What is the initial assessment and management for a patient with a suspected Cerebrovascular Accident (CVA) using the Face, Arm, Speech, Time (FAST) assessment?

Initial Assessment and Management for Suspected CVA Using FAST

For patients with suspected cerebrovascular accident (CVA), immediate recognition using the FAST (Face, Arm, Speech, Time) assessment tool and rapid transport to an appropriate stroke center is essential to reduce mortality and improve outcomes.

FAST Assessment Components

• F - Face: Ask the patient to smile or show their teeth. Look for facial asymmetry or drooping on one side 1
• A - Arm: Ask the patient to raise both arms and hold them up. Look for one arm drifting downward or inability to raise one arm 1
• S - Speech: Ask the patient to repeat a simple phrase. Listen for slurred, garbled speech or inability to speak 1
• T - Time: Note the time when symptoms first appeared. Time is critical for treatment decisions 1

Risk Stratification Based on Presentation

VERY HIGH Risk (Symptoms within 48 hours)

• Patients presenting with transient, fluctuating, or persistent:
  • Unilateral weakness (face, arm, and/or leg) 1
  • Speech disturbance/aphasia 1
  • Other symptoms suggesting posterior circulation stroke (diplopia, dysarthria, dysphagia, ataxia) 1

Action: Immediate transport to emergency department with advanced stroke care capabilities 1

HIGH Risk (Symptoms between 48 hours and 2 weeks)

• Patients with transient, fluctuating, or persistent:
  • Unilateral weakness (face, arm, and/or leg) 1
  • Speech disturbance/aphasia 1

Action: Comprehensive evaluation within 24 hours 1

MODERATE Risk (Symptoms between 48 hours and 2 weeks)

• Patients with symptoms without motor weakness or speech disturbance:
  • Hemibody sensory symptoms 1
  • Monocular vision loss 1
  • Binocular diplopia 1
  • Hemifield vision loss 1
  • Ataxia 1

Action: Comprehensive evaluation within 2 weeks 1

LOWER Risk (Symptoms more than 2 weeks)

• Patients presenting more than 2 weeks after symptom onset 1

Action: Evaluation by neurologist or stroke specialist within one month 1

Immediate Management Steps

1. Activate EMS: Call emergency services immediately for suspected stroke 1

2. Minimize on-scene time: EMS should aim for a median on-scene time of 20 minutes or less for patients within the treatment window 1

3. Perform initial assessment:

   • Obtain blood glucose measurement 1
   • Gather information about symptom onset time, medications (especially anticoagulants), and medical history 1
   • Perform FAST assessment and a validated stroke severity screening tool 1

4. Transport to appropriate facility:

   • Direct transport to a hospital capable of providing acute stroke services 1
   • Consider bypass protocols to reach appropriate stroke centers 1

Essential Investigations Upon Arrival

1. Immediate Brain Imaging:

   • CT or MRI brain should be completed without delay 1
   • CT angiography (CTA) from aortic arch to vertex should be performed at the time of initial brain CT 1

2. Vascular Imaging:

   • Extracranial and intracranial vascular imaging to identify significant carotid stenosis 1
   • CTA is recommended to assess both extracranial and intracranial circulation 1

3. Cardiac Assessment:

   • 12-lead ECG should be completed without delay 1
   • Consider cardiac monitoring for potential atrial fibrillation 1

4. Laboratory Tests:

   • Complete blood count 1
   • Electrolytes 1
   • Coagulation studies (aPTT, INR) 1
   • Renal function (creatinine, eGFR) 1
   • Blood glucose 1
   • Troponin 1

Common Pitfalls to Avoid

• Delayed recognition: Failure to recognize subtle stroke symptoms, particularly in posterior circulation strokes 1
• Time window misconception: Assuming patients outside the thrombolytic window don't need urgent care 1
• Stroke mimics: Conditions such as seizures, migraines, or rare conditions like Creutzfeldt-Jakob disease can mimic stroke symptoms 2
• Incomplete vascular assessment: Focusing only on brain imaging without assessing the vascular system 1
• Missing atrial fibrillation: Failing to perform adequate cardiac monitoring in patients with cryptogenic stroke 1

Special Considerations

• Amaurosis fugax (transient monocular blindness): Often caused by atherosclerosis of the ipsilateral internal carotid artery and requires prompt evaluation 1
• Posterior circulation symptoms: May present with less obvious signs like dizziness, ataxia, or visual disturbances rather than classic FAST symptoms 1
• Age considerations: Both very young and elderly patients may present with atypical symptoms 3