Stroke: recognise the signs and act within 4 hours — the FAST test

01Stroke, a vital emergency where every minute counts#

Stroke (Cerebrovascular Accident, CVA) is one of the most dramatic medical emergencies because its prognosis literally depends on the minutes following the onset of the first symptoms. It is defined as a sudden interruption of blood circulation in a part of the brain, either by obstruction of an artery (ischaemic form, 80% of cases), or by rupture of a vessel (haemorrhagic form, 20% of cases). This interruption immediately deprives neurons of oxygen and glucose, causing their progressive death.

The temporal stake is crucial and summarised by the formula "Time is Brain". It is estimated that about 2 million neurons die every minute during an untreated ischaemic stroke, accompanied by the loss of 14 billion synapses and 12 kilometres of nerve fibres. By comparison, normal brain ageing destroys this quantity in 3 to 4 years. This means that a one-hour stroke causes as much brain damage as 3 to 4 years of accelerated ageing. This reality justifies the extreme urgency of management and the importance for the general population to know how to recognise stroke signs to immediately call for help.

In Morocco, stroke represents a major health issue. According to the Ministry of Health registries and combined CHU data, approximately 35,000 new strokes are recorded each year in the country. It is the second leading cause of death after coronary heart disease, and the leading cause of acquired disability in adults. The Moroccan situation presents several worrying particularities compared to European countries. The average age of occurrence is around 60 years, compared to 68-70 years in France and Europe — about 10 years earlier, which is explained by less control of risk factors (untreated hypertension, diabetes, tobacco, dyslipidaemia). The time to hospital arrival often exceeds 6 hours in remote areas, while the optimal therapeutic window is 4h30 for thrombolysis. Territorial coverage in Stroke Units is improving but remains uneven, with concentration in major cities.

Regarding overall prognosis, approximately 20% of patients die within 30 days following a stroke, 50% retain significant sequelae (motor, language, cognitive), and only 30% recover complete autonomy. These figures would be considerably improved by earlier management and better upstream control of risk factors.

02The FAST test: recognising signs in seconds#

The FAST test is a mnemonic acronym developed by the American Stroke Association and the British Stroke Association to allow any witness to quickly recognise the signs of a stroke. Its simplicity and efficacy make it the worldwide reference tool for general public awareness. Learning this test takes 30 seconds but can save a life or prevent major disability for a loved one.

If any one of these signs is positive, it is probably a stroke. Immediately call 141 (SAMU in Morocco) or 15 without any hesitation. Better a false alarm than a stroke treated late. Dispatchers are trained to quickly assess and prioritise calls suspicious of stroke, which are among the rare cases where vital emergency is immediate.

Several less-known additional signs can also reveal a stroke. Sudden paralysis or weakness of one half of the body (hemiplegia), loss of sensitivity in one half of the face or in a limb. Sudden visual disturbances: loss of vision in one eye or in one side of the visual field, double vision, sudden blurred vision. A sudden and intense headache, particularly described as "the worst headache of my life" or "thunderclap", can reveal a haemorrhagic stroke through cerebral aneurysm rupture. Sudden balance disturbances with rotational vertigo, incoordination of movements, falls. Sudden mental confusion with disorientation, comprehension disorders. All these symptoms, especially if they are sudden in onset and persistent, must raise suspicion of stroke.

The Transient Ischaemic Attack (TIA) deserves particular attention. It is a stroke whose symptoms completely regress in less than 24 hours (most often less than an hour). Classic temptation: "it's better, it was nothing". Dramatic mistake: TIA is an emergency just like a constituted stroke because 15% of TIAs progress to a major ischaemic stroke within the following 3 months, half of them within the first 48 hours. Any TIA must lead to an emergency consultation the same day for complete workup and urgent preventive treatment.

03The different types of stroke#

Understanding the two main stroke mechanisms is important because their treatments are radically different — hence the importance of brain imaging (CT or MRI) on hospital arrival to quickly distinguish them.

Ischaemic stroke (80% of cases)

Ischaemic stroke results from the sudden obstruction of a cerebral artery by a clot, depriving the corresponding cerebral territory of blood supply. Several mechanisms can explain the formation of this clot.

