BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005276 on 7 November 2014. Downloaded from FAST Warning Signs in Younger Stroke Patients: Implications for Stroke Education Campaigns ForJournal: peerBMJ Open review only Manuscript ID: bmjopen-2014-005276 Article Type: Research Date Submitted by the Author: 17-Mar-2014 Complete List of Authors: Kaps, M; JustusLiebig Universit�t Giessen Grittner, Ulrike; Department of Biostatistics and Clinical Epidemiology, Charité- University Medicine Berlin, Germany, Tanislav, Christian; Justus Liebig University , Neurology Jungehuelsing, Gerhard; Charit� Berlin, Department of Neurology Tatlisumak, Turgut; Helsinki University Central Hospital, Department of Neurology Kessler, Christof; University Greifswald, Neurology Schmidt, Reinhold; Department of Neurology, University of Graz, Austria, Putaala, Jukka; University of Helsinki, Department of Neurological Sciences; Helsinki University Central Hospital, Department of Neurology Norrving, Bo; Lund University Hospital Rolfs, Arndt; University of Rostock, Department of Neurology <b>Primary Subject http://bmjopen.bmj.com/ Health services research Heading</b>: Cardiovascular medicine, Diagnostics, Epidemiology, Health services Secondary Subject Heading: research, Neurology Stroke < NEUROLOGY, HEALTH SERVICES ADMINISTRATION & Keywords: MANAGEMENT, EPIDEMIOLOGY, MEDICAL EDUCATION & TRAINING, NEUROLOGY on September 25, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005276 on 7 November 2014. Downloaded from 1 2 3 FAST Warning Signs in Younger Stroke Patients: Implications for Stroke Education 4 5 Campaigns 6 7 8 9 Manfred Kaps professor1*, Ulrike Grittner PhD2*, Christian Tanislav MD1*, Gerhard 10 3 4 5 11 Jungehülsing, MD , Turgut Tatlisumak, PhD , Christoph Kessler professor , Reinhold 8 4 7 8 12 Schmidt professor , Putaala Jukka MD , Bo Norrving professor , Arndt Rolfs professor , on TM 13 behalf of the sifap1 Investigators 14 15 *equal contributionFor peer review only 16 17 1Department of Neurology, Justus Liebig University, Giessen, Germany 18 2Department of Biostatistics and Clinical Epidemiology, Charité- University Medicine Berlin, 19 Germany 20 3 21 Department of Neurology, Charité, Berlin, Germany 4 22 Department of Neurology, University, Helsinki, Finland 5 23 Department of Neurology, Moritz Arndt University Greifswald, Germany 24 6Department of Neurology, University of Graz, Austria 25 7Department of Neurology, Lund, Sweden 26 8Albrecht-Kossel Institute for Neuroregeneration, University of Rostock, Rostock, Germany 27 28 29 30 31 32 33 34 http://bmjopen.bmj.com/ 35 36 37 Corresponding author: 38 Christian Tanislav, MD 39 40 Department of Neurology 41 Justus Liebig University, Giessen, Germany 42 Klinikstr. 33 on September 25, 2021 by guest. Protected copyright. 43 35385 Giessen 44 Germany 45 Tel.: +49/641 98545301; Fax: +49/641 98545409 46 E-mail: [email protected]; 47 48 49 50 51 Key words: young stroke, awareness signs, FAST, clinical presentation. 52 Word count (manuscript): 2882 53 References: 14 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 25 BMJ Open: first published as 10.1136/bmjopen-2014-005276 on 7 November 2014. Downloaded from 1 2 3 Abstract 4 5 6 7 Background Clinical recognition instruments are important in a complex chain towards 8 timely treatment management in acute stroke. The present study aimed to evaluate the 9 10 frequency of individual warning signs reflected by the ‘FAST’ public stroke recognition 11 12 instrument (face, arm, speech, act timely) in younger stroke patients. 13 14 15 Methods InFor a multinational peer prospective review cross sectional study only (Stroke in Young Fabry 16 17 Patients; sifap1) including stroke patients aged below 56 the frequency of presenting 18 symptoms was analysed. The performance of the FAST scheme was investigated. 19 20 21 22 Results 5023 patients were enrolled in the study between 2007 and 2010. Information of 4535 23 patients with TIA (n=1071), ischemic stroke (n=3396) or other (n=68) were selected for this 24 25 analysis. FAST symptoms could be traced in 76.5% of all cases. 35% of those with at least 26 27 one FAST symptom had all three symptoms. The FAST instrument performed better in older 28 age groups: At least one FAST symptom could be recognised in 69.1% of 18-24 years old 29 30 patients, in 74.0% of those aged 25-34 years, in 75.4% of those aged 35-44 years, and77.8% 31 32 in 45-55 years old patients. Patients severely disabled (NIHSS<5: 69.0%, NIHSS 6-15: 33 98.9%, NIHSS>15: 100.0%) FAST signs were less sensitive for indicating cerebrovascular 34 http://bmjopen.bmj.com/ 35 events as well as in the posterior circulation (65.2%) and in patients with transient ischemic 36 37 attacks (62.3%). 