Nirali Vora, MD

Fothergill RT, Williams J, Edwards MJ, Russell IT, and Gompertz P. Does Use of the Recognition Of Stroke In the Emergency Room StrokeAssessment Tool Enhance Stroke Recognition by Ambulance Clinicians? Stroke. 2013

The burden to accurately predict stroke increasingly falls upon the paramedics who first respond and decide if a patient needs to be re-routed to a specialty (certified) stroke center. The traditional and widely used FAST score is easy, with its acronym prompts — deficit in Face, Arm, or Speech? However, FAST was criticized for missing 38% of posterior fossa strokes.

ROSIER score > or = 1 suggests stroke/TIA
The developers of FAST came out with the ROSIER score, which adds to FAST questions about vision and leg weakness and takes off points if there is seizure or syncope at presentation. In a prior study, ROSIER outperformed FAST in the emergency department in picking up more strokes and reducing non-stroke referrals to specialists. The current study, however, found that the ROSIER score was no better than FAST in the pre-hospital setting in the UK.

This was probably because no patients had isolated vision or leg disturbance. In our institution, we have adopted “BE-FAST” to include questions about Balance and Eyes (vision) to identify more posterior fossa strokes. This has not yet been validated in 
 the pre-hospital or emergency setting.

What do you, the ER, or your paramedics use to recognize stroke/TIA? In this study, a regression analysis identified the best predictors of stroke as face or arm weakness, or (absence of) seizure activity. Maybe the FAST + a question about seizure activity would improve sensitivity of stroke identification.