Janet Bray

Paramedic Identification of Stroke: Community Validation of the Melbourne Ambulance Stroke Screen

Background: Paramedics require an effective prehospital tool to eliminate stroke mimics and to assist in the identification of suitable candidates for thrombolytic therapy. The Faster Access to Stroke Therapies study combined two validated stroke assessment tools (the Los Angeles Prehospital Stroke Screen, LAPSS, and the Cincinnati Prehospital Stroke Scale, CPSS) to form the Melbourne Ambulance Stroke Screen (MASS), and performed an in-field validation by Australian paramedics. Methods: Over a 12-month period, 18 paramedics participated in the Faster Access to Stroke Therapies study and prospectively collected data contained in the MASS on all stroke dispatches, and for other patients with a focal neurological deficit. Sensitivity and specificity analysis of the LAPSS, CPSS and MASS was calculated and equivalence analysis performed. Results: Paramedics completed 100 MASS assessments for 73 (73%) stroke/transient ischemic attack patients and 27 (27%) stroke mimics. The sensitivity of the MASS (90%, 95% CI: 81–96%) showed statistical equivalence to the sensitivity of the CPSS (95%, p = 0.45) and superiority to the LAPSS (78%, p = 0.008). The specificity of the MASS (74%, 95% CI: 53–88%) was equivalent to that of the LAPSS (85%, p = 0.25) and superior to the CPSS (54%, p = 0.007). All patients misidentified by the MASS (7 strokes, 7 mimics) were ineligible for thrombolytic therapy. Conclusion: The MASS is simple to use, with accurate prehospital identification of stroke. It distinguishes stroke mimics, with good recognition of suitable patients for thrombolytic therapy.

Can the ABCD Score be dichotomised to identify high-risk patients with transient ischaemic attack in the emergency department?

Background: Recent evidence shows a substantial short-term risk of ischaemic stroke after transient ischaemic attack (TIA). Identification of patients with TIA with a high short-term risk of stroke is now possible through the use of the “ABCD Score”, which considers age, blood pressure, clinical features and duration of symptoms predictive of stroke. Aim: To evaluate the ability of dichotomising the ABCD Score to predict stroke at 7 and 90 days in a population with TIA presenting to an emergency department. Methods: A retrospective audit was conducted on all probable or definite TIAs presenting to the emergency department of a metropolitan hospital from July to December 2004. The ABCD Score was applied to 98 consecutive patients with TIA who were reviewed for subsequent strokes within 90 days. Patients obtaining an ABCD Score ⩾5 were considered to be at high risk for stroke. Results: Dichotomising the ABCD Score categorised 48 (49%) patients with TIA at high risk for stroke (ABCD Score ⩾5). This high-risk group contained all four strokes that occurred within 7 days (sensitivity 100% (95% confidence interval (CI) 40% to 100%), specificity 53% (95% CI 43% to 63%), positive predictive value 8% (95% CI 3% to 21%) and negative predictive value 100% (95% CI 91% to 100%)), and six of seven occurring within 90 days (sensitivity 86% (95% CI 42% to 99%), specificity 54% (95% CI 43% to 64%), positive predictive value 12.5% (95% CI 5% to 26%) and negative predictive value 98% (95% CI 88% to 100%)). Removal of the “age” item from the ABCD Score halved the number of false-positive cases without changing its predictive value for stroke. Conclusion: In this retrospective analysis, dichotomising the ABCD Score was overinclusive but highly predictive in identifying patients with TIA at a high short-term risk of stroke. Use of the ABCD Score in the emergency care of patients with TIA is simple, efficient and provides a unique opportunity to prevent stroke in this population of patients.

Is FAST stroke smart? Do the content and language used in awareness campaigns describe the experience of stroke symptoms?

