Characteristics of patients who had a stroke not initially identified during emergency prehospital assessment: a systematic review

Time is brain, so we must BEFAST: Improving stroke identification and triage in a rural emergency department

OBJECTIVE

Shoalhaven District Memorial Hospital is a rural (MM3) secondary hospital which is over an hour travel time from the nearest tertiary centre. The objective of the present study was to pilot the implementation of the BEFAST (Balance, Eyes, Face, Arms, Speech and Time) stroke screening tool at the ED, and determine whether its usage improved timely stroke detection.

METHODS

During initial implementation and training (October-December 2019), triage nurses consulted with senior medical officers before activating stroke calls. Data were collected for the subsequent 24 months (January 2020-2022), and retrospective records for confirmed strokes during a 24-month period prior to BEFAST implementation (October 2017-2019) were also collected. The main outcome measures were triage category, CT scan result time, discharge destination, length of stay (LOS) and Modified Rankin Score (MRS).

RESULTS

After BEFAST implementation, patients (n = 268) were three times more likely to be triaged at category 1 or 2, and door-to-CT scan time was reduced by 20.7 min on average. More patients were discharged to their usual residence and more quickly (LOS 7.9 vs 11.1 days). MRS 90 days after stroke was less, and patients were nearly twice as likely to experience an improvement in neurological symptoms.

CONCLUSIONS

Patient outcomes were improved after implementation of the BEFAST stroke triage tool. More stroke patients were identified upon presentation to the ED, and in a timely fashion. For those with a stroke diagnosis, time-critical interventions can take place earlier, allowing patients to return home sooner, and with less disability.

Detecting Stroke at the Emergency Department by a Point of Care Device: A Multicenter Feasibility Study

Purpose

To evaluate if the Strokefinder MD 100 by Medfield Diagnostics AB can be used as a point of care device in overcrowded Emergency Departments (ED).

Patients and Methods

We used the strokefinder MD 100 by Medfield Diagnostics AB in two Greek National Health System (NHS) Hospitals Emergency Departments. Our research protocol was approved by local scientific and ethics committees. We prospectively enrolled 71 adult patients from two NHS emergency departments in whom stroke was included as a differential diagnosis after triage. The feasibility of using the Strokefinder MD 100 by Medfield Diagnostics AB in various emergency department settings was evaluated through a structured questionnaire.

Results

The strokefinder MD 100 was used on 71 patients in various settings in the Emergency Department. In every case, the test was completed at the patient bedside without interfering with other ongoing and diagnostic and resuscitation procedures. There was no additional delay to patient care caused by performing the test when compared with current local Emergency Department practice and protocol. In almost 90% of the cases, a clear result was produced by the device.

Conclusion

The Strokefinder MD 100 can be safely used as a point of care device by all trained healthcare professionals, in the most overcrowded emergency department, in various ED locations.

MeSH terms

Point of Care Systems, Cerebrovascular Stroke, Proof of Concept Study.

Paramedic recognition of posterior circulation stroke: a vignette and focus group study

Introduction

The main pre-hospital screening tool used for stroke in Ireland and the United Kingdom is the FAST (face, arms, speech, time) test. However, posterior circulation stroke (PCS) patients may be FAST negative on exam, presenting with sudden dizziness, headaches, visual problems, nausea and vomiting and balance/co-ordination problems. There is a lack of research into paramedic recognition of PCS, and this study sought to evaluate recognition rates among paramedics (Ps) and advanced paramedics (APs) in Ireland.

Methods

A cross-sectional sequential exploratory design was chosen. An anonymous online survey was carried out, which informed focus group discussions. The survey contained six clinical vignettes, two of which were PCS presentations. Correct diagnosis, hospital destination and type of pre-alert were recorded. Focus groups were chaired by an independent moderator via Zoom. Recordings were transcribed and thematic analysis was carried out to create codes and themes.

