Recognition Of Stroke Symptoms Research Articles

Raising stroke awareness among rural dwellers with a Facts for Action to Stroke Treatment-based educational program

Stroke is the third leading cause of death in the United States with 780,000 new and/or recurrent strokes each year. Interventions aimed at the onset of stroke symptoms have been successful in decreasing long-term neurological deficits; however, providing the prompt medical interventions in rural areas involves unique challenges. To decrease time-to-treatment in rural areas, education about symptoms of stroke and the need for immediate medical attention are critical. The objective of this study was to measure the effectiveness of the Facts for Action to Stroke Treatment (FAST)-based educational intervention program focused on the improving knowledge about stroke of 402 rural-dwelling adults. Using a paired means t test, the participants had a significant increase in knowledge from pretest to posttest ( p = .000). Of those, 215 subjects participated in 2-month follow-up testing with the paired t test showing that the increased score from pretest to 2-month follow-up remained significant ( p = .000). The authors concluded that the FAST-based program was an effective tool to use when teaching recognition of stroke symptoms and the need for immediate medical intervention to rural adults.

Factors influencing emergency delays in acute stroke management.

Early admission to hospital with minimum delay is a prerequisite for successful management of acute stroke. We sought to determine our local pre- and in-hospital factors influencing this delay. Time from onset of symptoms to admission (admission time) was prospectively documented during a 6-month period (December 2004 to May 2005) in patients consecutively admitted for an acute focal neurological deficit presented at arrival and of presumed vascular origin. Mode of transportation, patient's knowledge and correct recognition of stroke symptoms were assessed. Physicians contacted by the patients or their relatives were interviewed. The influence of referral patterns on in-hospital delays was further evaluated. Overall, 331 patients were included, 249 had an ischaemic and 37 a haemorrhagic stroke. Forty-five patients had a TIA with neurological symptoms subsiding within the first hours after admission. Median admission time was 3 hours 20 minutes. Transportation by ambulance significantly shortened admission delays in comparison with the patient's own means (HR 2.4, 95% CI 1.6-3.7). The only other factor associated with reduced delays was awareness of stroke (HR 1.9, 95% CI 1.3-2.9). Early in-hospital delays, specifically time to request CT-scan and time to call the neurologist, were shorter when the patient was referred by his family or to a lesser extent by an emergency physician than by the family physician (p < 0.04 and p < 0.01, respectively) and were shorter when he was transported by ambulance than by his own means (p < 0.01). Transportation by ambulance and referral by the patient or family significantly improved admission delays and early in-hospital management. Correct recognition of stroke symptoms further contributed to significant shortening of admission time. Educational programmes should take these findings into account.

Factors influencing emergency delays in acute stroke management.

Early admission to hospital with minimum delay is a prerequisite for successful management of acute stroke. We sought to determine our local pre- and in-hospital factors influencing this delay. Time from onset of symptoms to admission (admission time) was prospectively documented during a 6-month period (December 2004 to May 2005) in patients consecutively admitted for an acute focal neurological deficit presented at arrival and of presumed vascular origin. Mode of transportation, patient's knowledge and correct recognition of stroke symptoms were assessed. Physicians contacted by the patients or their relatives were interviewed. The influence of referral patterns on in-hospital delays was further evaluated. Overall, 331 patients were included, 249 had an ischaemic and 37 a haemorrhagic stroke. Forty-five patients had a TIA with neurological symptoms subsiding within the first hours after admission. Median admission time was 3 hours 20 minutes. Transportation by ambulance significantly shortened admission delays in comparison with the patient's own means (HR 2.4, 95% CI 1.6-3.7). The only other factor associated with reduced delays was awareness of stroke (HR 1.9, 95% CI 1.3-2.9). Early in-hospital delays, specifically time to request CT-scan and time to call the neurologist, were shorter when the patient was referred by his family or to a lesser extent by an emergency physician than by the family physician (p < 0.04 and p < 0.01, respectively) and were shorter when he was transported by ambulance than by his own means (p < 0.01). Transportation by ambulance and referral by the patient or family significantly improved admission delays and early in-hospital management. Correct recognition of stroke symptoms further contributed to significant shortening of admission time. Educational programmes should take these findings into account.

