Symptom Recognition and Reaction

When it comes to stroke, time is brain!

Stroke is a medical emergency. Most people do not recognize the five main symptoms of stroke and therefore do not seek immediate medical attention. It is critical that people with ischemic strokes (caused by a blocked artery) arrive in the emergency department as soon as possible, and within at least 3.5 hours of symptom onset, if they are to be eligible to receive clot-busting treatment. In the case of strokes caused by hemorrhage or leaking arteries in the brain, earlier assessment and treatment may allow time for life-saving intervention.

Efforts to enhance emergency medical system response to stroke calls and to encourage the public to recognize stroke signs and symptoms and contact emergency medical services result in timelier treatment and better outcomes.

• Public awareness initiatives focusing on the signs and symptoms of stroke, the sudden nature of the onset of signs and symptoms, awareness that not all signs or symptoms need to be present or that they may start to fade.
• Enhanced collaboration among community organizations on public education of the warning signs of stroke with a strong emphasis on the urgency of responding when the signs and symptoms of stroke are recognized.
• Training and education for emergency medical services, physicians, and nurses to increase ability to recognize potential stroke patients and provide rapid assessment and management.
• Heightened emergency response with appropriate protocols.

1. Proportion of the population aware of two or more signs of stroke (core).
2. Median time (hours) from stroke symptom onset to presentation at an emergency department.
3. Proportion of the population that can name the three main stroke symptoms — sudden weakness, trouble speaking, vision problems.
4. Proportion of patients who seek medical attention within 3.5, 4, and 4.5 hours of stroke symptom onset (core).
5. Proportion of emergency medical service providers trained in stroke recognition and the use of stroke triage algorithms for prioritizing stroke cases for transport within regions.
6. Proportion of the population with a family member who has had a stroke or transient ischemic attack that can name two or more signs and stroke symptoms.

Measurement Notes

• Performance measures 1 and 2: Data may be obtained from Heart and Stroke Foundation public polls.
• Performance measure 3: Data may be obtained from chart audit data.
• Performance measure 4: The unit of analysis may vary depending on the emergency health services management model used in the province or territory.
• Performance measures 3 and 4: Stroke symptom onset may be known if the patient was awake and conscious at the time of onset, or it may be unknown if symptoms were present on awakening. It is important to record whether the time of onset was estimated or exact. The time qualifies as exact provided that (1) the patient is competent and definitely noted the time of symptom onset or (2) the onset was observed by another person who took note of the time.
• Performance measure 5: Data sources include emergency department triage sheet or admission note, history and physical examination, consultant notes, emergency medical services ambulance records.

Warning Signs and Symptoms of Stroke: www.heartandstroke.ca/StrokeSigns⁵⁵

Successful care of the acute stroke victim begins with the public and the health professionals recognizing that stroke is a medical and sometimes a surgical emergency, like acute myocardial infarction and trauma.²⁹ Stroke interventions such as acute thrombolysis are time sensitive, with the current treatment window being within 4.5 hours after symptom onset.⁵⁶ The majority of stroke patients do not receive adequate therapy because they do not reach the hospital soon enough, ^56,57 thus losing an opportunity to potentially reduce the impact of the stroke.^58-64

Treating stroke as an emergency involves a four-step response chain: ⁵⁵

1. Rapid recognition of and reaction to stroke warning signs
2. Immediate contact with emergency medical system services
3. Priority transport with prenotification to the receiving hospital
4. Rapid and accurate diagnosis and treatment at the hospital

A retrospective study by Hodgson and colleagues⁶⁵ examined the effects of television advertising on public knowledge of warning signs of stroke. As a result of the public awareness campaign, public awareness increased, as evidenced by the consistent increase in the percentage of respondents who could name at least two warning signs of stroke, from 52 percent in 2003 to 72 percent in 2005 (p < 0.001). Emergency department records for over 20,000 stroke patients were examined, and during active advertising of the warning signs, a significant increase in the mean number of emergency department presentations for stroke was reported. This effect was not sustained after the campaign, and the rate of emergency department presentations decreased following a five-month advertising blackout. The study also reported a campaign effect (independent of year) for total presentations, presentation within five hours of when the patient was last seen symptom-free, and presentation within 2.5 hours. For transient ischemic attacks, the campaign effect was strong despite no change in presentation numbers. The authors concluded that although many factors may influence the presentation for stroke, there might be an important correlation between the advertising and emergency department presentations, particularly for transient ischemic attacks.

