1. Stroke Awareness, Recognition, and Response

When it comes to stroke, time is brain! On average, two million neurons die with every minute that elapses following symptom onset, leading to permanent damage to the brain (Saver JL. Stroke. 2006 Jan;37(1):263-6). Although stroke is a medical emergency, many people do not recognize it as such, or they attribute the signs and symptoms to a less serious health issue and delay seeking medical attention. It is critical that anyone with signs of stroke arrive at the emergency department as soon as possible, as earlier assessment and treatment may allow time for disability-limiting or life-saving interventions. People who experience a transient ischemic attack (TIA) are also considered a medical emergency and require rapid assessment and treatment; therefore, enhancing the emergency medical system response to improve public awareness of stroke signs and symptoms and need to contact EMS should be encouraged. These recommendations apply across all geographic regions in Canada, and education should be available uniformly, with targeted approaches for diverse populations and regardless of local issues related to time to access care.

People with lived experience emphasized the importance of recognizing stroke signs and symptoms in order to get the care that is needed. They highlighted the importance of ongoing research, particularly for women and for all age groups; and how ongoing education about stroke signs and symptoms for youth and adults and healthcare providers is critical to support access to appropriate care. Stroke can happen at any age, and the public and healthcare providers need to be able to recognize all signs of stroke in anyone, regardless of age.

To ensure people experiencing a stroke receive timely stroke assessments, interventions and management, interdisciplinary teams need to have the infrastructure and resources required. These may include the following components established at a systems level.

1. Government funding and support for awareness initiatives to improve the recognition and recall of the signs of stroke (e.g., FAST, which is a global best practice) and the importance of contacting 9-1-1 immediately. Awareness and education campaigns should prioritize reaching communities who are less aware of the signs of stroke and most at risk of stroke and should be informed collaboratively through community engagement activities with those audiences.
2. Enhanced collaboration among community organizations and healthcare professionals to ensure consistency in public education of the signs of stroke with a strong emphasis on the urgency of responding when the signs of stroke are recognized.
3. Training and education for EMS, emergency department and all in-hospital staff, medical and nursing students, physicians in primary and acute care as well as specialists, nurses, and allied health professionals to increase their ability to recognize potential patients with stroke and provide rapid assessment and management.
4. Comprehensive systems in place to ensure all people in Canada have access to timely and appropriate emergency medical services, including ambulatory services (e.g., outpatient services, emergency department, community health centres, nursing stations) without financial burden, and quality stroke care regardless of geographic location.
5. Enhanced monitoring and awareness of stroke among all people in Canada. Healthcare systems and provincial/territorial and federal governments should generate linked health and social surveillance population-based and regional data and use it to drive quality improvement through better understanding of the health and social issues facing people in Canada.

System Indicators:

1. Proportion of people with suspected stroke or TIA transported to hospital by paramedics (core). 
2. Proportion of the population who live within 4.5 and 6 hours by ground transportation of a Stroke services Level 3, 4, or 5 stroke-enabled hospital (e.g., has CT scanner on-site and ability to deliver intravenous thrombolysis).
3. Proportion of hospitals that pre-register patients or have workflows to bypass the ED.

Process Indicators:

4. Proportion of patients with stroke who contact any member of the healthcare system within 4.5, 6, and 24 hours of stroke symptom onset (core).
5. Median (and interquartile range) time lapse between stroke symptom onset and first contact with EMS, defined as time call placed to 9-1-1 or local emergency medical system dispatch.
6. Median time (hours) from stroke symptom onset to arrival at an emergency department for all suspected patients with stroke presenting to hospital.

Patient Oriented Outcomes and Experience Indicators:

7. Proportion of the population (and specific population subgroups) aware of the signs of stroke as presented in FAST/VITE (core).

Refer to Section 3 for additional performance measures related to prehospital care and transport.

Measurement Notes

1. Performance measure 6: Data may be obtained from specific public polling on the signs of stroke, by the Heart and Stroke Foundation, and other organizations.
2. Performance measures 1 to 5: Denominator is patients with stroke who are treated in hospital. Data may be obtained from the Canadian Institute for Health Information (CIHI) NACRS and DAD databases and Stroke Special Project 340 and/or from primary chart audit.
3. Performance measure 3: Emergency department triage time should always be used as the proxy time for emergency department arrival. This is available in CIHI NACRS, and a calculated value in the DAD. The three time windows reflect the treatment times in this 7^th edition (2022) of the Acute Stroke Management recommendations.
4. Performance measures 3 – 5: Time of stroke symptom onset may be known if the patient was awake and conscious at the time of onset, or it may be unknown if symptoms were present on awakening. It is important to record whether the time of onset is estimated or exact. The time qualifies as exact provided that (1) the patient is competent and definitely noted the time of symptom onset or (2) the onset was observed by another person who took note of the time.
5. Performance measure 3: These data may be obtained by performing geo-spatial analysis based on location of ambulance base stations, location of hospitals with hyperacute stroke services, and road geography for a specified region.
6. Hospitals should make all effort to still report the time of patient arrival as the ED triage time in CIHI NACRS. This will help stroke directors or administrative push the hospitals to do this.

