FAST

ROSIER

• Recognition of Stroke In the Emergency Room
• http://www.newcastle-hospitals.org.uk/downloads/clinical-guidelines/Care%20of%20the%20Elderly/ROSIERv15.pdf
• Assessment date___, time___
• Symptom onset: date___, time___
• GCS:___ E:___ V:___ M:___
• BP___/___
• BM:___ (* if <3.5 mmol/l treat urgently and reassess once blood glucose normal)
• Has there been loss of consciousness or syncope: Y___ (-1)  N___ (0)
• Has there been seizure activity? Y___ (-1)  N___ (0)
• Is there a NEW ACUTE onset (or on awakening from sleep)?
• asymmetric facial weakness: Y___ (+1)  N___ (0)
• asymmetric arm weakness: Y___ (+1)  N___ (0)
• asymmetric leg weakness: Y___ (+1)  N___ (0)
• speech disturbance: Y___ (+1)  N___ (0)
• visual field defect: Y___ (+1)  N___ (0)
• Total Score: _______ (-2 to +5) [Stroke is likely if total scores are >0. Scores </= 0 have a low possibility of stroke but not completely excluded.]
• Provisional diagnosis: ___ Stroke ____ Non-stroke (specify) ___________

ABCD2

• http://www.newcastle-hospitals.org.uk/downloads/clinical-guidelines/Care%20of%20the%20Elderly/ROSIERv15.pdf;

NIHSS

• 1a: ***Level of consciousness[0..3]:
• 0: alert;
• 1: not alert, arousable (arousable by minor stimulation to obey, answer or respond);
• 2: not altert, obtunded (requires repeated stimulation, obtunded, ...)
• 3: unresponsive (responds only with reflex motor (posturing) or totally unresponsive, flaccid)
• 1b: LOC questions[0..2]: month & his/her age
• 0: answers both correct;
• 1: answers one correct [or dysarthria, ET tube,...];
• 2: answers neither correct
• 1c: LOC commands[0..2]: open & close eyes, grip & release non-paretic hand
• 0: performs both correct;
• 1: performs one correct;
• 2: performs neither correct
• 2: Best gaze[0..2]:
• 0: normal;
• 1: partial gaze palsy (in 1|2 eyes, but eg overcome by reflexic=oculocephalic activity; or: isolated CN palsy);
• 2: total gaze palsy (forced deviation, or total gaze paresis not overcome by oculocephalic maneuver)
• 3: Visual[0..3]: visual fields (upper & lower quadrants) tested with finger counting / visual threat
• 0: no visual loss;
• 1: partial hemianopia;
• 2: complete hemianopia;
• 3: bilat. hemianopia (blind including cortical blindness)
• 4: ***Facial palsy[0..3]:
• 0: nml (symmetrical movements);
• 1: minor paralysis (flattened nasolabial fold);
• 2: partial paralysis;
• 3: complete paralysis;
• 5: Motor arm[0..4+0..4] [5a=L arm, 5b=R arm]: arm hold 10s
• 0: no drift;
• 1: drift before 10s;
• 2: some effort against gravity;
• 3: no effort against gravity: limb falls;
• 4: no movement;
• UN: amputation/joint fusion
• 6: Motor leg[0..4+0..4] [6a=L leg, 6b=R leg]: leg hold for 5 sec
• 0: no drift;
• 1: drift before 5s;
• 2: some effort against gravity;
• 3: no effort against gravity: limb falls;
• 4: no movement; UN: amputation/joint fusion
• 7: ***Limb ataxia[0..2]: finger-nose-finger and heel-shin test on both sides, ataxia only if out of proportion of weakness
• 0: absent;
• 1: present in 1 limb;
• 2: present in 2 limbs;
• UN: amputation or joint fusion;
• 8: Sensory[0..2]: pinprick sensation
• 0: normal;
• 1: mild-to-moderate sensory loss [eg less sharp or dull];
• 2: severe to total sensory loss
• 9: Best language[0..2]:
• 0: aphasia,
• 1: mild-to-moderate aphasia [loss of fluency or comprehension];
• 2: severe aphasia [fragmentary expression];
• 3: mute, global aphasia;
• 10: ***Dysarthria[0..2]:
• 0: nml;
• 1: mild-to-moderate dysarthria [if aphasia: clarity of speech];
• 2: severe dysarthria [unintelligible];
• UN: intubated,...
• 11: Extinction and Inattention[0..2] (formerly Neglect): bilat. simultaneous visual/tactile/auditory/spatial/personal stimulation
• 0: no abnlty;
• 1: inattention or extinction to sensory modalities;
• 2: profound hemi-inattention or extinction in >1 modality [does not recognize own hand or orients to only one side of space]

Pubmed:

• http://www.ncbi.nlm.nih.gov/pubmed/19110146: Percent change in NIHSS: a useful acute stroke outcome measure;
• in moderate stroke severity (baseline NIHSS 7-15) improvement of >=55% was best predictor of functional independence
• http://www.ncbi.nlm.nih.gov/pubmed/16781990: Clincal interpretation and use of stroke scales (2006) Lancet Neurol;
• 11 of 15 items have greater reliability than other (***): 11-item modified NIHSS (mNIHSS); also 8-item and 5-item NIHSS for prehospital assessment being tested;
• validity: good correlation (r=0.4..0.8) with infarct volumes; and with predictive validity:
• baseline NIHSS>15: very few pts with excellent outcomes at 3 months
• baseline NIHSS<=5: ~80% discharged home;
• baseline NIHSS 6..12: usually acute inpatient rehabilitation;
• baseline NIHSS>=14: often long-term care in nursing facilities;
• NIHSS<=3 at day 7: ~2/3 of pts with excellent outcome;
• Caution: equivalent NIHSS with slightly larger volumes of right-hemisphere strokes vs left-hemisphere strokes; no detailed assessment of cranial nerves; relatively low NIHSS scores may occur with disabling infarctions of brainstem or cerebellum [eg Wallenberg syndrome (lat. medulla) may NIHSS 2-4 but may be life-threatening]; also: complete Hx, neurol exam, and neuroimaging still needed to exclude stroke mimics

NICE Guideline 2008

• if sudden onset neurol sympts outside hospital: Face Arm Speech Test (FAST) to screen for stroke/TIA, exclude hypoglycaemia, Recognition Of Stroke In the Emergency Room (ROSIER) in ER
• if suspected TIA and hi risk of stroke (ie ABCD2 >=4 or crescendo TIA: >=2 TIA/wk) Rx Aspirin 300 stat, specialist assessm and Ix (for exclusion of stroke mimics, identification of vascular Tx, ...)  <=24h, measures of 2ry prevention if Dx confirmed

• if suspected stroke: assess and admit specialist stroke unit
• immediate (ie <=1h) brain imaging if indications for thrombolysis/early anticoag | on anticoag Tx/known bleeding tendency | GCS<13 | unexplained progressive/fluctuating sympts | papilloedema/neck stiffness/fever | severe headache at onset of stroke sympts

• trained swallowing screen before oral intake

• if all of the following
• if MCA infarction
• clin deficits suggestive of infarction in MCA territory with National Institutes of Health Stroke Scale (NIHSS) score > 15
• dcr in level of consciousness (score >=1 on item 1a in NIHSS)
• signs on CT on >=50% infarct of MCA territory, +- additional infarction in ACA/PCA territory same side, or infarct volume > 145cm3 on diffusion-weighted MRI
• refer <=24h of onset
• surgery <=48h of onset
• skilled monitoring of neurological function