Stroke: Causes, Symptoms and Treatment

Stroke: Causes, Symptoms and Treatment

Stroke is the sudden death of brain cells caused by interruption of the blood supply to part of the brain. It is the second most common cause of death worldwide and the most common cause of serious long-term disability in adults. In China, stroke is the leading cause of death and disability — an estimated 1.3 million people die from stroke in China each year, and 7 million are living with its consequences.

The brain is uniquely vulnerable: unlike other organs, it cannot store oxygen or glucose. Brain cells begin dying within 4–6 minutes of losing their blood supply. Every 30 minutes of delay in treatment results in additional brain cells lost and worse functional outcomes. Time is brain.

Types of Stroke

Ischaemic Stroke (80% of cases)

A blood clot blocks an artery supplying the brain, cutting off blood flow to the region that artery feeds. The affected region can contain an irreversibly injured infarct core and surrounding potentially salvageable tissue, called the ischaemic penumbra. Without timely restoration of blood flow, more of the penumbra may progress to infarction.

Mechanisms of ischaemic stroke:

• Cardioembolic — a clot forms in the heart (most commonly in atrial fibrillation, where the irregular rhythm allows blood to pool and clot in the left atrial appendage) and breaks off, travelling through the bloodstream to lodge in a brain artery. Cardioembolism can cause large, disabling infarcts, but it is not the universal leading mechanism in younger patients; causes vary across populations.
• Large artery atherothrombotic — atherosclerotic plaque in the carotid or vertebral arteries or within the brain arteries ruptures, triggers local clot formation, and occludes the vessel.
• Small vessel (lacunar) — lipohyalinosis of small penetrating arteries (caused by hypertension and diabetes) produces small, deep infarcts in the basal ganglia, internal capsule, pons and thalamus.
• Cryptogenic — no cause identified after full investigation (30–40% of cases); many are suspected to be cardioembolic from paroxysmal atrial fibrillation.

Haemorrhagic Stroke (20% of cases)

An artery within or around the brain ruptures, and blood enters the brain tissue (intracerebral haemorrhage) or the space surrounding the brain (subarachnoid haemorrhage).

• Intracerebral haemorrhage (ICH) — most commonly caused by chronic hypertension weakening small perforating arteries, which then rupture. Blood pours into the brain parenchyma, causing a haematoma that compresses surrounding structures and triggers oedema. ICH has the highest 30-day mortality of all stroke subtypes (40–50%).
• Subarachnoid haemorrhage (SAH) — rupture of a cerebral aneurysm (a localised balloon-like weakness in an artery wall) into the subarachnoid space surrounding the brain. Classic presentation: sudden-onset "thunderclap headache" — the worst headache of the patient's life — with neck stiffness. Medical emergency with high mortality and frequent rebleeding risk.

Transient Ischaemic Attack (TIA)

A TIA causes temporary neurological symptoms from reduced blood flow to the brain, spinal cord or retina without acute infarction. Symptoms may resolve quickly, but duration alone cannot distinguish TIA from stroke; even brief symptoms require urgent assessment and appropriate imaging. TIA is a critical warning: As many as 10–15% of patients may have a stroke within 3 months of a TIA; about half of these subsequent strokes occur within the first 48 hours. TIA must be treated as an emergency.

Risk Factors

Major modifiable risk factors for both ischaemic and haemorrhagic stroke:

Risk Factor	Contribution
Hypertension	Single most important stroke risk factor; doubles stroke risk per 20 mmHg rise in systolic BP
Atrial fibrillation	5× increased stroke risk; anticoagulation prevents 60–70% of AF-related strokes
Diabetes mellitus	2–3× increased stroke risk from accelerated atherosclerosis and small vessel disease
Smoking	2× increased ischaemic stroke risk; particularly raises SAH risk
Hypercholesterolaemia	Promotes carotid and intracranial atherosclerosis
Obesity and physical inactivity	Independent risk factors for stroke
Heavy alcohol consumption	Increases both ischaemic and haemorrhagic stroke risk
Prior TIA or stroke	Highest single predictor of future stroke

Non-modifiable risk factors: Age (risk doubles each decade after 55), male sex, South Asian or Black African ethnicity, family history of stroke.

Symptoms — FAST Recognition

Stroke symptoms come on suddenly. The FAST mnemonic captures the three most common presentations:

• F — Face drooping: one side of the face droops or is numb; the smile is uneven
• A — Arm weakness: one arm is weak or numb; when both arms are raised, one drifts down
• S — Speech difficulty: slurred speech, unable to speak, or unable to understand speech
• T — Time to call emergency services immediately

Other stroke symptoms:

• Sudden severe headache with no known cause (SAH — thunderclap headache)
• Sudden vision loss or double vision
• Sudden dizziness, loss of balance, or incoordination
• Sudden numbness or weakness of face, arm or leg — typically on one side
• Sudden confusion or difficulty understanding

Important: even if symptoms resolve within minutes, call emergency services — this may be a TIA and stroke risk is highest in the hours that follow.