Temporal Trends in Public Awareness of Stroke

Delay in seeking medical attention after stroke symptom onset is the most important reason for low rates of thrombolytic use for ischemic stroke (IS) in the United States. This may be related to poor recognition of stroke symptoms, or to lack of awareness of time-sensitive stroke treatments. We describe public knowledge of t-PA as a treatment for IS, as well as changes over time in knowledge of stroke warning signs (WS) and risk factors (RF). Survey respondents were drawn from our biracial population of 1.3 million using random-digit dialing in 1995, 2000, and 2005 to reflect the age, race, and gender distribution of stroke patients, based on an ongoing stroke incidence study in the same region. They were asked open-ended questions regarding stroke WS, RF, and, in 2005, specific questions regarding t-PA. Comparisons over time were made using chi(2) analysis, and were corrected for multiple comparisons. Over the 10-year study period, 6209 surveys were completed. Knowledge of WS and RF improved between 1995 and 2000. Between 2000 and 2005, knowledge did not improve significantly; however, there was a significant improvement in knowledge of 3 warning signs (12% in 1995 vs 16% in 2005, P=0.0004). In 2005, only 3.6% of those surveyed were able to independently name t-PA or "clot buster" when asked: "Suppose you were having a stroke. Do you know of any medication your doctor could give you into the vein to increase your chance of recovering from a stroke?"-although 19% claimed to have heard of t-PA once it was mentioned to them. Despite numerous national stroke public awareness campaigns, public knowledge of stroke WS and RF has not improved over the last 5 years. In addition, knowledge of t-PA as a treatment for IS is extremely poor. Public awareness messages in the future should focus on the possibility of urgent treatments, in addition to stroke WS and RF, so the public can translate their knowledge into action and present to medical attention more quickly. This may be the highest yield approach to increasing rates of treatment of IS with t-PA.

Knowledge of Tissue Plasminogen Activator for Acute Stroke Among Michigan Adults

Although tissue plasminogen activator (tPA) is an effective therapy for acute ischemic stroke, treatment rates remain low. Efforts to address the underuse of tPA include public education to increase the recognition of stroke symptoms and the awareness of tPA treatment. Our objective was to determine the level of knowledge about tPA treatment for acute stroke among a representative sample of Michigan adults. The Michigan Behavioral Risk Factor Survey (BRFS) is a random-digit-dial telephone survey of adults conducted annually as part of the national BRFS. Questions regarding tPA treatment for acute stroke were included in the 2004 Michigan BRFS. We examined the prevalence of awareness using chi(2) tests and generated multivariable logistic regression models. Among 4724 respondents, only 32.2% (95% CI=30.8 to 33.8%) were aware of the existence of tPA treatment for acute stroke, of whom 52.7% (50.0 to 55.4%) knew that it needed to be administered within 3 hours of symptom onset. Awareness of tPA was higher among middle aged adults, females, whites, and those with higher education and income. Awareness of the time window for tPA was higher among middle aged adults and whites. In this population-based survey only a third of the public were aware of tPA as a treatment for stroke, and only 1 in 6 were aware that the treatment exists and needs to be given within 3 hours of symptom onset. Continuing efforts are necessary to increase public knowledge about tPA treatment for acute stroke.

NICE guideline on acute stroke and TIA: commentary

The National Stroke Strategy,1 published in 2007, outlined a “National Ambition for Stroke” where every patient with stroke or transient ischaemic attack (TIA) receives timely and evidence-based stroke care from...