38 39 40 Conclusions Nearly one-quarter of young stroke patients is not targeted by the FAST scheme; 41 the performance is higher in patients with worse stroke severity addressing almost all these 42 on September 25, 2021 by guest. Protected copyright. 43 individuals. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005276 on 7 November 2014. Downloaded from 1 2 3 Article Summary 4 5 6 Warning signs of stroke are probably the most important step in the complex chain towards 7 timely treatment management. For this purpose different stroke recognition instruments with 8 9 different symptoms and different wording have been developed, offering criteria to identify 10 11 stroke for public education. Currently many distinguished awareness campaigns to propagate 12 the signs of stroke use the simplified FAST message, which adopts weakness of face, arm as 13 14 well as speech and essentially time. In the present study we aimed to ascertain the 15 For peer review only 16 performance of FAST criteria in the sifap1 cohort, a unique prospectively collected 17 population of young (18-55 years) stroke victims. 18 19 The main finding indicates nearly one quarter of young strokes is not targeted by the FAST 20 21 scheme. However FAST fits very well to capture patients with acute stroke eligible for 22 thrombolysis due to the increasing performance in worse disability. It performs far less 23 24 sensitive for the large number of cases not eligible for thrombolysis but for secondary 25 26 prevention, for young stroke and for the posterior circulation. However, the main purpose of 27 sifap1 was not to validate a stroke recognition instrument. This might by the main limitation 28 29 of the present investigation. The “FAST wording” was primarily not covered with a specific 30 31 slot in the case report form. FAST items were derived from different sources after the 32 cerebrovascular event (e.g. after employing the NIH Stroke Scale immediately after hospital 33 34 admission (median delay: one day)). http://bmjopen.bmj.com/ 35 36 In conclusion we confirm FAST as a useful tool in the recognition of strokes in this specific 37 group of young strokes. Because risk factors and aetiology profiles in the sifap1 cohort 38 39 resembled those found in elderly stroke patients, conclusions from our study may be also 40 41 valid in older age groups. 42 on September 25, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 25 BMJ Open: first published as 10.1136/bmjopen-2014-005276 on 7 November 2014. Downloaded from 1 2 3 Introduction 4 5 6 Getting stroke patients to the acute care hospital on time is the major requirement for effective 7 8 stroke therapy. Knowing warning signs of stroke is the first and most important step in a 9 10 complex chain towards timely treatment management. Effective public education follows 11 simple rules: the message must be simple to remember, effective and consistent. For this 12 13 purpose different stroke recognition instruments with different symptoms and different wording 14 15 have been developedFor [1-6], peer offering criteria review to identify stroke only for public education [1-3;7;8]. 16 Currently many distinguished awareness campaigns to propagate the signs of stroke use the 17 18 simplified FAST message [9], which adopts weakness of face, arm as well as speech and 19 20 essentially time (National Health Service: “When stroke strikes act FAST”). Although the 21 mnemonic FAST is most frequently adopted, there are so far no prospective multicentre studies 22 23 from large cohorts, which evaluate distinct stroke signs for the use in public campaigns. 24 25 26 The aim of the present study is to ascertain the performance of FAST signs in a large cohort of 27 28 younger stroke patients the Stroke in Young Fabry Patients study (sifap1) [10] and to analyse 29 30 factors which influence the affectivity in identifying CVEs. This is a secondary analysis of the 31 sifap1 data which was originally supposed to investigating the relation of juvenile stroke and a 32 33 genetic disorder known as Fabry disease. Fabry disease was diagnosed in 0.9% of all patients 34 http://bmjopen.bmj.com/ 35 (n=45) [11]. 36 37 38 Methods 39 40 41 The protocol of the sifap1 study was published recently [10]. Described briefly, the sifap1 42 on September 25, 2021 by guest. Protected copyright. 43 study was designed as a multicenter multinational prospective observational study of young 44 45 stroke patients across Europe (Table 1). A total of 5023 stroke patients below 56 years were 46 enrolled in the sifap1 study, 271 patients with primary haemorrhages and 217 patients without 47 48 classification of the cerebrovascular event (CVE) were excluded.