Diagnosis

Brain Imaging

CT scan — the first investigation in any suspected stroke. A non-contrast CT rapidly and reliably identifies haemorrhagic stroke (blood appears bright white) and rules out haemorrhage before thrombolysis can be given. CT is less sensitive for acute ischaemic infarction in the first hours.

CT angiography (CTA) — rapid imaging of cerebral arteries to identify large vessel occlusion (LVO), determine thrombectomy eligibility, and assess carotid stenosis.

MRI with diffusion-weighted imaging (DWI) — detects ischaemic infarction within minutes of onset; more sensitive than CT for small and posterior fossa strokes. NICE recommends considering MRI with diffusion-weighted and blood-sensitive sequences after specialist assessment of suspected TIA; if selected, it should be performed the same day. MRI is not required for every TIA evaluation, and waiting for it must not delay urgent clinical assessment.

MR angiography and perfusion imaging — identifies salvageable brain tissue (mismatch between infarct core and penumbra) to guide late-window thrombectomy decisions.

Further Investigation

• ECG and cardiac monitoring — detects atrial fibrillation (including paroxysmal AF requiring prolonged monitoring)
• Echocardiography — identifies cardiac sources of embolism (thrombus, valvular disease, patent foramen ovale)
• Carotid Doppler ultrasound — evaluates ipsilateral carotid stenosis for possible endarterectomy
• Blood tests — full blood count, coagulation, glucose, lipids, HbA1c

Treatment

Emergency Treatment — Ischaemic Stroke

Intravenous thrombolysis (IV alteplase)

Alteplase (tPA) is a clot-dissolving treatment that can improve functional outcomes in eligible patients. Intravenous thrombolysis is usually assessed within 4.5 hours of symptom onset or last known well; selected patients with unknown onset or a later presentation may qualify using advanced imaging criteria. This is not a reason to delay emergency care. Brain imaging must exclude haemorrhage. Eligibility depends on bleeding risk, blood pressure and details such as the type and timing of recent surgery, anticoagulant drug and last dose, and relevant coagulation tests; these require an urgent specialist decision.

Mechanical thrombectomy

For strokes caused by large vessel occlusion (LVO) — blockage of a major brain artery — mechanical thrombectomy is transformative. A catheter is threaded from the femoral artery into the brain under fluoroscopy, a stent retriever or aspiration device is deployed across the clot, and the clot is physically removed.

Thrombectomy is indicated up to 24 hours from symptom onset in selected patients (based on imaging showing salvageable brain tissue). It achieves recanalisation in over 80% of cases and doubles the proportion of patients who are functionally independent at 3 months. It is the most effective acute stroke treatment for LVO.

Thrombectomy and thrombolysis are not mutually exclusive — many LVO patients receive both ("drip and ship" or "drip and drive").

Emergency Treatment — Haemorrhagic Stroke

Intracerebral haemorrhage: carefully monitored blood pressure control (for selected mild-to-moderate cases presenting with systolic pressure 150–220 mmHg, targeting around 140 and maintaining 130–150 mmHg may be reasonable; lowering below 130 mmHg can be harmful, and severe cases require individual targets); reversal of anticoagulation; urgent neurosurgical assessment. Immediate evacuation is recommended for cerebellar haemorrhage with neurological deterioration, brainstem compression, obstructive hydrocephalus or haematoma volume ≥15 mL. For lobar/supratentorial haemorrhage, evacuation is a selected-case decision: routine craniotomy has uncertain benefit for survival or function, but may be considered as a life-saving measure in deteriorating patients.

Subarachnoid haemorrhage: emergency neurosurgical or endovascular treatment of the ruptured aneurysm (surgical clipping or endovascular coiling) to prevent rebleeding; early enteral nimodipine to reduce delayed cerebral ischaemia and improve functional outcomes.