Results

One hundred and fifty-one staff members (91 Ps, 60 APs) completed the survey (response rate 40%). Of these, 67% did not recognise PCS symptoms and 77% did not choose to transport to a stroke unit. For those correctly suspecting PCS, 42% requested resus at the stroke unit and 18% requested resus in the local emergency department (ED). Two focus groups of four practitioners (n = 8) took place. Three main themes were created: (1) comfort levels with posterior stroke, with subthemes of recognition and personal experiences; (2) education, with subthemes of clinical practice guideline (CPG) issues and training issues; and (3) hospital factors, with subthemes of pre-alerting and disconnect between hospital and emergency medical services. Participants were uncomfortable with PCS recognition and bypassing their local ED. More training was called for, with a dedicated CPG. Relationships with hospital staff affected willingness to pre-alert.

Conclusions

In this sample group, recognition of PCS and onward transfer to a stroke unit was low. Focus groups showed that practitioners were uncomfortable recognising PCS and bypassing a local ED without adequate training and a dedicated CPG. Relationships with hospital staff also affected pre-alert decisions.

Different words for stroke: the same concept? an analysis of associated symptoms and intended reaction in Brazil

BACKGROUND

Different names for stroke might mislead physicians and emergency medical service workers. This study aimed to assess the different words for stroke in Brazil and both intended response and related symptoms associated with those names.

METHODS

Cross-sectional study enrolling healthy individuals from urban areas in Northeast of Brazil for an open-ended survey. We presented a typical clinical case of a stroke (an elderly who had sudden onset of hemiparalysis and slurred speech) and asked "what is happening?", "what would you do?" and "which other symptoms could happen in this condition?".

RESUTS

From 1,475 interviewed individuals, 1,220 (82,7%) recognized the scenario as a stroke. There were 3 words to correctly identify (based on correct intended response and spontaneously evoked associated symptoms) the stroke, which were "AVC" (acronym for cerebrovascular accident, in Portuguese), "derrame" (spillage) and "trombose" (thrombosis). There were significant differences among them concerning demographic, economic, educational and geographical aspects, but there was no difference according to the intended reaction among them. The most cited associated symptoms (excluding those present in the case) were impaired consciousness (10.6%), headache (8.9%) and dysesthesia (7.7%). "Aneurisma" (aneurism) was also cited, by 3 individuals.

CONCLUSION

There are at least three words for stroke in Portuguese ("AVC", "derrame" and "trombose"); they were similar in terms of correct intended responses and spontaneously cited accompanying symptoms. Stroke campaigns should apply different names to reach a broader audience and to improve stroke recognition.

Diagnostic Evaluation of Stroke Etiology

OBJECTIVE

Precise therapies require precise diagnoses. This article provides an evidence-based approach to confirming the diagnosis of ischemic stroke, characterizing comorbidities that provide insights into the pathophysiologic mechanisms of stroke, and identifying targets for treatment to optimize the prevention of recurrent stroke.

LATEST DEVELOPMENTS

Identifying the presence of patent foramen ovale, intermittent atrial fibrillation, and unstable plaque is now routinely included in an increasingly nuanced workup in patients with stroke, even as ongoing trials seek to clarify the best approaches for treating these and other comorbidities. Multicenter trials have demonstrated the therapeutic utility of patent foramen ovale closure in select patients younger than age 60 years. Insertable cardiac monitors detect atrial fibrillation lasting more than 30 seconds in about one in ten patients monitored for 12 months following a stroke. MRI of carotid plaque can detect unstable plaque at risk of being a source of cerebral embolism.

ESSENTIAL POINTS

To optimize the prevention of recurrent stroke, it is important to consider pathologies of intracranial and extracranial blood vessels and of cardiac structure and rhythm as well as other inherited or systemic causes of stroke. Some aspects of the stroke workup should be done routinely, while other components will depend on the clinical circumstances and preliminary testing results.