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices team or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Healthcare Provider Information

• Heart & Stroke: Signs of Stroke
• Heart & Stroke: FAST Signs of Stroke
• World Stroke Organization
• Stroke Engine
• The Ontario Acute Stroke Best Practice Coordinators and the Ontario Regional Education Group in collaboration with Heart & Stroke: Key Changes to the 2022 Acute Stroke Management Canadian Stroke Best Practice Recommendations

Information for people with lived experience of stroke, including family, friends and caregivers 

• Heart & Stroke: FAST Signs of Stroke
• Heart & Stroke: Signs of Stroke
• Heart & Stroke: What is stroke?
• Heart & Stroke: Acute Stroke Management Infographic 
• Heart & Stroke: Your Stroke Journey
• Heart & Stroke: A Family Guide to Pediatric Stroke
• Heart & Stroke: Stroke in Young Adults: a Resource for Patients and Families
• Heart & Stroke: Transient Ischemic Attack
• Stroke Engine

Evidence Table and Reference List

Sex and Gender Considerations Reference List

Failure to recognize the signs of an acute stroke, by witnesses or the person experiencing the stroke, can delay the time to contact emergency services, which may in turn decrease a patient’s opportunity to receive time-sensitive treatments. 

The results from many cross-sectional surveys indicate that, among members of the general public, knowledge of the signs and symptoms associated with stroke remains disappointingly low. Lundelin et al. (2012) conducted telephone surveys of 11,827 adults living in Spain who had participated in the Study on Nutrition & Cardiovascular Risk, to assess their ability to identify stroke symptoms, including sudden confusion or trouble speaking; numbness of face, arm, or leg; sudden trouble seeing in one or both eyes; sudden chest pain (decoy); sudden trouble walking; dizziness or loss of balance; or severe headache. While 65.2% of the participants could correctly identify four to six symptoms of stroke, only 19% could identify all 6 symptoms correctly, and 11.4% were unable to identify a single symptom. In addition, 81.1% of participants indicated they would call an ambulance if they suspected someone was having a stroke. Persons who could identify more stroke symptoms were more likely to call for an ambulance. Mochari-Greenberger et al. (2014) surveyed 1,205 women aged ≥25 years living in the United States who had participated in the American Heart Association National Women’s Tracking Survey. Participants were contacted by telephone and asked standardized questions related to stroke warning signs and actions to take in the event of stroke. Sudden weakness and/or numbness of the face or limb of one side was the most commonly cited symptom (51%). Loss of or trouble understanding speech was also frequently recognized as a symptom (44%); while headache, unexplained dizziness, and loss of vision in one eye were recognized by fewer participants (23%, 20% and 18%, respectively). One in 5 women could not name a stroke warning sign. 

In a survey of 790 respondents who were friends and family members of patients at a Canadian vascular outpatient clinic waiting room, who were sampled on two occasions 5 years apart, over 80% of participants were able to identify one or more stroke risk factors (Metias et al., 2017). Trouble speaking and weakness, numbness, or paralysis were the signs identified most frequently. The results of surveys conducted by random sampling of members of the general community in Saudi Arabia (Naguib et al., 2020) and New Zealand (Krishnamurthi et al., 2020) also indicate that most people were familiar with at least one stroke risk factor and almost 80% recognized slurred speech and weakness as stroke symptoms. 

When surveyed even after they had suffered a stroke, many patients remained unaware of stroke risk factors, including their own. Of 173 patients admitted to a stroke unit following a first-ever stroke, only 21% of patients could identify hypertension as a risk factor. Smoking was recognized by 26.6% and obesity by 12% of patients (Faiz et al., 2018). Of 195 patients admitted to hospital following a confirmed stroke or TIA, a high percentage could not identify their own stroke risk factors (Soomann et al., 2015). Diabetes was the most recognized risk factor at 89%, while 78% and 77% of patients were aware of atrial fibrillation and previous stroke, respectively. Sundseth et al. (2014) reported that among 287 patients admitted to hospital with a suspected stroke or TIA, 43.2% were able to name at least one stroke risk factor, while 13.9% could identify two and 1.7% knew three. Smoking and hypertension were the two most commonly cited risk factors for stroke, while 70.7% of patients knew at least one symptom of stroke. In terms of their knowledge of the signs and symptoms of stroke, 66.6% identified numbness or weakness of the face, arm, or leg; 45.6% identified confusion or trouble speaking or understanding speech; and 42.9% were able to identify both of these symptoms of stroke. 

