Welcome to Stroke Education.CO.UK

Stroke Screening Tools

(Updated 2nd October 2017)

Learning objectives

  • Use and application of pre hospital assessment scores
  • Understand that these score only useful if well taught and familiar in populations at risk
  • Ensure robust systems to audit effectiveness
  • Screening in the ED with ROSIER to enable rapid escalation to stroke team

Introduction: Prehospital Stroke Assessment

  • These were devised to help first responders and the general public to focus on stroke patients from all their other call so that these patients could be rapidly brought to the correct hospital with a stroke centre and to the appropriate team for revascularisation therapies to reduce disability.
  • Early recognition is key to early treatment and therefore there has to be a good level of bystander ability to recognise a stroke and act quickly. There has been a huge amount of publicity to make the public and other healthcare workers more aware of the early signs of possible stroke.
  • Various assessment tools have been suggested for public and paramedical staff. For the sake of interest I have included a few of them here but the one which is used nationally is the FAST test which we will go on to to discuss.

The Cincinnati Prehospital Stroke Scale

Cincinnati Prehospital Stroke Scale: Tests three things - face, arm droop and speech and as you will see it is very similar to FAST. It was based on a simplification of the National Institutes of Health (NIH) Stroke Scale.
Facial droop Have the person smile or show his or her teeth. If one side doesn't move as well as the other so it seems to droop, that could be sign of a stroke. Normal: Both sides of face move equally or Abnormal: One side of face does not move as well as the other (or at all)
Arm drift Have the person close his or her eyes and hold his or her arms straight out in front for about 10 seconds. If one arm does not move, or one arm winds up drifting down more than the other, that could be a sign of a stroke. Normal: Both arms move equally or not at all. Abnormal: One arm does not move, or one arm drifts down compared with the other side
Speech Have the person say, "You can't teach an old dog new tricks," or some other simple, familiar saying. If the person slurs the words, gets some words wrong, or is unable to speak, that could be sign of stroke. Normal: Patient uses correct words with no slurring. Abnormal: Slurred or inappropriate words or mute
Assessment The CPSS was found to have excellent reproducibility among prehospital personnel and physicians. It has good validity in identifying patients with stroke who are candidates for thrombolytic therapy, especially those with anterior circulation stroke [Kothari et al. 1999].

Face Arm Speech Test (FAST)[Harbinson et al 2003]

Face Arm Speech Test (FAST) : This is very similar to CPSS. Suspect stroke if any of the following is answered "yes"
Face Facial movements - Ask patient to smile or show teeth. Look for new asymmetry. Is there an unequal smile or grimace or obvious facial asymmetry.
Arm Arm movements : Lift the patient's arms together to 90 degrees if sitting, or 45 degrees if supine. Ask him to hold that position for 5 sec and then let go. Does one arm drift down or fall more rapidly?
Speech Speech impairment : Look for new disturbances in speech. Look for slurred speech and word finding difficulties.
Test test all three and ring 999/911 if any one of these is positive

Paramedics using the Face Arm Speech Test achieved high levels of detection and diagnostic accuracy of stroke


List of Acute Stroke Screening Tools

  • Cincinnati Prehospital Stroke Scale (CPSS)
  • Face Arm Speech Test (FAST)
  • Los Angeles Prehospital Stroke Screen (LAPSS)
  • Melbourne Ambulance Stroke Screen (MASS)
  • National Institutes of Health Stroke Scale (NIHSS)
  • Recognition of Stroke in the Emergency Room (ROSIER)

Screening in the Emergency Department - ROSIER Scale

  • Once patients get to the ED where they can be seen by a physician then the ROSIER scale (Recognition of Stroke in the Emergency Room) has been advocated and is widely used. The ROSIER scale as detailed is simply an enhanced FAST test that subtracts from the stroke score if there is documented hypoglycaemia or a seizure at symptom onset. It also includes visual loss and leg weakness within the clinical criteria.
  • As a screening test more recent studies have shown that it does not add much beyond the sensitivity and specificity of the simpler FAST test (Whitely et al. 2011) and it may just delay escalation to the stroke service. Locally we would alert stroke team on basis of FAST and initial clinical assessment. ROSIER is included here for your information and to be aware of it as it is on the stroke proforma of many hospitals. It may well be used in your local hospital. There are other screening tools.
ROSIER SCALE
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)? Y(-1) N (0)
I. Asymmetric facial weakness Y(+1) N(0)
II. Asymmetric arm weakness Y(+1) N(0)
III. Asymmetric leg weakness Y(+1) N(0)
IV. Speech disturbance Y(+1) N(0)
V. Visual field defect Y(+1) N(0)
Total score = (-2 to 5)
If total score > 0 (1 to 6) a diagnosis of acute stroke is likely. If total scores 0, -1 or -2 stroke unlikely but is not excluded and patient should be discussed with the stroke team.

If at this stage an acute stroke with onset within past 4-4.5 hours is diagnosed please alert stroke team urgently and arrange an urgent head CT.

Screening tests


ROSIER (90% CI) CPSS (95% CI) FAST (95% CI) LAPSS (95% CI)
Sensitivity 93 (89-97) 85 (80-90) 82 (76-78) 59 (52-56)
Specificity 83 (77-89) 79 (73-85) 83 (77-89) 85 (80-90)
Positive Predictive value 90 (85-95) 88 (83-93) 89 (84-94) 87 (82-92)
Negative Predictive Value 88 (83-93) 75 (68-82) 73 (66-80) 55 (48-62)

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