Gender Differences in Presenting and Prodromal Stroke Symptoms

Prompt recognition of stroke symptoms is critical to timely treatment and women have increased delay to treatment. Women may be more likely to present with atypical symptoms, but this hypothesis has not been extensively evaluated. We examined gender differences in the prevalence of presenting and prodromal stroke symptoms among 1107 consecutive patients hospitalized with neurologist-confirmed acute ischemic stroke. Patient demographics, clinical variables, and stroke symptoms were abstracted from medical records by trained abstractors using standardized forms. Estimates were age-standardized to the age distribution of men and women combined. Presenting symptoms occurred within 24 hours of incident stroke admission; prodromal symptoms occurred >or=24 hours of admission. Women were significantly older (P<0.001), more likely to have cardioembolic stroke (P<0.01), and less likely to receive aspirin (P=0.014) or statins (P<0.001). Thirty-five percent of the sample (n=389) reported prodromal symptoms. Women were more likely to have >or=1 somatic prodromal and presenting symptoms (P=0.03; P=0.008), but did not differ from men on specific somatic symptoms. Women did not differ from men in classic presenting stroke symptoms (P=0.89). Women did not differ significantly in the prevalence of traditional stroke symptoms but were more likely to have somatic presenting and prodromal symptoms. We found no differences in specific prodromal symptoms, making it difficult to craft a public health message about gender differences in early warning signs of stroke. These results suggest that the focus of stroke prevention education for women should continue to emphasize traditional stroke risk factors.

Stroke Prevention and Management in Older Adults

Stroke is the third leading cause of death and a foremost cause of serious, long-term disability in the United States. As cardiovascular and metabolic disease incidence rises with age, older people are more likely to experience strokes. Age is the single most important risk factor for stroke. For each successive 10 years after age 55, the stroke rate more than doubles in both men and women. However, stroke is not an inevitable consequence of aging. By identifying and modifying risk factors in older people, nurses can partner with other providers to reduce the incidence, morbidity, and mortality associated with stroke in older adults. Control of hypertension, resolution of dyslipidemia, management of diabetes mellitus, anticoagulation for atrial fibrillation, promotion of exercise and healthy diet, and cessation of cigarette smoking are of particular importance in older adults. Recognition of stroke symptoms, access to emergency evaluation and treatments, and participation in comprehensive rehabilitation may determine stroke outcomes in aging. This article presents stroke risk factors and primary and secondary prevention in the context of aging, with special considerations in the identification and management of acute stroke, recovery, and rehabilitation for older adults who survive stroke.

Place of Death After Stroke—United States, 1999-2002

Stroke is the third leading cause of death in the United States. Successful acute stroke intervention depends on early recognition of symptoms, prompt emergency transport, and rapid in-hospital treatment. However, approximately half of stroke decedents die before admission to the hospital. During 1990-1998, the proportion of stroke deaths that occurred in hospitals declined, and the proportion occurring before transport to hospitals increased. This report summarizes trends in the place of death among all stroke decedents, the proportion of stroke deaths occurring before emergency assistance arrives, and characteristics associated with place of death. Among 162,672 persons who died of stroke in 2002, 49.2% died pre-transport, 0.4% were dead on arrival (DOA), 3.3% died in emergency departments (EDs), and 47.0% died after admission to a hospital. Early patient and bystander recognition of stroke symptoms and timely action in calling for emergency assistance might reduce the number and proportion of stroke deaths. In addition, improving timely arrival of emergency care and appropriate treatment of stroke patients can reduce the proportion of pre-transport deaths and serious sequelae that lead to severe disabilities.

Community Socioeconomic Status and Prehospital Times in Acute Stroke and Transient Ischemic Attack

Timely access to medical treatment is critical for patients with acute stroke because acute therapies must be given very quickly after symptom onset. We examined the effect of socioeconomic status on prehospital delays in stroke and transient ischemic attack (TIA) patients within a large, biracial population. By screening all local hospital ICD-9 codes 430 to 436, all stroke and TIA patients were identified during the calendar year of 1999. Cases must have used emergency medical services (EMS), lived at home, had their stroke at home, and had documented times of the 911 call and arrival to the emergency department. Socioeconomic status was estimated using economic data regarding the geocoded home residence census tract. Only 38% of stroke and TIA patients used EMS. There were 978 cases of stroke and TIA included in this analysis. The mean times were call to arrival on scene 6.5 minutes, on-scene time 14.1 minutes, and transport time 13.1 minutes. Lower community socioeconomic status was associated with all 3 EMS time intervals; however, all time differences were small: the largest difference was 5 minutes. Within our population, living in a poorer area does not appear to delay access to acute care for stroke in a clinically significant way. We did find small, statistically significant delays in prehospital times that were associated with poorer communities, black race, and increasing age. However, delays related to public recognition of stroke symptoms, and limited use of 911, are likely much more important than these small delays that occur with EMS systems.

