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Practice Practice Pointer

Is it a stroke?

BMJ 2015; 350 doi: (Published 15 January 2015) Cite this as: BMJ 2015;350:h56
  1. Graeme J Hankey, Winthrop professor of neurology; consultant neurologist12,
  2. David J Blacker, clinical professor; consultant neurologist123
  1. 1School of Medicine and Pharmacology, University of Western Australia, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Perth, Western Australia, Australia 6009
  2. 2Department of Neurology, Sir Charles Gairdner Hospital, Nedlands, Perth, Australia
  3. 3Western Australian Neuroscience Research Institute, Nedlands, Perth, Australia
  1. Correspondence to: G J Hankey graeme.hankey{at}
  • Accepted 24 November 2014

The bottom line

  • Suspect the diagnosis of stroke in all patients with abrupt onset of neurological symptoms, particularly in those with risk factors for stroke. Early and accurate diagnosis of stroke enables early interventions targeted to the cause, which may improve survival and functional recovery and minimise early recurrent stroke.

  • Some stroke patients will present with atypical stroke symptoms in which the symptom onset is not sudden or the loss of neurological function is not clearly anatomically-localising.

  • The FAST (Facial drooping, Arm weakness, Speech difficulties and Test (or Time)) score is a useful screening test in the community, while emergency department doctors may use the FAST or ROSIER scales, and stroke physicians will undertake a more complete and systematic neurovascular assessment.

  • Stroke lacks a perfect diagnostic test, and current diagnosis relies on clinical history and examination, supported by brain imaging (such as computed tomography and magnetic resonance imaging, which can be normal).

  • Seizures, syncope, and sepsis account for 20-25% of suspected strokes.

Stroke is increasingly common and often fatal or disabling.1 The absence of a definitive diagnostic test for stroke and the potential for emergency interventions to restore brain perfusion,2 improve survival free of handicap, and minimise early recurrent stroke3 mean that doctors need to be able to diagnose acute stroke rapidly and accurately.

What is a stroke?

Stroke is not consistently defined in clinical practice, clinical research, and public health. Traditionally, stroke has been defined clinically by the abrupt onset of symptoms of focal neurological dysfunction that last more than 24 hours (or lead to earlier death) and are caused by acute vascular injury to part of the brain.4 The vascular causes include inadequate blood supply to part of the brain or spinal cord (ischaemic stroke, arterial or venous) and spontaneous haemorrhage into part of the brain (primary intracerebral haemorrhage) or over …

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