The Heart and Stroke Foundation of Canada commissioned Environics Research Group to conduct two public opinion polls to examine the impact of a national media campaign on the knowledge of stroke warning signs among Canadians.⁶⁶ In May 2009, prior to the campaign, approximately 2,700 Canadians from across the country were polled to establish a baseline level of awareness. The campaign objectives were to expand the stroke awareness warning signs message to a national level, to sustain stroke awareness support in Ontario and Alberta, and to launch stroke awareness in all other provinces. The post-campaign study then polled approximately 2,700 Canadians in November and December 2009. These studies found that Canadians’ ability to correctly identify warning signs had improved for each of the five warning signs. There was also an increase in the number of Canadians who could identify at least two (50% to 57%) and at least three (26% to 32%) of the stroke warning signs at follow up. The number of Canadians unable to identify any warning signs decreased in the post-campaign poll (28% to 22%). ⁶⁶

A similar evaluation of a stroke media campaign by the New York State Department used the FAST (F - Face drooping, A - Arm weakness, S - Speech slurred, and T - Time to call 9-1-1) mnemonic to develop a multimedia campaign that included print, television, and radio.⁶⁷ The study compared pre- and post-stroke knowledge in a region exposed to the media campaign with a control region. A random-digit telephone survey was conducted before and after the campaign in both regions, and found increased recognition of the four FAST signs in the intervention region compared to the control region (60 percent compared to 20 percent). Retention of the information following the campaign was not measured. Stroke awareness was impacted by demographic, socioeconomic, and regional factors at both baseline and follow up. Specifically, younger, less educated, low-income, and non-English speaking Canadians demonstrated lower awareness of stroke warning signs.

Kleindorfer examined the effectiveness of the FAST mnemonic (Face, Arm, Speech, Time) for identifying stroke and transient ischemic attack.⁶⁵The FAST mnemonic identified 88.9 percent of cases of stroke or transient ischemic attack, and was more effective for ischemic stroke than for hemorrhagic stroke.⁶⁹

A large study in Ireland focused on assessing stroke knowledge in persons over the age of 65 years who were considered more vulnerable to stroke.⁷⁰ Interviews were conducted with 2,033 people (68 percent response rate). Interview questions assessed knowledge of stroke warning signs and risk factors, and personal risk factors for stroke. Less than half of the overall sample identified established risk factors (e.g., smoking, hypercholesterolemia), with the exception of hypertension (identified by 74 percent). Less than half of the respondents were able to identify some or all of the warning signs (e.g., weakness, headache), with slurred speech (54 percent) as the exception. Overall, there were considerable gaps in awareness of stroke warning signs with poorest levels evident in those with primary level education only. Some geographic differences were also found. This study emphasizes the need to target high-risk populations with specific educational initiatives as many older adults may not recognize early symptoms of stroke in themselves or others and they may lose vital time in presenting for medical attention.

Mosley and associates examined pre-hospital delays after stroke symptom onset in an attempt to determine patient factors associated with stroke recognition, as well as factors associated with calling for ambulance assistance within one hour of symptom onset.⁷¹ Of 198 patients included in the study, more than half of the calls were made within one hour of symptom onset, and only 43 percent identified the problem as “stroke.” Unprompted stroke recognition was independently associated with facial droop and history of stroke or transient ischemic attacks. Those factors independently associated with a call for ambulance assistance within one hour of onset included speech problems, caller’s family history of stroke, and the patient not being alone at time of symptom onset.

The American Heart Association’s Council on Cardiovascular Nursing and Stroke Council issued a scientific statement providing context for system application of what is known about why people delay seeking treatment for stroke and acute coronary syndrome.⁷² This statement pushed for changes in mass public education campaigns, noting that messages showing the benefits of not delaying treatment are more effective than the fear-based messages commonly used by providers.

Although stroke is not typically thought of as a health emergency for children, it does occur in newborns, young children, and adolescents. Cerebrovascular diseases are among the top 10 causes of death in children.⁷³ Of crucial concern for paediatric stroke patients is the burden of illness caused by developmental and motor impairments that may last throughout their lifetime.⁷⁴ Neurologic deficits in this population have been indicated in over 60 percent of older infants and children following a stroke event, and the risk of recurrence is between 10 percent and 25 percent.⁷⁵ Recognition of stroke may be difficult, especially in infants and younger children.⁴¹