Development and Validation of the Stroke Action Test

Accurately assessing the public's readiness to respond to stroke is important. Most published measures are based on recall or recognition of stroke symptoms, or knowledge of the best action for stroke when the diagnosis is provided. The purpose of this study was to develop and evaluate a new written instrument whose items require the respondent to associate individual symptoms with the most appropriate action. The Stroke Action Test (STAT) contains 21 items that name or describe stroke symptoms from all 5 groups of warning signs and 7 items that are nonstroke symptoms. For each item, the respondent selects 1 of 4 options: call 911, call doctor, wait 1 hour, or wait 1 day. The instrument validation sample included 249 subjects from community-based organizations. Score reliability and validity were analyzed using multiple data and information sources. The mean overall STAT score (all 28 items) for the lay people was 36.8%. On average, they chose call 911 for 34.1% of the stroke symptoms. They chose call doctor for 39.4% of the stroke symptoms, wait 1 hour for 20.1%, and wait 1 day for 6.0%. Score reliability is good (alpha=0.83). Evidence confirming score validity is presented based on analysis of item content and response patterns, and examination of the relationships between test scores and key variables related to stroke knowledge. STAT directly assesses a critical aspect of practical stroke knowledge that has been largely overlooked and provides scores with good reliability and validity.

Critical Care and Emergency Medicine Neurology in Stroke

Dramatic changes have occurred in the area of critical care and emergency stroke treatments of intracerebral hemorrhage (ICH). New data from three sponsored clinical trials: STICH (British National Health System-Medical Research Council), NOVO Seven (Novonordisk), and intraventricular hemorrhage (IVH) clot lysis (FDA Orphan Drug Program)1 were presented at the 29th International Stroke Meeting2 and the World Stroke Congress. Several avenues of approach to the problem of ICH are opening. Although the data from these trials are now under peer review, the initial presentations have demonstrated several principles that seem clear. First, craniotomy (though not better than initial medical management) is safe and not worse than initial medical management. Second, deterioration occurs frequently (≈25% of the time) in the initial days after ICH. Deterioration was treated with surgery. Third, a strategy of emergent clot stabilization is safe and shows trends toward efficacy in the NOVO Seven dose finding study.2 Finally, catheter-assisted removal of blood clot from the obstructed ventricular system in IVH can be accomplished safely with low dose recombinant tissue plasminogen activator (rtPA).3 These trial results suggest that the basic elements of aneurysm care are now being applied to ICH care: emergent stabilization of the bleeding site, followed by removal of blood and management of cranial vault mechanics. Data are now beginning to support that applying these principles leads to improvement in mortality and morbidity. We hope that the robustness of the peer-reviewed data continues to point to the value of emergent intervention for the ICH patient. New sponsored trials have already started: CLEAR IVH, a phase IIb dose optimization trial directed at finding the best dose of rtPA to rapidly remove blood from the ventricles (FDA Orphan drug program)4; MISTIE, an NIH sponsored phase II safety study of minimally invasive surgery plus …