Development and validation of a clinical nomogram for differentiating hemorrhagic and ischemic stroke prehospital

OBJECTIVES

The early detection and identification of stroke are essential to the prognosis of patients with suspected stroke symptoms out-of-hospital. We aimed to develop a risk prediction model based on the FAST score to identify the different types of strokes early for emergency medical services (EMS).

METHODS

This retrospective observational study enrolled 394 stroke patients at a single center from January 2020 to December 2021. Demographic data, clinical characteristics, and stroke risk factors with patients were collected from the EMS record database. Univariate and multivariate logistic regression analysis was used to identify the independent risk predictors. The nomogram was developed based on the independent predictors, in which the discriminative value and calibration of the nomogram were verified by the receiver operator characteristic (ROC) curve and calibration plots.

RESULTS

A total of 31.90% (88/276) of patients were diagnosed with hemorrhagic stroke in the training set, while 36.40% (43/118) in the validation set. The nomogram was developed based on the multivariate analysis, including age, systolic blood pressure, hypertension, vomiting, arm weakness, and slurred speech. The area under the curve (AUC) of the ROC with nomogram was 0.796 (95% CI: 0.740-0.852, P < 0.001) and 0.808 (95% CI:0.728-0.887, P < 0.001) in the training set and validation set, respectively. In addition, the AUC with the nomogram was superior to the FAST score in both two sets. The calibration curve showed a good agreement with the nomogram and the decision curves analysis also demonstrated that the nomogram had a wider range of threshold probabilities than the FAST score in the prediction risk of hemorrhagic stroke.

CONCLUSIONS

This novel noninvasive clinical nomogram shows a good performance in differentiating hemorrhagic and ischemic stroke for EMS staff prehospital. Moreover, all of the variables of nomogram are acquired in clinical practice easily and inexpensively out-of-hospital.

Current diagnosis and treatment practice of central retinal artery occlusion: results from a survey among German stroke units

Background

Central retinal artery occlusion (CRAO) is a neuro-ophthalmological emergency whose optimal management is still under debate and due to the absence of definite guidelines, practice is expected to vary. We aimed to characterize early evaluation as well as acute treatment and diagnostic approaches in German hospitals with a stroke unit (SU).

Methods

In 07/2021, all 335 certified German SUs were invited to participate in an anonymous online survey endorsed by the German Stroke Society on emergency department care organization, diagnostic procedures, and treatment of patients with unilateral vision loss (UVL) subsequently diagnosed with CRAO.

Results

One hundred and sixty-three (48.6%) of the 335 eligible centers responded. Most (117/135; 86.7%) stated that UVL patients were treated as an emergency, in 62/138 (44.9%) hospitals according to specific guidelines. First-line evaluation was performed by neurologists in 85/136 (62.5%) hospitals, by ophthalmologists in 43/136 (31.6%) hospitals. Seventy of 135 (51.9%) respondents indicated a lack of on-site ophthalmological expertise. Seventy-four of 129 (57.4%) respondents performed thrombolysis in CRAO and 92/97 (94.8%) stated that patients with CRAO–if admitted to neurology–were treated on a SU.

Conclusions

Our findings reflect notable heterogeneity in early intrahospital care of CRAO in German SUs but demonstrate a preference for work-up and management as acute stroke by the involved neurologists. Streamlining interdisciplinary emergency evaluation is essential for ongoing and future prospective trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-022-00193-w.