Local thrombosis corresponds to the formation of a clot directly on an atheromatous plaque narrowing a cerebral artery or an upstream carotid artery. This mechanism predominates in patients with old cardiovascular risk factors (hypertension, diabetes, hypercholesterolaemia, smoking). Cardiac embolism corresponds to a clot formed in the heart (cardiac chambers dilated in case of atrial fibrillation, valvular disease, recent infarction, endocarditis) which detaches and migrates to the brain. Atrial fibrillation, a very common cardiac rhythm disorder after age 65, is alone responsible for 20 to 30% of ischaemic strokes and its screening in elderly subjects is crucial. More rarely, arterial dissections (tear in the wall of a cervical artery, sometimes post-traumatic), vasculitis (inflammation of vessels), coagulation disorders (thrombophilia, antiphospholipid syndrome) can cause stroke in young subjects without classic risk factors.

Haemorrhagic stroke (20% of cases)

Haemorrhagic stroke results from the rupture of a cerebral vessel with formation of a haematoma which compresses the surrounding brain tissue and causes injury through compression and secondary ischaemic suffering. Several main causes.

Uncontrolled arterial hypertension is by far the most frequent cause, responsible for so-called "intracerebral" haemorrhages typically deep (basal ganglia, internal capsule, cerebellum, brainstem). In Morocco, where hypertension affects 30% of adults but remains largely undertreated, it is a dominant factor. Cerebral aneurysms (abnormal dilatation of an artery, sometimes congenital) can rupture suddenly, generally on the occasion of effort or blood pressure rise, causing a characteristic subarachnoid haemorrhage with sudden "thunderclap" headache. Arteriovenous malformations (congenital cerebral vascular anomalies) sometimes reveal themselves in adulthood by haemorrhage. Anticoagulant treatments (warfarin, DOACs) significantly increase the risk of haemorrhagic stroke, justifying rigorous monitoring of their dosage. Cocaine consumption, amphetamines or other vasoactive substances can cause cerebral haemorrhages in young subjects. Amyloid angiopathies in elderly subjects manifest as recurrent superficial haemorrhages.

The distinction between ischaemic and haemorrhagic stroke is crucial because treatments are opposite: thrombolysis (which dissolves clots) is useful in ischaemic but dramatically worsens haemorrhagic. This is why an emergency brain CT scan is systematic before any treatment.

04Modifiable and non-modifiable risk factors#

Identifying risk factors allows preventive action, which is the major issue given that 80% of strokes are preventable by better control of modifiable risk factors according to WHO.

Modifiable risk factors

Arterial hypertension is by far the leading factor, responsible for approximately 50% of strokes, both ischaemic and haemorrhagic. A reduction in systolic blood pressure of 10 mmHg decreases stroke risk by approximately 30-40%. Strict blood pressure control (target below 140/90 mmHg, or 130/80 mmHg in diabetics) is the most powerful preventive measure.

Diabetes mellitus multiplies stroke risk by 2 to 3 independently of other factors. Strict glycaemic control, use of new cardio-protective antidiabetics (SGLT2 inhibitors, GLP-1 agonists), and global management of metabolic syndrome are essential.

Smoking approximately doubles stroke risk, mainly through accelerated atherosclerosis and increased coagulability. Quitting progressively restores risk to that of a non-smoker over 5 to 10 years.

Hypercholesterolaemia, mainly elevated LDL, contributes to atherosclerosis. Statins reduce ischaemic stroke risk by 20-25% in patients at high cardiovascular risk.

Obesity (BMI over 30) and particularly abdominal obesity increase stroke risk, partly mediated by other factors (hypertension, diabetes, dyslipidaemia). Weight loss simultaneously improves all these parameters.

Sedentary lifestyle is an independent risk factor — regular physical activity (at least 150 minutes per week of moderate intensity) decreases stroke risk by approximately 25-30%.

Atrial fibrillation (AF) is responsible for 20-30% of ischaemic strokes and multiplies risk by 5. Screening for AF in elderly subjects (regular pulse palpation, ECG, sometimes Holter) and its treatment with anticoagulants in at-risk patients (according to the CHA2DS2-VASc score) are major preventive measures.

Untreated sleep apnoea doubles stroke risk. Its screening and CPAP treatment in snoring patients with daytime sleepiness are important.