Low public recognition of major stroke symptoms

Background A Healthy People 2010 objective includes increasing public awareness of the warning signs of stroke, yet few data exist about the level of awareness. Recognition of stroke symptoms and awareness of the need to call 911 for acute stroke events were examined among the general population. Methods Data are from 61,019 adults participating in the 2001 Behavioral Risk Factor Surveillance System, a state-based telephone survey. Respondents indicated whether the following were symptoms of stroke: confusion/trouble speaking; numbness/weakness of face, arm, or leg; trouble seeing; chest pain (false symptom); trouble walking, dizziness, or loss of balance; and severe headache with no known cause. Persons also reported the first action they would take if they thought someone was having a stroke. Results Only 17.2% of respondents overall (5.9% to 21.7% by state) correctly classified all stroke symptoms and indicated that they would call 911 if they thought someone was having a stroke. Recognition of all symptoms and knowledge of when to call 911 were comparable by gender but lower among ethnic minorities, younger and older people, those with less education, and current smokers compared to whites, middle-aged people, those with more education, and nonsmokers, respectively. There were no substantive differences by history of hypertension, diabetes, heart disease, or stroke. Conclusions Public recognition of major stroke symptoms is low. Educational campaigns to increase awareness among the general population and targeted messages to those at high-risk persons and their families may help to improve time to treatment for adults suffering acute strokes.

Emergency calls in acute stroke.

In the last 10 years, stroke has become a medical emergency. Subsequently, early recognition of stroke symptoms and rapid activation of the medical system are essential. We sought to investigate what witnesses or victims of an acute stroke syndrome recognize and report in the actual situation. We analyzed the recordings of all patients admitted to our stroke unit via the Emergency Medical System (EMS) dispatch center in Nuremberg within 1 year. With a structured evaluation form, the calls were screened for symptoms reported and for any diagnosis or other facts mentioned spontaneously or in response to a question by the dispatcher. We also evaluated data about EMS response and patient condition on admission. Of 482 patients treated in our stroke unit, 141 calls were evaluated. Main symptoms reported included speech problems (25.5%), motor deficits (21.9%), and disturbances of consciousness (14.8%). In many cases, a fall (21.2%) was presented as the main problem. Sensory deficits (7.8%) and vertigo (5.6%) were rarely mentioned. In 28 calls (19.8%), stroke was mentioned as a possible cause of the acute health problems. The dispatcher suspected a stroke in 51.7% of all cases. This is one of the first studies to investigate emergency calls in acute stroke. We found that motor deficits and speech problems were the most dramatic symptoms that led to activation of the EMS. Other symptoms were less frequently reported, or atypical descriptions were given. Educational efforts are needed to improve recognition of atypical stroke symptoms by stroke victims and EMS professionals.

KNOWLEDGE OF STROKE SYMPTOMS AND RISK FACTORS AMONG AT‐RISK ELDERLY PATIENTS IN THE UK

SUMMARYAssessing patient knowledge can help healthcare providers in planning measures directed at prevention, early identification and referral of patients. An incorrect understanding of stroke symptoms may delay patients seeking emergency help, thus missing the benefits of acute stroke treatments. Insufficient knowledge about stroke risk factors may affect risk factor control. We conducted a questionnaire‐based interview among elderly patients at risk of stroke and assessed their baseline knowledge of stroke symptoms and risk factors. A large proportion were found to have an improper understanding of stroke symptoms and risk factors. Stress was considered the commonest risk factor for stroke. Most patients did not consider themselves to be at further risk of stroke. Further education is needed as part of stroke prevention strategies to remove misconceptions. Improved recognition of stroke symptoms when they occur will help when seeking emergency medical help.

Keynote address.

"Acute strokes are here to stay": this could be the sad conclusion after decades of stroke research. Generalized prevention of ischemic stroke is not fully successful. After the decline in stroke incidence observed by 1970, partly related to better management of vascular risk factors, there has again been an increase in stroke frequency all around the world. This phenomenon may be explained by the lack of educational modalities for modification of lifestyle behavior, the small impact of high-risk individual prevention strategy, and the lack of rationale and guidelines for multiple approaches. In the meantime, the benefits of acute intensive management of stroke have been demonstrated. There is now considerable evidence that careful monitoring and management of general and cerebral functions in a dedicated stroke unit or by a specialized stroke team are superior to management in a neurologic or general ward. Currently, one way of optimizing limited personnel resources is to connect the stroke unit of a main hospital with peripheral hospitals via a computer network. Experts in the central stroke unit can then make on-line evaluations of CT and ultrasound examinations performed in the local hospital and recommend the best course of patient management. This new approach of treating stroke as an emergency will also require educational programs directed at the general public, general practitioners, and primary and emergency department physicians, to teach the recognition of stroke symptoms and the importance of treating stroke with the same urgency as for myocardial infarction (MI).

