2. Stroke Awareness, Recognition and Response

Although stroke is a medical emergency, many individuals do not recognize it as such, or they attribute the signs and symptoms to a less serious health issue and delay seeking medical attention. Prompt recognition of stroke symptoms is critical for timely activation of emergency medical services and access to time-sensitive treatments such as thrombolysis or thrombectomy. Public awareness campaigns, such as those promoting the FAST (Face, Arm, Speech, Time) acronym, have been shown to improve knowledge and increase the likelihood of rapid response. On average, two million neurons die with every minute that elapses following symptom onset, leading to permanent damage to the brain. ⁵⁵ Delays in recognizing stroke symptoms are associated with worse functional outcomes and increased mortality, underscoring the need for sustained public education efforts. Individuals who experience a TIA are also considered a medical emergency and require rapid assessment and treatment. These recommendations apply across all geographic regions in Canada, and education should be available uniformly, with targeted approaches for diverse populations, including cultural and language considerations, and regardless of local issues related to time to access care.

Individuals with lived experience of stroke emphasize the importance of recognizing stroke signs, symptoms and risk factors both for community members and for healthcare providers. They believe the FAST signs are critically important to know as well as the importance of knowing other potential signs and symptoms. They stress the importance of ongoing research, particularly for women and for different age groups.  Ongoing targeted education about stroke signs and symptoms is critical to support access to appropriate care and should be available in culturally appropriate contexts. Emphasis is placed on the need to destigmatize stroke and acknowledge that stroke can happen at any age.

To ensure individuals experiencing a stroke receive timely stroke assessments, interventions and management, interdisciplinary teams need to have the infrastructure and resources required. These may include the following components established at a systems level.

1. Government funding and support for awareness initiatives to improve the recognition and recall of the signs of stroke (e.g., FAST, which is a global best practice) and the importance of contacting 9-1-1 immediately. Awareness and education campaigns should prioritize reaching communities who are less aware of the signs of stroke and most at risk of stroke and should be informed collaboratively through community engagement activities with those audiences.
2. Enhanced collaboration among community organizations and healthcare professionals to ensure consistency in public education of the signs of stroke with a strong emphasis on the urgency of responding when the signs of stroke are recognized.
3. Equity focused awareness campaigns and stroke education that is culturally appropriate to the target populations.
4. Training and education for EMS, emergency department and all in-hospital staff, medical and nursing students, physicians in primary and acute care as well as specialists, nurses, and allied health professionals to increase their ability to recognize potential individual with stroke to support rapid assessment and management.
5. Comprehensive systems in place to ensure all individuals in Canada have access to timely and appropriate emergency medical services, including ambulatory services (e.g., outpatient services, emergency department, community health centres, nursing stations) without financial burden, and quality stroke care regardless of geographic location.
6. Enhanced monitoring and awareness of stroke among all individuals in Canada. Healthcare systems and provincial/territorial and federal governments should generate linked health and social surveillance population-based and regional data and use it to drive quality improvement through better understanding of the health and social issues facing individuals in Canada.

System indicators

1. Proportion of individuals with suspected stroke or TIA transported to hospital by paramedics. 
2. Proportion of EMS services that use a two-stage screening for stroke that includes both FAST signs of stroke and screening for possible large vessel occlusion.

Process indicators

1. Proportion of individuals with stroke who contact any member of the healthcare system within 4.5, 6, and 24 hours of stroke symptom onset.
2. Median (and interquartile range) time lapse between stroke symptom onset and first contact with EMS, defined as time call placed to 9-1-1 or local emergency medical system dispatch.
3. Proportion of individuals with stroke who arrive to hospital by ambulance following onset of stroke symptoms.
4. Median time (hours) from stroke symptom onset to arrival at an emergency department for all suspected individual with stroke presenting to hospital.
5. Median time (hours) from arrival at an emergency department for all suspected individual with stroke to administration of intravenous thrombolysis (door-to-needle time).
6. Median time (hours) from arrival at an emergency department for all suspected individual with stroke to arterial access for endovascular thrombectomy (door-to-puncture time). Median time from arrival in one emergency department to transfer to a higher-level stroke hospital for endovascular thrombectomy (Door in – Door out time).

Patient-oriented outcome and experience indicators

1. Proportion of the population (and specific population subgroups) aware of the signs of stroke (as presented in FAST/VITE).