Not so FAST: pre-hospital posterior circulation stroke

Introduction: Posterior circulation strokes account for 20% of ischaemic strokes, but may present differently to their anterior circulation counterparts. Patients may not exhibit unilateral facial weakness, speech disturbances and unilateral limb weakness, but instead present with more vague symptoms of sudden headache, dizziness, loss of balance and visual problems. This case describes a patient displaying signs and symptoms of a posterior stroke, but who eluded the FAST (face, arm, speech, time) test.Case presentation: An ambulance was called for a 60-year-old man who had a sudden onset of generalised weakness, diaphoresis and one episode of emesis at home in rural Ireland. He had a history of hypertension, hypercholesterolaemia, angina and a coronary stent placed 4 months previously. Cardiac, respiratory, abdominal, urinary and gastrointestinal exams were unremarkable. Vital signs and 12-lead electrocardiogram were normal. He was FAST negative on exam. Due to persistent dizziness, further neurological exams were carried out, showing a left visual field neglect, new nystagmus, left-sided dysmetria on finger-to-nose and heel-to-shin tests and he was unable to walk unassisted upon standing. A posterior circulation stroke was suspected, and the nearest stroke unit was pre-alerted en route. A rapid assessment and computed tomography took place at hospital, with timely thrombolysis with tissue plasminogen activator. The patient subsequently had a full neurological recovery.Conclusion: This case describes a patient displaying signs and symptoms of a posterior circulation stroke albeit being FAST negative on exam. There is potential here to improve our recognition of posterior stroke in the pre-hospital field by including additional neurological exams to the FAST test. Use of ‘BEFAST’ (balance, eyes, face, arm, speech, time), the finger-to-nose test, and the ‘5 Ds’ and ‘DANISH’ mnemonics may help increase recognition of these subtle presentations.

Artificial intelligence in Emergency Medical Services dispatching: assessing the potential impact of an automatic speech recognition software on stroke detection taking the Capital Region of Denmark as case in point

BACKGROUND AND PURPOSE

Stroke recognition at the Emergency Medical Services (EMS) impacts the stroke treatment and thus the related health outcome. At the EMS Copenhagen 66.2% of strokes are detected by the Emergency Medical Dispatcher (EMD) and in Denmark approximately 50% of stroke patients arrive at the hospital within the time-to-treatment. An automatic speech recognition software (ASR) can increase the recognition of Out-of-Hospital cardiac arrest (OHCA) at the EMS by 16%. This research aims to analyse the potential impact an ASR could have on stroke recognition at the EMS Copenhagen and the related treatment.

METHODS

Stroke patient data (n = 9049) from the years 2016-2018 were analysed retrospectively, regarding correlations between stroke detection at the EMS and stroke specific, as well as personal characteristics such as stroke type, sex, age, weekday, time of day, year, EMS number contacted, and treatment. The possible increase in stroke detection through an ASR and the effect on stroke treatment was calculated based on the impact of an existing ASR to detect OHCA from CORTI AI.

RESULTS

The Chi-Square test with the respective post-hoc test identified a negative correlation between stroke detection and females, the 1813-Medical Helpline, as well as weekends, and a positive correlation between stroke detection and treatment and thrombolysis. While the association analysis showed a moderate correlation between stroke detection and treatment the correlation to the other treatment options was weak or very weak. A potential increase in stroke detection to 61.19% with an ASR and hence an increase of thrombolysis by 5% in stroke patients calling within time-to-treatment was predicted.

CONCLUSIONS

An ASR can potentially improve stroke recognition by EMDs and subsequent stroke treatment at the EMS Copenhagen. Based on the analysis results improvement of stroke recognition is particularly relevant for females, younger stroke patients, calls received through the 1813-Medical Helpline, and on weekends.

TRIAL REGISTRATION

This study was registered at the Danish Data Protection Agency (PVH-2014-002) and the Danish Patient Safety Authority (R-21013122).

Detection to Hospital Door: Gender Differences of Patients With Acute Stroke Symptoms

Although prehospital stroke management is challenging, it is a crucial part of the acute stroke chain to enable equal access to highly specialised stroke care. It involves a critical understanding of players usually not specialized in acute stroke treatments. There is contradictory information about gender inequity in prehospital stroke detection, dispatch, and delivery to hospital stroke centers. The aim of this narrative review is to summarize the knowledge of gender differences in the first three stages of acute stroke management. Information on the detection of acute stroke symptoms by patients, their relatives, and bystanders is discussed. Women seem to have a better overall knowledge about stroke, although general understanding needs to be improved. However, older age and different social situations of women could be identified as reasons for reduced and delayed help-seeking. Dispatch and delivery lie within the responsibility of the emergency medical service. Differences in clinical presentation with symptoms mainly affecting general conditions could be identified as a crucial challenge leading to gender inequity in these stages. Improvement of stroke education has to be applied to tackle this inequal management. However, specifically designed projects and analyses are needed to understand more details of sex differences in prehospital stroke management, which is a necessary first step for the potential development of substantially improving strategies.

