The following article is a part of conference coverage from the 2021 American Association of Nurse Practitioners National Conference (AANP 2021), held virtually from June 15 to June 20, 2021. The team at the Clinical Advisor will be reporting on the latest news and research conducted by leading NPs. Check back for more from AANP 2021.


Stroke diagnosis can be challenging for clinicians, primarily because the clinical manifestations, patient reported symptoms, and physical examination findings are highly variable. Subtle stroke signs are frequently missed, researchers reported at the 2021 American Association of Nurse Practitioners National Conference (AANP 2021).1

In the US, over 795,000 people are impacted by stroke each year, representing a leading cause of chronic adult disability. Rapid recognition of stroke signs and symptoms, transportation to and treatment at an accredited stroke center, and thrombolytic administration can reduce both disability and cost of care.

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The FAST acronym—face, arm, speech, and time—is widely used in both public and health care settings to identify stroke symptoms, but the tool can exclude more subtle signs and symptoms. To describe the limitations of currently available stroke screening as well as newer modifications made to these tools to improve diagnostic accuracy, Stephanie Rosser, DNP, APRN, of the University of Texas Medical Branch School of Nursing in Galveston, Texas, conducted a literature review.

Twenty-four articles were reviewed and 8 were included in the final analysis: 4 systematic reviews and 4 case control, cohort, or descriptive studies. Four studies were determined to provide level 1 evidence and 4 studies were of level 4 evidence.

The first systematic review, published in 2016, found that the Melbourne Ambulance Stroke Scale (MASS), Medic Prehospital Assessment for Code Stroke (MedPACS), and Ontario Prehospital Stroke Screening (OPSS) tools were evaluated only in a single prehospital setting, with high variability in the sensitivity and specificity of the studies.2 The remaining 3 systematic reviews, found that the Cincinnati Pre-Hospital Stroke Scale (CPSS) had a high degree of both sensitivity and specificity in field settings and should be used preferentially over other scales.3-5

ROSIER Test Has a Higher Sensitivity Over FAST

Zhelev et al found that in emergency department settings, both Recognition of Stroke in the Emergency Room (ROSIER) and FAST demonstrated similar levels of accuracy.4 However, the ROSIER scale was evaluated in more studies with “consistently higher sensitivity” compared with FAST, making it the test of choice.4 Meyran and colleagues reported that both FAST and OPSS were associated with “a positive increase in the number of patients who received timely reperfusion treatment.”5

BE-FAST May Improve Diagnostic Accuracy

The case control, cohort, and descriptive studies found that patients who presented with typical posterior stroke symptoms (nausea, vomiting, and dizziness) received delayed evaluation and 14% of stroke diagnoses were missed using the FAST acronym.6-8 However, adding balance and eye examination to the acronym (BE-FAST) reduced the number of missed strokes.8

Finally, results of a study by Oostema and colleagues showed that adding the finger to nose test to the CPSS improved recognition of posterior stroke in field settings.9

“Current stroke screening tools generally perform well when patients display overt signs of stroke [hemiparesis and neglect],” Dr Rosser concluded. “However, they lack sensitivity in recognizing more subtle signs associated with [posterior circulating stroke] including visual changes, balance, dizziness, nausea, and vomiting.”

“Providers must be aware of the limitations of existing stroke screening tools and suggested modifications to improve identification of acute stroke, particularly [posterior circulating stroke], to ensure timely treatment,” she concluded.

Visit Clinical Advisor’s meetings section for complete coverage of AANP 2021. All conference sessions are available to registered attendees through August 31, 2021.


1. Rosser S. Beyond FAST: Barriers to recognizing the subtle signs of acute stroke. Presented at: 2021 American Association of Nurse Practitioners National Conference; June 15-20, 2021. Poster 2.

2. Rudd M, Buck D, Ford GA, Price CI. A systematic review of stroke recognition instruments in hospital and prehospital settings. Emerg Med J. 2016;33(11):818-822. doi:10.1136/emermed-2015-205197

3. De Luca A, Giorgi Rossi P, Villa GF; Stroke group Italian Society pre-hospital emergency Services. The use of Cincinnati Prehospital Stroke Scale during telephone dispatch interview increases the accuracy in identifying stroke and transient ischemic attack symptoms. BMC Health Serv Res. 2013;13:513. doi:10.1186/1472-6963-13-513

4. Zhelev Z, Walker G, Henschke N, Fridhandler J, Yip S. Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack. Cochrane Database Syst Rev. 2019;4(4):CD011427. doi:10.1002/14651858.CD011427.pub2

5. Meyran D, Cassan P, Avau B, Singletary E, Zideman DA. Stroke recognition for first aid providers: a systematic review and meta-analysis. Cureus. 2020;12(11):e11386. doi:10.7759/cureus.11386

6. Sarraj A, Medrek S, Albright K, et al. Posterior circulation stroke is associated with prolonged door-to-needle time. Int J Stroke. 2015;10(5):672-678. doi:10.1111/j.1747-4949.2012.00952.x

7. Arch AE, Weisman DC, Coca S, Nystrom KV, Wira CR 3rd, Schindler JL. Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke. 2016;47(3):668-673. doi:10.1161/STROKEAHA.115.010613

8. Aroor S, Singh R, Goldstein LB. BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): reducing the proportion of strokes missed using the FAST mnemonic. Stroke. 2017;48(2):479-481. doi:10.1161/STROKEAHA.116.015169

9. Oostema JA, Chassee T, Baer W, Edberg A, Reeves MJ. Educating paramedics on the finger-to-nose test improves recognition of posterior stroke. Stroke. 2019;50(10):2941-2943. doi:10.1161/STROKEAHA.119.026221