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Healthcare Provider Information

• Heart & Stroke: Signs of Stroke
• Heart & Stroke: FAST Signs of Stroke…what are the other signs?
• World Stroke Organization
• Stroke Engine

Resources for Individuals with Stroke, Families and Caregivers 

• Heart & Stroke: Acute Stroke Management infographic
• Heart & Stroke: Secondary Prevention of Stroke infographic
• Heart & Stroke: Signs of Stroke
• Heart & Stroke: FAST Signs of Stroke…what are the other signs?
• Heart & Stroke: What is Stroke?
• Heart & Stroke: Transient Ischemic Attack
• Heart & Stroke: Your Stroke Journey
• Stroke Engine

Evidence Table and Reference List 2

Failure to recognize the signs of an acute stroke, either by the persons witnessing one, or the person experiencing one can delay the time to contact emergency services, which may in turn decrease a patient’s opportunity to receive time-sensitive treatments. The results from many cross-sectional surveys indicate that, among members of the general public, knowledge of the signs and symptoms associated with stroke remains disappointingly low. Lundelin et al. ⁵⁶ conducted telephone surveys of 11,827 adults living in Spain who had participated in the Study on Nutrition & Cardiovascular Risk in Spain to assess their ability to identify stroke symptoms, including sudden confusion or trouble speaking, numbness of face, arm or leg, sudden trouble seeing in one or both eyes, sudden chest pain (decoy), sudden trouble walking, dizziness or loss of balance or severe headache. 65.2% of the participants could correctly identify 4-6 symptoms of stroke, although only 19% could identify all 6 symptoms correctly and 11.4% were unable to identify a single symptom. 81.1% of participants indicated that they would call an ambulance if they suspected someone was having a stroke. Persons who could identify more stroke symptoms were more likely to call for an ambulance. Mochari-Greenberger et al. ⁵⁷ surveyed 1,205 women aged ≥25 years living in the United States, who had participated in the American Heart Association National Women’s Tracking Survey. Participants were contacted by telephone and asked standardized questions related to stroke warning signs and actions to take in the event of stroke. Sudden weakness and/or numbness of the face or limb of one side was the most commonly cited symptom (51%). Loss of/trouble with understanding speech was also frequently recognized as a symptom among 44% of respondents, while headache, unexplained dizziness and loss of vision in one eye were recognized by fewer women (23%, 20% and 18%, respectively). One in 5 women could not name a stroke warning sign. In a survey of 790 respondents who were friends and family members of patients at a Canadian vascular outpatient clinic waiting room, who were sampled on two occasions 5 years apart, over 80% of participants were able to identify ≥1 stroke risk factor. ⁵⁸ Trouble speaking and weakness, numbness or paralysis were the signs identified most frequently. The results of surveys conducted by random sampling of members of the general community in Saudi Arabia ⁵⁹ and New Zealand ⁶⁰ also indicate that most people were familiar with at least one stroke risk factor and almost 80% recognized slurred speech and weakness as stroke symptoms. In Thailand, 133 of 281 survey participants (47%) had good knowledge of stroke awareness and were able to identify 3-5 signs of stroke based on the BE FAST mnemonic; however, only 65% of participants responded “immediately” when questioned how fast they should come to the ER if they suspected an acute stroke. ⁶¹

The number of public health campaigns designed to increase the recognition of the signs and symptoms of stroke has increased over the past decade. One of the most recognized programs is FAST. The results of several studies indicate that persons exposed to these campaigns become more aware of the signs and symptoms of stroke. Response to the FAST campaign (television + public transit displays), which ran from 2009 intermittently though 2014 in the UK ⁶² was associated with significantly increased use of EMS services for major stroke (58.8% before April 1, 2009, vs. 78.9% after April 1, 2009) and first medical attention was sought more quickly (within 3 hours) after April 1, 2009 (67.6% vs. 81.3%; OR=2.08; 95% CI, 1.40-3.11). The effect of a 27-month long public awareness campaign, designed to increase knowledge of the Swedish translation of FAST was less successful. ⁶³ From pre-campaign (survey 1) to end of the campaign (survey 8), the number of persons who had heard of FAST increased from 15%-50%. The percentage of respondents who could recall all keywords in the mnemonic increased from 0.3% to only 2%, while those who could recall some/all keywords in the mnemonic had increased from 4% to 14%. 

