Characterizing TIA and stroke symptomatology in a population-based study: implications for and diagnostic value of FAST-based public education

Abstract

Abstract Background Urgent medical treatment is crucial after stroke and transient ischemic attack (TIA), but hindered by extensive prehospital delays. Public education campaigns based on FAST (Face-Arm-Speech-Time) have improved response after major stroke, but not minor stroke and TIA. We aimed to provide strategies to improve public education on a national level, by characterizing TIA and stroke symptoms in a population-based cohort, and extrapolating findings to the general Dutch population. Methods We included all patients with first-ever stroke or TIA from 2002–2016 in the population-based Rotterdam Study (N = 17,931). We determined the prevalence of focal neurological symptoms and their combinations by event severity (i.e., TIA, minor stroke [National Institutes of Health Stroke Scale (NIHSS) 0–3], and major stroke [NIHSS > 3]). We assessed sensitivity of the FAST test for TIA and stroke, and estimated specificity using survey data on the incidence of focal neurological symptoms of non-vascular origin from the same source population. Finally, we determined the diagnostic value of adding visual symptoms and vertigo to the FAST test. Results Of all 900 patients (mean age: 77.6 years, 57.2% women), 409 (45.4%) had a TIA, 254 (28.2%) had minor stroke, and 237 (26.3%) had major stroke. At least one FAST symptom was present in 233/237 (98.3%) of patients with major stroke, compared to 186/254 (73.2%) patients with minor stroke, and 250/402 (62.2%) with TIA. Minor strokes and TIA not captured by the FAST test most commonly involved visual symptoms (52.7%), dizziness/vertigo (19.5%), disturbed coordination (19.1%), and sensory disturbance (18.2%). Sensitivity of FAST for TIA/minor stroke increased from 66.4 to 80.8% with the addition of visual symptoms, and to 86.1% with further incorporation of dizziness/vertigo, albeit with a > 40% increase in the number of false positive events. Nearly all patients with major stroke (97.5%) experienced a combination of multiple symptoms, whereas 58.9% of patients with TIA and 26.4% of those with minor stroke reported only a single symptom. Conclusions In contrast to major stroke, sensitivity of the FAST test is limited to around 65% for TIA and minor stroke in a population-based setting. Sensitivity increases by incorporating visual symptoms and vertigo, but this comes with a large number of false positives. Findings of this study may favor a focus on the importance of isolated or transient symptoms, rather than additional symptoms, in future stroke public education campaigns.

Keywords

• Stroke
• TIA
• FAST
• Stroke recognition
• Stroke prevention