Stroke and TIA: FAST Recognition and Urgent Referral
Every stroke symptom is a 999 call: recognise FAST, act immediately, and never give aspirin in the pharmacy 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 |
What to do in pharmacy
Key takeaways
- Any FAST-positive symptom is a 999 call without exception: do not wait to see if it resolves.
- A TIA with fully resolved symptoms is still a medical emergency: the 48-hour stroke risk is up to 10%.
- Do not give aspirin in the pharmacy before hospital imaging: NICE NG128 recommends 300mg aspirin for ischaemic stroke, but only after CT imaging excludes haemorrhage; around 15% of strokes are haemorrhagic and aspirin worsens them.