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Types of Stroke

Stroke Signs You Should Know

My hygienist asks me to evaluate an 86-year old patient who is having difficulty speaking. The word stroke flashes before my eyes. His age, history of diabetes, and high blood pressure are all ominous warnings that my patient is at high risk for a stroke. But, before I discuss my patient any further, let’s review a bit about how to recognize strokes and what to do when you suspect someone you know may be having one.

These days, most people are familiar with the common mnemonic F.A.S.T. However, many are not aware that the AHA gave the mnemonic an update in 2017, neither was I. The mnemonic is now B.E.F.A.S.T. which is as follows:

  • Balance – Loss of balance, headache, dizziness
  • Eyes – Blurred vision
  • Face – One side of the face is drooping
  • Arms – Arm or leg weakness
  • Speech – Speech difficulty
  • Time – Time to call an ambulance!

In a study commissioned by the American Heart Association, the addition of B.E. (Balance and Eyes) to the F.A.S.T. recognition protocol decreased the percentage of missed strokes from around 14% to just 4%.

An Alternative Recognition Protocol

Even more effective than either F.A.S.T. (86% effective) or B.E.F.A.S.T. (96% effective) is the Give Me 5 for Stroke recognition tool (99.9% effective). However, it is more difficult to remember than the other recognition tools, which is probably why it hasn’t caught on as much as the other two. The Give Me 5 recognition protocol is as follows:

  • Walk – Is balance off?
  • Talk – Is speech slurred?
  • Reach – Is one side weak or numb?
  • See – Is vision entirely or partially lost?
  • Feel – Is there a severe headache?

One Sign Is Enough

Clinical diagnosis of stroke

The thing I find most confusing about all of these stroke recognition protocols is that they are written like checklists. With F.A.S.T. it seems like your patient must exhibit facial asymmetry, arm or leg weakness, and speech difficulties, to qualify as a likely stroke. This couldn’t be further from the truth. Any one of these could be a sign of a stroke, and should be taken very seriously.

Getting back to my 86-year old patient; he is firmly in the geriatric category, which places him at higher risk for stroke. He also has a history of high blood pressure and diabetes, two additional risk factors for stroke. Before I even meet this patient, I assume he is suffering a stroke unless proven otherwise.

When I sit down to introduce myself to the patient, he seems perfectly fine. He greets me normally, and doesn’t seem to have any trouble speaking during our brief initial interaction. I decided to go through the F.A.S.T. protocol that I had been taught in dental school.


I start with the patient’s face, and evaluate facial symmetry by asking him to smile for me. I also look for signs of facial drooping in repose. Looks fine, I thought.


I then ask the patient to elevate his arms simultaneously as I resist with mine. Again, everything seems normal.


I speak with the patient some more to see if he is having difficulty with speech. It isn’t until I engage him in an in-depth conversation that it becomes apparent he is struggling to form multi-syllable words. He is mixing up syllables and stuttering, stumbling over words like Blackstone and Broadway. After a few attempts at a word, he is visibly bewildered at his inability to form words properly.

I ask the patient a few basic questions. He gets the day and month right, but he struggles with the year. He isn’t sure if it is 2011 or 2012, though he does know that Joe Biden is the current president. Despite his normal outward appearance, I am confident that my patient is suffering from a stroke.

Types of Stroke

Types of Stroke

A stroke occurs any time blood flow to part of the brain is disrupted. There are five generally recognized types of stroke:

  1. Ischemic
  2. Hemorrhagic
  3. Brain Stem
  4. Transient Ischemic
  5. Cryptogenic

Ischemic Stroke

If blood stops flowing to part of the brain due to a blockage, then an ischemic stroke will result. Ischemic strokes may commonly be caused by arterial plaques, or atrial fibrillation.

There are two types of ischemic stroke which are categorized based on where they form:

  1. Thrombotic: Occurs when a blood clot forms inside an artery that supplies the brain with blood.
  2. Embolic: Occurs when a blood clot forms elsewhere in the body and travels through the bloodstream to a vessel in the brain where it causes a blockage.

It is very important to have physical examinations from your general practitioner annually if you are over the age of 50. Younger people can suffer strokes as well, so it is important to stick to the recommended physical exam schedule for your age group.

Hemorrhagic Stroke

Unlike ischemic strokes which are the result of a blockage, hemorrhagic strokes occur when there is bleeding in the brain. The bleeding creates pressure which damages nearby cells. There are two types of hemorrhagic stroke:

  1. Subarachnoid Hemorrhage: Occurs when there is bleeding between the brain and the skull.
  2. Intracerebral Hemorrhage: Occurs when there is bleeding inside the brain.

Brain Stem Stroke

Other types of stroke typically afflict one side of the body, and lead to varying levels of impairment. Brain stem strokes display a wide range of signs and symptoms, making them difficult to diagnose. They may also lead to varying levels of impairment depending on where they occur in the brain stem.

Severe brain stem strokes on the other hand may affect both sides of the body, and leave the victim in a locked-in state. Like a permanent state of sleep paralysis, the most severe brain stem strokes leave their victims unable to speak or move from the neck down.

Transient Ischemic Stroke

Sometimes called a “mini-stroke,” a Transient Ischemic Stroke, or TIA for short, is a temporary blockage that afflicts part of the brain. TIAs may last anywhere from a few minutes to a few days. Having a TIA is sometimes considered a warning sign that a person is at high risk for suffering from a future ischemic stroke, so a TIA should still be treated as an emergency situation just like any other form of stroke.

Cryptogenic Stroke

A cryptogenic stroke is a fancy medical way of saying we don’t know how the stroke happened. Basically, you are suffering from stroke symptoms and tissue damage, but no one knows what caused it.

Don’t Delay

Our patient was lucky to have seen us for a cleaning that fateful day. In addition to the three risk factors I listed earlier, he has a fourth risk factor: he lives alone. It’s a very real possibility that he could have gone the entire day without knowing he was having a stroke. Like heart attacks, time is of the essence with strokes. The longer it takes to recognize and treat a stroke, the more irreversible tissue damage occurs.

Because our patient was treated fairly early, he suffered only minor speech loss. He was admitted to the hospital for five days and given medications to break up the blockage that was causing his stroke. Early recognition and intervention limited the damage our patient suffered. He is currently in speech therapy, but the outcome could easily have been much worse if my hygienist hadn’t recognized his speech difficulties and raised the alarm.

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