The number of public health campaigns designed to increase the recognition of the signs and symptoms of stroke has increased over the past decade. One of the most recognized programs is FAST, a mnemonic standing for (F)ace drooping, (A)rm weakness, (S)peech difficulties and (T)ime to call 911. The results of several studies indicate that persons exposed to these campaigns become more aware of the signs and symptoms of stroke. Response to the FAST campaign, through television and public transit displays, which ran from 2009 intermittently though 2014 in the UK (Wolters et al., 2018) was associated with significantly increased use of EMS for major stroke (58.8% before April 1, 2009 vs. 78.9% after April 1, 2009) and first medical attention was sought more quickly (within 3 hours) after April 1, 2009 (67.6% vs. 81.3%; OR=2.08; 95% CI, 1.40-3.11). The effect of a 27-month public awareness campaign designed to increase knowledge of the Swedish translation of FAST was less successful (Nordanstig et al., 2017). From pre-campaign (survey 1) to end of the campaign (survey 8), the number of persons who had heard of FAST increased from 15% to 50%. The percentage of respondents who could recall all keywords in the mnemonic increased from 0.3% to only 2%, while those who could recall some or all of the keywords increased from 4% to 14%. 

Bray et al. (2013) surveyed 12,439 people ≥40 years of age from the general population in Australia and reported that from 2004 to 2010, there had been a significant increase in the number of respondents who were aware of the national multimedia stroke awareness campaigns (31% vs 50%), which included FAST. There was also an increase in the number or participants who were able to name one or more warning signs of stroke (69% vs 81%), two or more (43% vs 63%), and three or more (19% vs 32%). Respondents who could identify two or more warning signs were significantly more likely to be aware of the campaign (OR= 1.88, 95% CI 1.74 to 2.04). Bray et al. (2015) also reported increases in the monthly volumes of ambulance dispatches for stroke associated with 12 National Stroke Foundation multimedia regional public awareness campaigns that ran from 2004 to 2014. The increases ranged from 1.0% to 9.9%. In 2006, there was a decrease of 2.2% in call volumes. 

Jurkowski et al. (2010) also reported that following a public awareness campaign to increase awareness of FAST, respondents who were exposed to a three-phase multimedia campaign over a seven-month period were more likely to be aware of the campaign and its primary message to call 9-1-1. The percentage of respondents who reported they would call 9-1-1 in response to specific stroke symptoms increased from 9% to 12% for specific symptoms identified in oneself and 4% to 12% for specific symptoms, from pre-to post campaign, compared to those who had not been exposed to the campaign.

Mass media campaigns have also been shown to be associated with increases in the use of thrombolytic agents following acute stroke. Advani et al. (2016) reported the average number of patients treated with t-PA increased significantly from 7.3 to 11.3 patients per month (an increase of 54.7%, p=0.02) during the period from the 12 months preceding the mass media intervention, featuring the FAST mnemonic, to the 6 months after. The average number of patients treated in the emergency department increased significantly from 37.3 to 72.8 patients per month (an increase of 95.7%, p<0.001) during the same period. Although the mean number of patients treated with t-PA dropped to 9.5 per month after the first 6 months of the campaign, it was still significantly higher than the preceding 12 months. In a telephone survey of 1,400 participants, the number of people who could name any stroke symptom increased from 66% to 75%. Of those who could name a symptom, 52% recognized facial droop, 42% named speech difficulties, and 42% named arm weakness.

Sex and Gender Considerations

Women have been reported to have better knowledge of stroke symptoms and stroke risk factors and learn more from public stroke awareness campaigns (Stroebele et al. 2011). Marx et al. (2010) reported that prior to a mass media campaign designed to improve stroke recognition and response, significantly more women than men could correctly answer the question “where does stroke happen in the body?” and knew the stroke emergency call number to call. Following the intervention, while the number of men and women who could answer the two questions correctly increased, although the percentage change from pre to post intervention was higher for women. There were increases in the mean number of stroke warning signs that could be named before and after the intervention (women: 5.4 to 6.2; men: 5.1 to 5.9). Following a public health campaign conducted in Ontario, significantly more women could identify ≥2 stroke warning signs (Hodgson et al. 2007).