Stroke and TIA in PreHospital Practice

This article explores Stroke and TIA in PreHospital Practice Stroke is a common medical condition requiring emergency care. 10,000 people experience a stroke per year, with a stroke occurs in the UK every 5 minutes [Stroke Association, 2021].

In the UK, ambulance services are to prioritise rapid recognition and transport to specialist care in acute stroke patients [Haworth and McCelland, 2019].

Early specialist stroke care reduces complications and benefits all patients [McCelland et al, 2013].

Improving stroke and transient ischaemic attack (TIA) care is a priority for UK healthcare, with recent JRCALC guidelines developed by Intercollegiate Stroke Guideline Working Party and published in Royal College of Physicians [JRCALC, 2025] to allow for high quality stroke care.  

Pathophysiology  

Stroke refers to a sudden lack of blood flow and perfusion to the brain, affecting functions such as voluntary movement and speech [NHS, 2024]. Stroke is a clinical condition of vascular origin with rapidly developing signs of disturbed cerebral function lasting longer than 24 hours – this can be due to ischaemic, haemorrhagic, or unknown/silent causes [NICE CKS, 2025].

Cerebrovascular Accident (CVA) or cerebrovascular infarct may also be used by some professionals, however, there is always a cause for stroke; the term ‘accident’ can be misleading and is now discouraged [Stroke Association, 2012]. Transient Ischaemic Attack (TIA) refers to a sudden onset of neurological deficit (of vascular origin) lasting less than 24 hours – this is caused by a temporary non-function of brain area due to disrupted blood flow and perfusion [Al-Shamaa and Daly, 2023].

TIA can be caused by focal brain, spinal cord or retinal ischaemia without evidence of acute infarction [NICE CKS, 2025]. The current incidence of stroke within 48 hours of TIA is reported to be 5% [Faiz et al, 2013], with a further 1 in 12 patients experiencing a subsequent stroke within 1 week if treatment is withheld [Al-Shamaa and Daly, 2023]. Differentials for TIA may include: Hypoglycaemia, migraine aura, seizure, syncope [Al Shamaa and Daly, 2023].

This highlights the importance of history, witnesses and accurate assessment (including blood glucose measurement) in assessing and managing patients. Risk factors for stroke and TIA include: Aged over 55 years, male sex, smoking, hypertension, atrial fibrillation, diabetes, family history, prior stroke/TIA, vasculitis [Al Shamaa and Daly, 2023].  

Management and Care 

Ambulance clinicians cannot offer specific stroke treatment, hence, rapid recognition and transport to appropriate definitive care is prioritised [McCelland et al, 2013].

FAST tests are a well-known and useful tool in the recognition of acute ischaemic stroke [Chen et al, 2022].
Recent analysis of National Institutes of Health Stroke Scale data shows the addition of balance and visual abnormalities to FAST symptoms would improve recognition of stroke from 86% to 96%, however would still not recognise all stroke patients [Jones et al, 2021].
Any patient who is presenting as suspected stroke but negative for a validated tool should be treated as a stroke until diagnosis is excluded by a specialist stroke clinician [National Clinical Guideline for Stroke for the United Kingdom and Ireland, 2023].

BEFAST considers:

• Balance: Gait disturbances, ataxia, leg weakness.

• Eyes: Visual disturbances, visual field loss, diplopia (double vision).

• Face: Unilateral facial weakness and/or drooping.

• Arms: Unilateral limb weakness, unable to raise both arms or legs.

• Speech: Slurred speech, confused speech, dysphasia.

• Time: Time to act quickly, urgent admission to hyper-acute stroke/stroke unit.

BEFAST has increased use recently [Jones et al, 2021]. The use of the FAST test in stroke patients must be monitored by ambulance services, this requires careful documentation, assessment and management of patients and timings is vital to improve stroke patient care and outcomes [AACE, 2013].

Clinicians should assess patient capillary blood glucose [National Clinical Guideline for Stroke for the United Kingdom and Ireland, 2023], as hypoglycaemia must be excluded in patients with sudden onset of neurological symptoms [NICE CKS, 2008].

In emergency departments (EDs), the Recognition of Stroke in the Emergency Room (ROSIER) tool is commonly used.

