FAST to recognise, ROSIER to confirm, CT to exclude haemorrhage
Expansion
FAST, for public and prehospital recognition:
- F - Face: has the face fallen on one side?
- A - Arms: can they raise both arms and keep them there?
- S - Speech: is it slurred?
- T - Time to call emergency services
ROSIER is the hospital tool, and it subtracts points for seizure and syncope, which are the main mimics.
Immediate steps
- Blood glucose, the commonest mimic
- Immediate non-contrast CT head, to distinguish infarct from haemorrhage
- Establish the time of onset, or the time last seen well
Thrombolysis with alteplase or tenecteplase within 4.5 hours of onset, once haemorrhage is excluded and there is no contraindication.
Thrombectomy within 6 hours for a proximal anterior circulation occlusion, and up to 24 hours in selected patients with favourable perfusion imaging.
If not thrombolysed: aspirin 300 mg for 2 weeks, then long term antiplatelet. Aspirin is delayed 24 hours after thrombolysis, with a repeat CT first.
Stroke mimics: hypoglycaemia, seizure with Todd’s paresis, migraine with aura, space occupying lesion, sepsis in a previous stroke, and functional disorders.