Not so FAST: pre-hospital posterior circulation stroke.

Area of Science:

• Neurology
• Emergency Medicine
• Stroke Medicine

Background:

• Posterior circulation strokes represent 20% of ischemic strokes.
• These strokes often present with non-specific symptoms like headache, dizziness, and visual disturbances, differing from anterior circulation strokes.
• The standard FAST (Face, Arm, Speech, Time) test may not identify posterior circulation strokes due to atypical presentations.

Observation:

• A 60-year-old male presented with generalized weakness, diaphoresis, and emesis, initially testing negative on the FAST assessment.
• Persistent dizziness prompted further neurological examination, revealing left visual field neglect, nystagmus, left-sided dysmetria, and gait instability.
• These findings indicated a potential posterior circulation stroke despite the initial negative FAST evaluation.

Findings:

• The patient received timely thrombolysis with tissue plasminogen activator after hospital assessment.
• Prompt diagnosis and treatment led to a full neurological recovery for the patient.
• This case highlights the limitations of the FAST test in recognizing posterior circulation strokes.

Implications:

• There is a need to enhance pre-hospital stroke recognition protocols.
• Incorporating additional neurological assessments, such as the 'BEFAST' mnemonic (Balance, Eyes, Face, Arm, Speech, Time), the finger-to-nose test, and the '5 Ds' and 'DANISH' mnemonics, can improve the detection of posterior circulation strokes.
• Improved recognition of subtle stroke symptoms can lead to earlier intervention and better patient outcomes.