The ROSIER scale is a scoring system which considers 7 items of clinical history and neurological signs, encompassing:

• Loss of consciousness,
• Seizure activity,
• Facial asymmetry,
• Arm and leg weakness,
• Speech disturbance, and
• Visual field deficit [Chehregani and Azimi, 2023

ROSIER scores from -2 to +5, with a score of +1 or higher indicates a positive stroke or TIA diagnosis [Chehregani and Azimi, 2023]. Any suspected stroke patient is to be directly admitted to a hyper-acute stroke unit within 4 hours of presentation, with early commencement of reperfusion methods (IV thrombolysis or mechanical thrombectomy) within 4.5 hours of onset being ideal standard of treatment in EDs [BMJ Best Practice, 2025].
Rapid assessment and early access (within the hour of presentation) to non-contrast computed tomographic (CT) imaging is recommended; note, a normal CT does not exclude stroke but does exclude intracranial haemorrhage [BMJ Best Practice, 2025].

Any suspected stroke/TIA patients should be monitored primary survey concerns including airway deficiencies and new onset arrhythmias [National Clinical Guideline for Stroke for the United Kingdom and Ireland, 2023], treat and reverse any time-critical ABCDE abnormalities [JRCALC, 2022].

The phrase “Time is Brain” is used to emphasise the importance of time management and acting quickly for stroke patients [Faiz et al, 2013].
In recent years, on-scene time has increased, rising from 20 minutes in 2011 to 33 minutes in 2019 – this can be affected by:
Call length/time, dispatch delays, travel distance to/from scene and on-scene time [McCelland et al, 2013].

Timings can be reduced by performing certain interventions (E.G 12 lead ECGs and IV cannulation) en route or only when absolutely necessary [McCelland et al, 2013].
It is difficult to distinguish between TIAs and acute stroke during symptoms, so it is vital the patient is assessed by specialist teams as soon as possible [National Institute of Neurological Disorders and Stroke, 2025].

 TIA diagnosis in the community is often based on given patient history or witness accounts after resolve of symptoms.

JRCALC [2025] dictates aspirin 300mg can be given for suspected TIA with full resolve of symptoms, patient is not being conveyed to ED, and patient has been referred/accepted to local TIA pathway.

Prevention guidance should also be offered to TIA patients, including: support to modify lifestyle factors (smoking, alcohol consumption, diet, exercise); antiplatelet or anticoagulant therapy; statin therapy and/or antihypertensive therapy [National Clinical Guideline for Stroke for the United Kingdom and Ireland, 2023].  

Current Research 

The use of BEFAST is currently debated, as the addition of further symptoms to stroke tools requires further evaluation of the sensitivity and specificity of these tools [Jones et al, 2021].

There is multiple screening tools used in the pre-hospital environment, including V-FAST, ABCD-E2, ROSIER, FAST/AVVV, BEFAST [Rowe et al, 2022].

There is current research and ongoing studies into the most effective screening tool to implement into the prehospital environment, as there is currently no standard screening for visual impairment in strokes [Rowe et al, 2022].

Furthermore, the Golden Hour for Stroke (GHoST) study involves West Midlands Ambulance Service University NHS Foundation Trust (WMAS UNHSFT), Midlands Air Ambulance Charity (MAAC) and University Hospitals Birmingham NHS Trust (UHBNHSFT), this aims to identify biomarkers in blood, urine and saliva to develop a rapid lateral flow test for the diagnosis of stroke [University of Birmingham, 2023].  

Key Points

References 

Al-Shamaa, N. and Daly, D. Geeky Medics: Transient Ischaemic Attack (TIA). Uploaded 8th November 2023, last updated 17th September 2024. Last accessed 29th August 2025 via: https://geekymedics.com/transient-ischaemic-attack-tia/

Association of Ambulance Chief Executives (AACE). Section 3: Medical – Specific Conditions. Specific Stroke/Transient Ischaemic Attack (TIA). Published 2013. Accessed 14th August 2025 via: https://aace.org.uk/wp-content/uploads/2017/03/cpg-2013-text press-175.pdf

British Medical Journal (BMJ) Best Practice. Ischaemic Stroke. Last Reviewed 30th July 2025. Accessed 20th August 2025 via https://bestpractice.bmj.com/topics/en-gb/1078  

Chehregani, I. and Azimi, A. Recognition of Stroke in the Emergency Room (ROSIER) Scale in Identifying Strokes and Transient Ischemic Attacks (TIAs); a Systematic Review and Meta-Analysis. Archives of Academic Emergency Medicine. Volume 11, Issue 1. Published 5th October 2023. DOI: 10.22037/aaem.v11i1.2135

Chen, X. Et al. A Systematic Review and Meta-Analysis Comparing FAST and BEFAST in Acute Stroke Patients. Frontiers in Neurology. Volume 12. Published 28th January 2022. DOI: 10.3389/fneur.2021.765069