Saturday, November 6, 2010

Seeing Stroke

Traditionally, the numbers for stroke have been written like this: "In the United States, 750,000 strokes per year. 500,000 new strokes, and the remaining 250,000 recurrent strokes." But by 2015 the estimate is well over 1 million per year. And here's where the stats get grim.

The "well over 1 million per year" bumps the number of recurrent strokes to over 300,000. For the five years after a stroke the chances of having another stroke are somewhere between 25 and 40%. So here's the question: do you know the symptoms of stroke? If you're stroke survivor, of course you do. Or do you? You might very well be an expert in the symptoms of stroke you HAD. But what if you have another one? Would you know the symptoms? So what are the symptoms that you're supposed to know? I work for the University of Cincinnati. They suggest the
FAST test. But its a mnemonic and here's some funny: I get confused about it even though I talk about it, a lot. I think, OK, FAST. What does the F stand for? Why Fast, of course, but yeah, not so much.

So what are the symptoms that stroke survivors should know? One way is to use the FAST test. FAST is based on the Cincinnati Prehospital Stroke Scale and National Institutes of Health Stroke Scale. FAST was developed by Rosie Miller, RN, a nurse who worked with The Greater Cincinnati / Northern Kentucky Stroke Team for 15+ years.

FAST stands for:

· FACE: Ask the person to smile. Do both sides of the mouth, elevate equally?

· ARMS: Ask the person to raise both arms. Do both arms lift equally?

· SPEECH: Ask the person to repeat a sentence. Are they able to repeat a sentence? Are the words slurred?

· TIME: If the person shows any of these symptoms of, call 911 or get to the hospital FAST.

Initiating treatment as soon as possible is vital because time saved is neurons saved. Every minute 2 million neurons and 14 billion synapses die.

It should be pointed out that there's some controversy about the FAST test. The FAST test is great because it is simple. And simple is good. If it's not simple people will forget what the letters stand for. But any test of signs and symptoms of an emerging stroke should be comprehensive enough to capture as many strokes in as possible. Which signs and symptoms to include is hotly debated. Even in the English-speaking world (US, UK, Canada, Australia and New Zealand) there is discrepancy over which and how many and which to include. Further, the wordings used in the various lists are inconsistent. Although there is little research to compare other ways of informing the public, the FAST test has been put to the test. Kleindorfer et al did a study in which they determined that the FAST test missed only about 8% of ischemic strokes but up to 30% of hemorrhagic strokes.

What else is typically included in tests other than the FAST test? Other tests include numbness, intense headache, vision issues, balance problems, loss of coordination, dizziness, difficulty swallowing, and confusion. Also included in some of the tests are the words "even if temporary" after the signs and symptoms. This is an attempt to capture transient attacks which often act as precursor warning signs of a full on stroke.

Consistency is essential to the success of communicating the symptoms and urgency of stroke to the general public. A single unified message increases the number of times it would be experienced by the general public. This would allow for more repetitive memorization of that consistent message. Again, however, there has been insufficient research to indicate which of the mnemonic devices is the most effective at capturing the most strokes.

But there may be a bigger question than what specific signs and symptoms to add. The question is: how do we best learn? Quick, answer this question: You see somebody that looks panicked and is holding their hand to their throat. What pathology does this represent? Here's another one: You see somebody clutching their chest. What is the pathology? While hardly comprehensive, the visual impact of these two examples is universally understood. The question is not what mnemonic is the best, but whether mnemonics are the best way. In my book, "Stronger After Stroke" (Demos 2008) I mention the Cincinnati Prehospital Stroke Scale. But I also suggest another way of memorizing the signs and symptoms of stroke: visualizing. Here's what I suggest:

The easiest way (to memorize the symptoms of stroke) is to start at the top of the head and move downward.

• Skull: Sudden, severe headache and/or dizziness with no known cause.

• Eyes: Sudden trouble seeing in one or both eyes.

• Face: Facial weakness.

• Ears: Sudden trouble understanding.

• Mouth: Sudden trouble speaking.

• Body: Sudden numbness, weakness or paralysis on one side of the body.

Stroke survivors have a much higher chance of having a second stroke than the general population has of having a first stroke. No matter what system you use, educate stroke survivors of the risk of recurrent stroke. And make sure they know as many signs and symptoms as possible


oc1dean said...

Pete, The World Stroke Organization has a statistic of:The lifetime risk of stroke is 1 in 5 for women, 1 in 6 for men.
Any idea of what it might be for the US?
I need ammunition for emails.

Peter G Levine said...

Dean! Sorry about the late reply. Check this set of weird stats:

There's also this weird set of numbers:


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