Clinical exam · Nervous system
Recognising a stroke: BE-FAST and the NIH Stroke Scale !
- Topic
Sudden signs of a brain attack: balance, eyes, face, arm and speech; every minute counts.
Updated 2026-11-01
See it in 3D: Middle cerebral artery · Anterior cerebral artery · Posterior cerebral artery · Cerebellum · Motor cortex
What it is
A stroke is a sudden loss of brain function from a blocked or ruptured vessel. Early recognition is decisive, because reperfusion treatments work only in the first hours. BE-FAST is a rule for spotting it in and out of hospital, and the National Institutes of Health Stroke Scale (NIHSS) measures its severity in a standard way.
Key facts
- Ischaemic stroke: the most common type, from a thrombus or embolus.
- Haemorrhagic stroke: intracerebral or subarachnoid haemorrhage; a sudden, very severe headache suggests subarachnoid haemorrhage.
- Non-contrast head CT separates ischaemic from haemorrhagic stroke.
- Stroke mimics: hypoglycaemia, seizure with post-ictal paralysis, migraine with aura, tumour.
Step by step
- B (balance): 'Do you feel dizzy or unsteady? Can you walk?'
- E (eyes): 'Are you seeing double, or have you lost vision in one eye or to one side?'
- F (face): ask the patient to smile or show the teeth and look for asymmetry.
- A (arms): ask the patient to raise both arms with the eyes closed and watch for one that sinks.
- S (speech): ask the patient to repeat a simple phrase and listen for slurred, odd or absent speech.
- T (time): record the onset or last-known-well time and activate the stroke code or call emergency services.
- In hospital, the full NIHSS is given in its fixed item order, without going back to change scores.
Clinical notes
- Middle cerebral artery: face and arm weaker than leg, aphasia if dominant hemisphere, neglect if non-dominant.
- Anterior cerebral artery: the opposite leg weaker than the arm.
- Posterior circulation: vertigo, ataxia, diplopia, loss of one visual field, dysarthria.
- Nursing: safe positioning, nothing by mouth until swallowing is assessed, frequent neuro checks and reporting any deterioration.
Test yourself
Think of the answer, then tap the question to see it.
What does each letter of BE-FAST stand for?
Balance, Eyes (vision), Face, Arm, Speech and Time (onset time and calling emergency services).
Why is glucose checked in every patient with suspected stroke?
Hypoglycaemia can cause focal deficits and confusion that mimic a stroke, and it is quickly corrected.
What is the range of the NIHSS and what does a high score mean?
It runs from 0 to 42; a higher score means a more severe stroke.
See it in 3D
The structures of Durgical's 3D anatomy where it is found.
Related
- Pronator drift
- Cranial nerve examination
- Mental status: orientation, attention and screening tests
- Upper vs lower motor neuron syndrome
- The neurological examination: order and screening exam
Related conditions
- Ischaemic stroke
- Intracerebral haemorrhage
- Transient ischaemic attack
- Subarachnoid haemorrhage
- Hypoglycaemia (including insulin-induced)
Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.
Sources: Signs and Symptoms of Stroke (Centers for Disease Control and Prevention (CDC), 2024); 16.1 Overview of the Neurological Exam (OpenStax, Anatomy and Physiology 2e, 2022); 26.2 Physical Assessment - Clinical Nursing Skills (OpenStax, 2024).
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Representative model, for educational purposes only.