Secondary Prevention

After TIA or ischaemic stroke, the priority is preventing the next event:

• Antiplatelet therapy for non-cardioembolic stroke: short-term aspirin + clopidogrel for 21 days, then monotherapy, is an option for selected patients with acute minor ischaemic stroke or high-risk TIA who are not at high bleeding risk; it is not a regimen for every stroke, and timing and suitability require clinical assessment
• Anticoagulation (direct oral anticoagulants — apixaban, rivaroxaban) for AF-related stroke
• Statin therapy — high-intensity statin to reduce LDL and stabilise atherosclerotic plaque
• Antihypertensive therapy — target BP <130/80 mmHg; reduces stroke recurrence by 25–30%
• Carotid intervention — carotid endarterectomy is recommended for suitable patients with a recent non-disabling ischaemic stroke or TIA and ipsilateral 70–99% stenosis; selected patients with 50–69% stenosis may also benefit. Eligibility requires assessment of clinical factors and procedural risk. The choice between endarterectomy and carotid stenting depends on patient comorbidities and vascular anatomy.
• Lifestyle: smoking cessation, alcohol reduction, weight loss, exercise, diabetic control

Stroke Rehabilitation

Rehabilitation assessment begins during acute care, with activity tailored to the person’s clinical condition. NICE advises against high-intensity mobilisation during the first 24 hours after symptom onset when a person needs help to sit out of bed, stand or walk. The treating team determines when and how to begin safe activity; earlier or more intensive mobilisation is not automatically better. Recovery can continue for months to years through neuroplasticity — the brain's ability to form new connections.

Rehabilitation components:

• Physiotherapy — retraining walking, balance, coordination, and limb function
• Occupational therapy — restoring ability to perform daily activities; upper limb rehabilitation; assistive equipment
• Speech and language therapy — for aphasia (language disorder) and dysphagia (swallowing difficulty)
• Cognitive rehabilitation — for post-stroke cognitive impairment, memory, and attention
• Neuropsychological support — depression affects approximately 33% of stroke survivors and impairs recovery; treatment with antidepressants and psychotherapy is beneficial

Stroke Care in China

China's cerebrovascular centres offer:

• 24/7 stroke unit care: dedicated stroke teams with immediate CT/MRI, thrombolysis protocols and catheter laboratory access for thrombectomy
• Mechanical thrombectomy: eligibility and treatment decisions are made by the treating stroke team
• Advanced imaging: CT perfusion and MR perfusion to identify late-window thrombectomy candidates beyond standard time windows
• Suspected TIA: seek immediate local medical assessment, even if symptoms resolve; do not wait for overseas travel or a PriumCare appointment. NICE recommends immediate referral for specialist assessment within 24 hours of symptom onset. This is an urgent-care recommendation, not a promised PriumCare booking time; investigations depend on the treating team.
• Multidisciplinary rehabilitation: inpatient and outpatient rehabilitation combining physiotherapy, occupational therapy, speech therapy, and neuropsychology
• Cost: care in China is generally less expensive than UK private treatment, but the hospital prices each case individually — ask us for the written quote before you commit.

Contact a PriumCare care navigator to arrange a stroke assessment, second opinion on stroke prevention, or rehabilitation consultation.

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External source attribution: the original article cites MSD Manuals, authored by Andrei V. Alexandrov MD (University of Arizona) and Balaji Krishnaiah MD (University of Tennessee), with a review date of June 2025. These names and dates credit the external source, not authorship or medical review of this PriumCare article.

Timing and emergency-care source clarification

Editorial source clarification: 25 October 2026. This targeted update addresses timing and care-setting statements, not a whole-article medical review. Original publication date is retained.

• NICE: stroke and TIA initial management
• American Heart Association: TIA definition

Additional targeted source clarification

Editorial source check: 25 October 2026. This clarifies the specific claims linked below; it is not a whole-article medical review or a new clinical reviewer attribution. The original publication date is retained.

• AHA/ASA 2026: acute ischaemic stroke treatment and imaging selection
• AHA/ASA 2022: intracerebral haemorrhage blood pressure management
• AHA/ASA 2023: nimodipine and delayed cerebral ischaemia
• Canadian Stroke Best Practices: selected short-term dual antiplatelet therapy
• Primary cohort: causes of stroke in 1322 young adults

Further targeted source clarification

Editorial source check: 25 October 2026. This update checks only the specific residual claims linked below; it is not a whole-article medical review and does not add a named clinical reviewer. The original publication date is retained.

• AHA/ASA: 2021 secondary stroke prevention
• AHA/ASA: 2022 ICH clinical update, surgical indications

Targeted TIA imaging clarification

Editorial source check: 25 October 2026. This checks only the TIA imaging requirement clarified above; it is not a whole-article medical review and adds no named clinical reviewer. The original publication date is retained.

• NICE NG128: urgent TIA assessment and selective MRI

Targeted hospital-claim clarification

Editorial clarification: 26 October 2026. This targeted change removes comparative hospital-volume and rapid-treatment wording. It is not a whole-article medical review, adds no named clinical reviewer, and retains the original publication date.

Targeted TIA-risk timing clarification

Editorial source check: 26 October 2026. This update checks only the TIA stroke-risk estimate and the share of subsequent strokes occurring early. It is not a whole-article medical review, adds no named clinical reviewer, and retains the original publication date.

• CDC: TIA is an emergency and subsequent stroke risk
• AHA scientific statement: early stroke risk after TIA