Background Public education campaigns for stroke are used worldwide. However, there are few published evaluations of such campaigns. Aim This cross-sectional study examined patient and bystander awareness of two Australian campaigns, ‘FAST’ (face, arm, speech, time) and ‘Signs of Stroke’, and evaluated the campaigns ability to identify stroke and to describe the symptom experience. Methods Interviews were conducted with either stroke patients or a key bystander for consecutive eligible cases admitted to two metropolitan hospitals between August 2006 and April 2008. Participants were asked to describe awareness of the FAST campaign, the symptoms experienced and to evaluate the symptom descriptions of Signs of Stroke against their own experience. Results A total of 100 patients and 70 bystanders were interviewed for 170 cases (71% of eligible cases). Only 12% of those interviewed were aware of the FAST campaign, and of these few (19%) were able to recall all FAST symptoms, with only one bystander using the FAST assessments to identify stroke. At least one FAST symptom was reported by 84% and one Signs of Stroke symptom by 100%. Less than half of those experiencing ‘weakness or paralysis’ thought this description exactly described their experience. Common descriptors of symptoms were: face or mouth droop or drop; trouble using, coordinating or moving arm, hand or leg; trouble walking or standing; numbness; and slurring or loss of speech. Conclusion Awareness of the FAST and Signs of Stroke campaigns was low, with poor recall and little use of the FAST assessments. Some symptom descriptions used in the campaign were not reflective of the symptom experience. The content and language of these campaigns could be improved to portray stroke symptoms more realistically.

Thrombolytic therapy for acute ischaemic stroke: successful implementation in an Australian tertiary hospital

Background: The use of tissue‐type plasminogen activator (t‐PA) in ischaemic stroke outside of experienced stroke centres remains controversial. The aim of this study was to present the initial experience with t‐PA in patients with ischaemic stroke at an institution with no prior experience in i.v. stroke thrombolysis and to compare results to published reports.

Clinical recognition of neurally mediated syncope

Abstract

Lessons Learnt in Implementation of ABCD Score in an Emergency Department

To the Editor:nnSciolla et al’s article1 regarding the prospective validation of the ABCD score is relative to our results. Our group recently reported our own data, which also found the ABCD score highly predictive of stroke (ABCD score of 5 to 6 predicting 4/4 strokes at 7 days and 6/7 at 90 days) and prompted the creation of a …

Success With Paramedic Diagnosis of Stroke

To the Editor:nnWe read with interest the recent article by Frendle et al,1 the first study to demonstrate a lack of improvement in paramedic stroke diagnosis after training and implementation of a prehospital stroke scale. Having implemented a similar program to Australian paramedics with success (stroke detection …

Author Response to Social Marketing and the FAST Campaign

Dear Editor, We thank Dr Bolam and colleagues from the National Stroke Foundation of Australia for their letter regarding our paper evaluating the FAST campaign in a sample of stroke patients and bystanders. These authors make significant points regarding the potential reach of stroke awareness campaigns that have limited funding and exposure. We agree that these should be considered when reading our paper. We also acknowledge that the evaluation of the awareness of such campaigns needs to be performed on a larger scale. However, the benefits of undertaking such an evaluation on a patient population similar to the one in this publication should not be discounted. In our paper we have acknowledged the study limitations outlined by Bolam et al. We do however feel that the sample interviewed was a valid representation of stroke patients who attend a public hospital, and their responses were indicative of the retention of a health message such as the FAST campaign, as it was undertaken at that time. Our results would suggest that the FAST information may not be reaching those who potentially can benefit the most – stroke patients and their families. Indeed such information, if replicated on a larger scale, could be used to convince public health authorities to invest in the FAST campaign. We would also like to take this opportunity to clarify a misinterpretation of the data regarding the population sample. In their letter Bolam et al. note ‘‘the unusually high proportion of inhospital stroke patients excluded, 23% of all stroke admissions’’. The 23% of patients they refer to as ‘‘in-hospital strokes’’ included in-hospital strokes as well as those strokes occurring in patients in institutional care (nursing homes and rehabilitation). The exclusion of these patients was intentional because the focus of this study was to obtain a community, lay-persons perspective. Yours sincerely,

The definition of prehospital delay matterswhen exploring factors related to delay in stroke

Internal capsular genu infarcts infrequently cause cognitive impairment and behavioral changes, and little is known about the underlying mechanism. Using diffusion-tensor imaging (DTI) and the fractional anisotropy (FA) index in the region of interest (ROI) and ipsilesional frontal cortex, we evaluated two patients with internal capsular genu infarction who presented with frontal dysfunction and cognitive impairment. The reported findings help to elucidate the mechanism underlying cognitive deterioration in internal capsular genu infarction. J Korean Neurol Assoc 28(2):104-107, 2010