Prehospital recognition of stroke is associated with a lower risk of death

Objective

Among patients assessed by the emergency medical service (EMS) and hospitalized with a final diagnosis of stroke, to describe delays, patient characteristics, actions taken and outcome in relation to the early recognition of stroke by the EMS clinician.

Methods

Patients admitted to any of six stroke units in Region Västra Götaland, Sweden, with a final diagnosis of stroke from 1 January 2013 to 31 December 2015 were included. Data on follow‐up were retrieved from the Swedish Stroke Register.

Results

In all, 5467 patients were included. Stroke was recognized by the EMS clinician in 4396 cases (80.4%). The mean difference in the time from dialling 112 until arrival at the stroke unit was 556 min shorter when stroke was recognized, while the mean difference in the time from dialling 112 until a preliminary report from a computed tomography (CT) scan was 219 min shorter as compared with the patients in whom stroke was not recognized. After adjustment for age, sex, neurological deficits and coma, a lack of suspicion of stroke on EMS arrival was associated with an increased risk of death during three months of follow‐up (odds ratio 1.66; 95% confidence interval 1.19–2.32; p = .003).

Conclusion

Among patients with a stroke, more than 80% were recognized by the EMS clinician. Early recognition of stroke was associated with a markedly shorter time until arrival at the stroke unit and until the preliminary report of a CT scan. A lack of early stroke recognition was associated with an increased risk of death.

[Time is Brain - Preclinical Emergency Care for Acute Ischemic Stroke]

Stroke is one of the most common neurological emergencies and requires rapid detection and treatment (time is brain). There is still insufficient knowledge about stroke warning signs. It is therefore of crucial importance that trained personnel in the preclinical setting recognize the relevant warning symptoms and collect the necessary information to quickly refer the patient to the appropriate additional care structure. For this purpose, training of the emergency medical services (EMS) and the correct triage are of particular importance. The on-site assessment of a patient with a suspected stroke by EMS should include airway, breathing, vital functions, a basic neurological examination, blood glucose testing and cardiac monitoring.Patients with suspected acute ischemic stroke should be brought to the nearest hospital with a stroke unit, ideally connected with a tertiary stroke centre. From there, once the primary diagnosis has been carried out and appropriate therapy initiated, the patient can be transferred to a thrombectomy center if necessary. To improve supply times, teleradiological networking plays a major role both between clinics of different levels of care and in communication between pre- and intra-hospital care providers. Also, the use of mobile stroke units can improve preclinical stroke care and reduce delays in access to intravenous thrombolytic therapy and mechanical thrombectomy. The identification of preclinical biomarkers could also save time.

Pitfalls in the Diagnosis of Posterior Circulation Stroke in the Emergency Setting

Posterior circulation stroke (PCS), caused by infarction within the vertebrobasilar arterial system, is a potentially life-threatening condition and accounts for about 20–25% of all ischemic strokes. Diagnosing PCS can be challenging due to the vast area of brain tissue supplied by the posterior circulation and, as a consequence, the wide range of—frequently non-specific—symptoms. Commonly used prehospital stroke scales and triage systems do not adequately represent signs and symptoms of PCS, which may also escape detection by cerebral imaging. All these factors may contribute to causing delay in recognition and diagnosis of PCS in the emergency context. This narrative review approaches the issue of diagnostic error in PCS from different perspectives, including anatomical and demographic considerations as well as pitfalls and problems associated with various stages of prehospital and emergency department assessment. Strategies and approaches to improve speed and accuracy of recognition and early management of PCS are outlined.