Excessive alcohol consumption (beyond 2 glasses per day) increases risk, particularly haemorrhagic stroke. Cocaine consumption, amphetamines or other stimulants is a major stroke factor in young subjects.

Non-modifiable factors

Age is the main risk factor: stroke frequency doubles every 10 years after age 55. Male sex is associated with higher risk in young subjects, but this difference fades and then reverses after age 80. Family history of stroke doubles risk. Ethnic origin: populations of African origin, including Maghreb populations, have a higher stroke incidence, partly due to higher hypertension prevalence. Personal history of stroke or TIA considerably multiplies the risk of recurrence (up to 30% at 5 years without preventive treatment).

05What to do urgently when stroke is suspected#

The conduct to follow when stroke is suspected is simple but must be applied without hesitation. Every minute lost represents millions of destroyed neurons.

Step 1 — Immediately call 141 (SAMU in Morocco) or 15. Do not call your treating doctor, do not go to consultation. SAMU regulators are trained to quickly identify stroke suspicions and send a medicalised ambulance to the nearest Stroke Unit for optimal management. Do not bring the person by your own means to the hospital unless waiting for SAMU is manifestly excessive — the medicalised ambulance allows stabilisation and orientation to the appropriate centre faster than a non-medicalised arrival to general emergencies.

Step 2 — Note the exact time of the first signs. This information is crucial because it determines the therapeutic window: thrombolysis is only possible within 4h30 after symptom onset, mechanical thrombectomy up to 24h in some cases. If the person woke up with the symptoms (stroke during sleep), note the time when they were last seen normal.

Step 3 — Lay the person down in a semi-sitting position (head and torso slightly raised at 30°) to favour cerebral venous return. If unconscious, place them in the lateral safety position (lying on the side) to prevent aspiration in case of vomiting.

Step 4 — Give nothing to eat or drink. Swallowing may be impaired by stroke with major risk of aspiration and aspiration pneumonia. Any feeding and hydration will be resumed in hospital after assessment.

Step 5 — Give no medication, particularly no aspirin. Aspirin, intuitively useful in ischaemic stroke, is dangerous in case of haemorrhagic stroke (20% of cases) as it worsens bleeding. Only doctors after brain imaging can decide on treatment.

Step 6 — Loosen clothing at the neck and waist to facilitate breathing. Keep the person calm.

Step 7 — Stay with the person, talk to them calmly, reassure them. Note the evolution of symptoms (improvement, worsening, appearance of new signs) to inform the medical team on arrival. Prepare available medical documents (prescriptions, history, current treatments) which will be useful to the team.

06Hospital treatments#

On hospital arrival, several steps will unfold within minutes to allow the fastest possible treatment.

The clinical examination by the emergency physician or neurologist confirms the stroke suspicion and assesses severity by the NIHSS score (international scale of 0 to 42). An emergency brain CT scan (sometimes MRI if available) distinguishes ischaemic from haemorrhagic stroke and specifies the affected territory. A blood test assesses coagulation, blood glucose, kidney function. An ECG searches for atrial fibrillation.

Intravenous thrombolysis

For ischaemic strokes occurring within the previous 4h30, without major contraindication, intravenous thrombolysis with alteplase (rtPA) is the reference treatment. This molecule dissolves clots and restores cerebral circulation. The earlier it is administered, the better the prognosis — a patient treated within 90 minutes has twice the chance of good recovery as a patient treated at 4 hours. Thrombolysis improves prognosis at 3 months in approximately 30% of treated patients, but carries a haemorrhagic risk of about 6%.

Mechanical thrombectomy

For ischaemic strokes by occlusion of a large cerebral artery (internal carotid, proximal sylvian), an endovascular mechanical thrombectomy can be performed. A catheter passed through the femoral artery up to the brain allows mechanical extraction of the clot (by stent retriever or aspiration). This technique has revolutionised the prognosis of these major strokes, with proven benefit up to 24 hours after symptom onset in some cases (according to imaging criteria of brain tissue viability). In Morocco, thrombectomy is now available in several reference centres (CHU Ibn Rochd Casa, CHU Ibn Sina Rabat, some private centres in Casablanca and Rabat), with progressive scaling up.

