July/August 2017

Clinical News: BE-FAST Improves Stroke Detection
By Sushanth Aroor, MBBS; Rajpreet Singh, MD; and Larry B. Goldstein, MD
Today's Geriatric Medicine
Vol. 10 No. 4 P. 5

According to the American Heart Association, nearly 800,000 Americans suffer from stroke annually, and more than 130,000 die as a result, making stroke the fifth leading cause of death in the United States.1

About 87% of all strokes are ischemic strokes,1 which occur when blood flow to the brain is blocked. Individuals who have this type of stroke may be candidates for treatment with tissue-type plasminogen activator—a clot-busting drug—and/or endovascular clot retrieval, in which physicians insert a tube into a brain blood vessel to extract the clot. The benefit of these interventions decreases as the time between symptom onset and treatment increases.2,3

The bottom line is that speedy diagnosis and access to treatment is essential for improving the chances that these types of treatments will help. However, less than one-third of those with known time of onset arrive at a hospital within one hour.4

Recognizing that public knowledge of stroke symptoms is generally poor, organizations such as the American Heart Association have undertaken widespread community awareness campaigns promoting the acronym FAST [face, arm, speech, and time] to help people recognize the symptoms of stroke and facilitate rapid access to medical care.

Time, the final component of the FAST acronym, serves as a reminder to seek treatment immediately because strokes can be debilitating or even deadly. FAST can be helpful in identifying ischemic stroke events, having an 88% sensitivity for carotid artery distribution strokes,5 but missing up to 40% of those with posterior circulation event.6

Could a different catchphrase reduce the proportion of missed strokes? One alternative was "Give Me 5 for Stroke" (Walk: Is balance off? Talk: Is speech slurred or face droopy? Reach: Is one side weak or numb? See: Is vision all or partly lost? Feel: Is there a severe headache?) "Give Me 5" can identify more strokes than FAST (99.9% vs 88.9%) but is more difficult for the lay public to remember.7 Other educational programs have used the mnemonic BE-FAST, adding a B for balance and an E for eyes, but supportive data were limited.

Study Explores More Effective Alternatives to FAST
The authors undertook a retrospective study at the University of Kentucky that sought to determine the current proportion of acute ischemic stroke patients with symptoms not captured by FAST and whether the addition of gait-related or visual symptoms would improve detection rates.6

The study reviewed the records of all patients (n=858) admitted to the University of Kentucky Stroke Center between January and December 2014 with a discharge diagnosis of acute ischemic stroke. The study excluded 122 records that were misclassified, had missing NIH Stroke Scale data, or were for patients who were comatose or intubated.

Presenting symptoms, demographics, and examination findings based on the National Institutes of Health Stroke Scale (NIHSS) were abstracted from the remaining 736 records and analyzed to determine the proportion of patients missed based on FAST compared with the proportion missed after the inclusion of gait-related (gait imbalance or lower extremity weakness) or visual (visual loss and diplopia) symptoms. Additionally, the vascular distributions of strokes missed on FAST were determined by reviewing MRI brain reports.

BE-FAST is Better Than FAST Alone
Results of the study, published in Stroke in January 2017, indicate that 14.1% of patients did not have FAST symptoms at presentation. Of those patients who were FAST-negative, the most common presenting symptoms were gait imbalance (33%), leg weakness (10%), visual impairment (visual loss, diplopia, or blurring, 40%), headache (16%), and dizziness (8%). Seventy percent of these patients had symptoms of either a gait abnormality/leg weakness or a visual impairment, either alone (29%) or in combination with other non-FAST symptoms.

The 14.1% of stroke patients who would not have been identified by FAST alone was reduced to 4.4% with the addition of balance and visual symptoms (BE-FAST).

Patients without FAST symptoms tended to be younger and have less severe neurological impairments based on the NIHSS score compared with patients who had at least one FAST symptom.

FAST May Overlook Posterior Circulation Strokes
Based on a review of MRI records, 71% of strokes missed by FAST involved the vertebrobasilar territory, with 64% restricted to this distribution. If BE-FAST were applied to these cases, the proportion missed was reduced to 43%.

Challenges
While the results are tantalizing, the data are retrospective and come from one tertiary care center. The findings need to be validated, but many stroke centers had already been using BE-FAST, even before the new study was available.

Assuming these results are confirmed, focusing on BE-FAST instead of FAST could ultimately change how bystanders, first responders, and hospitals identify potential stroke victims, reduce the number of missed strokes, and speed access to treatments that could reduce or eliminate disability.

— Sushanth Aroor, MBBS, is a resident physician in neurology at the University of Kentucky Medical Center in Lexington.

— Rajpreet Singh, MD, is a visiting physician.

— Larry B. Goldstein, MD, is the Ruth L. Works professor, chairman of the University of Kentucky department of neurology, and codirector of the Kentucky Neuroscience Institute.

References
1. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics — 2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146-e603.

2. Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. 2014;384(9958):1929-1935.

3. Saver JL, Goyal M, van der Lugt A, et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA. 2016;316(12):1279-1288.

4. Saver JL, Smith EE, Fonarow GC, et al. The "golden hour" and acute brain ischemia: presenting features and lytic therapy in >30,000 patients arriving within 60 minutes of stroke onset. Stroke. 2010;41(7):1431-1439.

5. Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med. 1999;33(4):373-378.

6. Aroor S, Singh R, Goldstein LB. BE-FAST (balance, eyes, face, arm, speech, time): reducing the proportion of strokes missed using the FAST mnemonic. Stroke. 2017;48(2):479-481.

7. Kleindorfer DO, Miller R, Moomaw CJ, et al. Designing a message for public education regarding stroke: does FAST capture enough stroke? Stroke. 2007;38(10):2864-2868.