. This is also why no one should be given aspirin at home on suspicion of stroke.
What to do
- Call for emergency transport immediately. Do not drive yourself
- Note the exact time symptoms started, or the last time the person was definitely normal. This single piece of information decides treatment eligibility
- Keep the person lying down with the head slightly raised, turned to the side if they are vomiting or drowsy
- Do not give food, drink or any medication, including aspirin
- Loosen tight clothing
- Bring a list of their regular medications, especially blood thinners, and their medical history
- Stay with them and monitor breathing
What not to do
Do not wait to see if it passes. Do not take them to a small clinic without CT facilities first, since that wastes the window. Do not attempt home remedies, pressure points, pricking fingers, or other folk measures that circulate widely. Do not let the person sleep it off.
Transient ischaemic attack
A TIA, sometimes called a mini-stroke, produces the same symptoms but they resolve, usually within an hour. It is not a false alarm; it is a warning. The risk of a full stroke is highest in the following days, and urgent assessment with imaging, carotid studies and starting preventive treatment can prevent it. Resolution of symptoms is not a reason to stay home.
Who is at risk
- High blood pressure, the leading modifiable risk factor
- Atrial fibrillation
- Diabetes
- High cholesterol
- Smoking and tobacco in any form
- Obesity and physical inactivity
- Excess alcohol
- Previous stroke or TIA
- Carotid artery narrowing
- Obstructive sleep apnoea
- Family history
South Asian populations have a higher stroke burden and a younger average age at first stroke than many other groups, so age under 50 is not a reason to dismiss symptoms.
Prevention
Controlling blood pressure has the largest effect of any single intervention. Add treatment of atrial fibrillation with anticoagulation, lipid management, diabetes control, stopping tobacco, regular activity, a diet lower in salt and higher in fruit, vegetables and whole grains, and moderation of alcohol.
This is general information. If you suspect a stroke in anyone, call emergency services first and read later.