Management of haemorrhagic stroke

For haemorrhagic strokes, initial management aims to control arterial hypertension (target systolic pressure below 140 mmHg in acute phase), correct possible coagulation disorders (anticoagulant antagonists, platelets, fresh plasma), monitor and treat complications (cerebral oedema, intracranial hypertension). Surgical evacuation of the haematoma may be necessary for large haematomas of accessible location, particularly cerebellar haematomas. Ruptured aneurysms are treated by endovascular embolisation (coils) or more rarely surgery to prevent haemorrhagic recurrence.

Management in a Stroke Unit

Ideally, all stroke patients are admitted to a specialised Stroke Unit or Stroke Center. These units, equipped with a multidisciplinary team (neurologists, specialised nurses, physiotherapists, speech therapists, occupational therapists), offer 24/7 close follow-up with monitoring of vital parameters, prevention of complications (pneumonia, pressure ulcers, thrombosis), and early start of rehabilitation. The benefit of Stroke Units on mortality and disability is largely demonstrated: approximately 20% reduction in mortality and 30% reduction in disability compared to standard service management.

In Morocco, the Stroke Unit network has developed with about 12 centres having specialised units: CHU Ibn Rochd in Casablanca, CHU Ibn Sina in Rabat, CHU Hassan II in Fes, CHU Mohammed VI in Marrakech, and several regional hospitals. The National Stroke Plan 2020-2029 aims to extend this coverage to the entire territory and generalise access to thrombolysis and thrombectomy.

Stroke is recognised as ALD in Morocco, which entitles to 100% coverage of care (hospitalisation, medications, examinations, rehabilitation, immunosuppressants in case of vascular grafting).

07Rehabilitation and sequelae#

Long-term prognosis largely depends on the quality and earliness of rehabilitation, which should ideally begin from the first days post-stroke as soon as the clinical state allows.

Physiotherapy is the pillar of motor rehabilitation. It aims to recover motor function on the hemiplegic side, avoid immobilisation complications (tendon retractions, pressure ulcers, venous thrombosis), retrain balance and walking. 30 to 60 sessions are generally necessary in the initial phase, sometimes prolonged for several months. New techniques of robotic rehabilitation, transcranial magnetic stimulation or virtual reality bring promising additions.

Speech therapy is essential in case of aphasia (language disorders), which affects about 30% of patients after stroke. Progress can be significant even after several months or years. Dysphagia (swallowing disorders) also benefits from speech therapy rehabilitation with adaptation of food textures.

Occupational therapy retrains activities of daily living (dressing, washing, cooking, writing) and adapts the home to favour autonomy (ramps, supports, adapted wheelchair).

Psychotherapy is often necessary because post-stroke depression affects about 30% of patients within 6 months following, through direct impact of brain lesions and through reaction to the situation. SSRI antidepressants are effective in these situations.

Maximum recovery occurs in the first 3 to 6 months post-stroke, with possible improvement up to 2 years in some cases. Progress is greater the more intensive and early the rehabilitation.

08Secondary and primary prevention#

Stroke prevention rests on rigorous control of modifiable risk factors, both in primary prevention (before any event) and in secondary prevention (after a stroke or TIA to prevent recurrence).

Blood pressure control with a target below 140/90 mmHg (below 130/80 mmHg in diabetics or post-stroke) is the most powerful measure. Complete smoking cessation progressively restores risk towards a non-smoker. Regular physical activity of at least 150 minutes per week. A Mediterranean diet rich in fruits, vegetables, whole grains, fish, olive oil. Weight control with BMI below 25. Diabetes treatment with HbA1c control. Dyslipidaemia treatment by statins according to individual targets. Alcohol moderation (less than 2 glasses per day).

For patients with specific risk: oral anticoagulation in patients with atrial fibrillation with CHA2DS2-VASc score equal to or greater than 2 (direct oral anticoagulants such as rivaroxaban, apixaban, dabigatran, or warfarin) is essential. Antiplatelets (aspirin 75-100 mg, clopidogrel) are indicated after an ischaemic stroke or TIA. Statins are indicated post-ischaemic-stroke with LDL target below 0.70 g/L.

In Morocco, several national awareness campaigns for stroke sensitise the population to the FAST test and the urgency of calling 141. Making these signs known to your entourage can save lives — share this information with your relatives, it is probably the most impactful health prevention gesture you can make.