Treating stroke as a medical emergency: a survey of resident physicians' attitudes toward "brain attack" and carotid endarterectomy.

A major impetus of the "brain attack" campaign is the early recognition and treatment of acute stroke. Critical to this goal is the education of physicians during their residency training. Resident physicians in Los Angeles who were in family practice (18%), internal medicine (51%), emergency medicine (20%), and neurology (11%) and had already completed their first year of training responded to a questionnaire on stroke and the treatment of carotid stenosis. Of the 266 respondents, 76% had heard of the "brain attack" campaign, 22% did not identify dysarthria as a symptom of stroke, and 21% did not identify obtundation as a presentation of stroke. Twenty-eight percent chose not to use tissue plasminogen activator for acute ischemic stroke, and 60% recognized the need to begin treatment within 3 hours. More than 90% of respondents were able to identify correct screening tests for patients with suspected carotid stenosis. However, 56% responded that they would not advocate operating on patients with asymptomatic severe stenosis (>70%) until stenosis reached a critical value (85%). Conversely, 45% would recommend operative treatment for symptomatic patients who had less than 60% stenosis. Sixty-eight percent would refer patients to vascular surgeons, 14% to neurosurgeons, and 17% to both for carotid endarterectomy. Recognition of stroke as a medical emergency is improving. However, significant progress can still be made in the recognition of stroke symptoms. Primary care and neurology residents remain skeptical about carotid endarterectomy for asymptomatic patients, whereas there is enthusiasm for treating stroke survivors. Education by members of the surgical community could promote the aggressive treatment of asymptomatic patients to prevent stroke.

Management Of Acute Ischaemic Stroke

SummaryOver the past few years there have been enormous changes in the management of stroke patients. General practitioners, ambulance personnel/paramedics and the general public need to be well informed that stroke is a medical emergency. Prevention of secondary brain damage by normalising vital parameters and combating fever should already start at the scene or in the ambulance. Early recognition of stroke symptoms, immediate transfer to a suitable treatment facility, and rapid in hospital triage protocols should bring thrombolysis to a larger number of stroke victims. Admission to a unit that is dedicated to the care of stroke patients helps to reduce mortality and morbidity.

"Brain attack": an indication for thrombolysis?

The primary objective of this article is to introduce the reader to the use of thrombolytics in the acute treatment of ischemic stroke. Theory and experimental evidence to support this approach are emphasized in addition to potential adverse effects of thrombolysis. A MEDLINE search was used to identify pertinent literature, including reviews. Studies were selected for detailed review if they involved stroke patients and addressed possible toxicities of therapy. Any abstracts concerning ongoing clinical trials also were reviewed. Data from animal investigations using tissue plasminogen activator for the acute treatment of several models of cerebral ischemia were used to support the importance of early treatment (within six hours of symptom onset). Also, studies performed in animal models of stroke revealed that thrombolysis could be accomplished safely in acute ischemic stroke. All human studies published to data are anecdotal case reports, but point to the safety of thrombolysis if administered early. Reviews of ongoing multicenter trials are taken from published abstracts and proceedings. Thrombolysis holds promise as a hyperacute therapy for acute stroke; however, the risk of intracerebral hemorrhage remains. Crucial to the success of this and any other therapy for acute stroke is the ability to treat patients within hours of symptom onset. Also, the importance of concomitant medications such as heparin and aspirin has not yet been addressed. Pharmacists need to be knowledgeable of new treatments of stroke and the risks associated with them. As patient educators, pharmacists can contribute to public awareness by promoting the early recognition of stroke symptoms. As pharmacotherapists, pharmacists need to understand the risks and the important monitoring parameters related to thrombolysis. The results of ongoing multicenter clinical trials are awaited before making a final judgment on the usefulness of thrombolysis in acute ischemic stroke.