Bray et al. ⁶⁴ surveyed 12,439 individuals ≥40 years of age from the general population in Australia and reported that from 2004 to 2010, there had been a significant increase in the number of respondents who were aware of the national multimedia stroke awareness campaigns (31% vs 50%), which included FAST and in the number or participants able to name ≥1 (69% vs 81%), ≥2 (43% vs 63%), and ≥3 (19% vs 32%) warning signs of stroke. Respondents who could identify ≥2 warning signs were significantly more likely to be aware of the campaign (odds ratio [OR]= 1.88, 95% CI 1.74 to 2.04). Bray et al. ⁶⁵ reported increases in the monthly volumes of ambulance dispatches for stroke associated with 12 National Stroke Foundation multimedia regional public awareness campaigns (2004-2014).  The increases ranged from 1.0 to 9.9%. In one year (2006) there was a decrease of 2.2% in call volumes. 

Trobbiani et al. ⁶⁶ compared public stroke awareness campaigns in Australia (FAST), England (Act FAST), and Canada (Heart and Stroke Foundation's campaign) to evaluate their structure, delivery, and messaging. Using a qualitative review of campaign materials and implementation strategies, the study assessed the consistency and emphasis of stroke warning signs and emergency response messages. The authors found that while all three campaigns used similar core messages based on the FAST acronym, their delivery varied in intensity, duration, and use of mass media. Sixty-eight per cent of people in Australia and 57% in Canada could name two or more signs of stroke. After the campaign, knowledge of each of the FACE elements was significantly greater in England than in Australia. A high proportion of participants reported that they would call emergency services in the event of a stroke (97% in England, 90% in Australia, and 67% in Canada). In Quebec, among 2,451 unique respondents, after four waves of public health campaigns, there was a 26% improvement in FAST stroke sign knowledge, although 30.5% of participants were still unable to name a single FAST sign. Lower socioeconomic status (education and income) was associated with poorer performance as was male sex. ⁶⁷

Hickey et al. ⁶⁸ evaluated the impact of Ireland’s FAST public health campaign on population awareness of stroke warning signs, risk factors, and emergency response behavior. Using data from national cross-sectional telephone surveys conducted before and after the campaign, the authors compared responses from over 2,000 adults. There was a significant increase in recognition of stroke warning signs (particularly facial weakness and speech problems) and appropriate action (calling emergency services) following the campaign; however, the ability to identify 2 or more stroke risk factors did not improve.

Of 174 participants in the United States who were randomized to an educational session on either FAST or BE FAST, a significantly higher percentage of participants recalled all items in the FAST group (75% vs. 30.2% at 3-5 minutes; 70.5% vs. 41.9% 60 minutes and 51.1% vs. 24.4% at 30 days). ⁶⁹

A systematic review & meta-analysis including the results from 13 studies including 113,592 adults recruited from the general population. The effects of stroke education using mass media campaigns on stroke symptom recognition and intention to call emergency medical services, were evaluated. Pooling the results from 5 studies, mass media campaigns increased the likelihood of symptom recognition compared with pre-campaign by 20%. Mass media campaigns also increased the likelihood that people would call EMS, by 19%. ⁷⁰

Mass media campaigns have also been shown to be associated with increases in the use of thrombolytic agents following acute stroke. Advani et al. ⁷¹ reported the average number of patients treated with alteplase increased significantly from 7.3 to 11.3 patients per month (an increase of 54.7%, p=0.02) during the period from the 12 months preceding the mass media intervention, featuring the FAST mnemonic, to the 6 months afterwards. The average number of patients treated in the ER increased significantly from 37.3 to 72.8 patients per month (an increase of 95.7%, p<0.001) during the same period. Although the mean number of patients treated with t-PA dropped to 9.5 per month after the first 6 months of the campaign, it was still significantly higher than the preceding 12 months. In a telephone survey including 1,400 participants, the number of people who could name any stroke symptom increased from 66% to 75%. Of those who could name a symptom, 52% recognized facial droop, 42% named speech difficulties and 42% named arm weakness.

Sex & Gender Considerations

Women have been reported to have better knowledge of stroke symptoms and stroke risk factors and learn more from public stroke awareness campaigns. ⁷² Marx et al. ⁷³ reported that prior to a mass media campaign designed to improve stroke recognition and response, significantly more women than men could correctly answer the question “where does stroke happen in the body?” and knew the stroke emergency call number to call. Following the intervention, while the number of men and women who could answer the two questions correctly increased, although the percentage change from pre to post intervention was higher for women. There were increases in the mean number of stroke warning signs that could be named before and after the intervention (women: 5.4 to 6.2; men: 5.1 to 5.9). Following a public health campaign conducted in Ontario, significantly more women could identify ≥2 stroke warning signs.⁷⁴