I Just Kinda Kinda Wasted All My Precious Time: t-PA and Stroke Delay

Two eyes with startlingly different pupils. Plain background.

My Eyes in the Time of Apparition, August Natterer 1913

Just recently my daughter, who is Bipolar Blogger, sent me an article by Geoff Dyer: ‘Why Can’t I See You’.

Geoff is a well-known writer but what my daughter knew would hook me was that he wrote about the experience of having a stroke. More that that, his main symptom was vision loss.

Dyer is a powerful writer and I found his story moving, because I could identify with much of it. I’ve had a stroke with similar symptoms and for me his story is evocative. It’s so well written, I hope you will look at it.

Most stokes are ischemic – a blockage in a blood vessel cuts off the supply to some part of the brain and neurons deprived of oxygen and energy are quickly damaged and soon die.

But brain cells may live to fight again if the blood comes back. There is a drug, t-PA, that can disperse the blockage and allow the cells to recover. If you get it soon enough it could make a big difference to the rest of your life.

How soon is enough? Well, three hours about. Maybe a little more. And that needs to allow time for evaluation. Really it’s best if you can get to the stoke unit within an hour. After the three hours or so it’s probably too late for the intervention to make much difference. That’s the message behind the FAST checklist:

F stands for face

A stands for arm

S stands for speech

T stands for Treatment

and FAST for fast.

Fortunately Dyer got rapid attention. But FAST misses out another common symptom – the one Dyer had. Vision loss. Someone suddenly can’t see properly but thinks it will pass. They go to bed, and hope their vision will be back to normal in the morning. But it isn’t and they have wasted all their precious time. Much too late now for t-PA.

This quite common series of events is highlighted by Alex Leff of University College London, in an interview with ABC online radio. According to Dr Leff vision loss is probably the third most frequent stoke sign.

But many (not all) big publicity campaigns setting out to raise awareness of stroke signs don’t include vision loss, or only as an also ran. FAST steals all the attention.

Why? Alex Leff has suggested it may be because of a fear that including vision could clog up the ambulance system. Migraine is very common and what is called the migraine aura can certainly look like the symptoms of vision loss from stroke. In fact a correspondent said his stroke was like “the mother of all migraines”.

So if vision loss were added to FAST (I though of Very FAST) many people who “only” have migraine might call the ambulance and be whisked to hospital needlessly, so the story goes.

I’m not saying this was the reasoning, but it could have been. There is obviously another issue as well: the simple acronym FAST has been effective in reaching public consciousness and making people understand treatment is urgent. FAST campaigns have done a superb job on the whole.

But not for those with no Face, Arm or Speech signs. The problem is that FAST can be seen as ruling stroke OUT. It was not designed to do that, but to rule stroke IN, and for that it is very effective. The symptoms it covers are very likely to result from stoke and other causes are rare. It has a low rate of false positives.

But we intuitive think low false positives =  low false negatives. This is our gut feeling. So we think “I passed the FAST test, so it’s not a stroke, Woo Hoo!”.

I certainly felt this way – after the initial feeling of confusion had passed I self-tested and found no FAST signs, so I was (falsely) reassured. Phew! It was getting on in the evening, of course I wanted it to not be a stroke, and so I went to bed. Unfortunately tomorrow was another day.

Of course we can’t include all the possible stroke signs in a publicity campaign. It has to be short and memorable, which FAST is. But I’m worried that vision loss is missing. I don’t believe including it would really clog up the ambulances so very much.

So I’d like to make a modest proposal for VFAST. Is it Vision, Face, Arm, Speech, Treatment? Or maybe V for Very?


Painting: My Eyes in the Time of Apparition, from WikiPaintings



About partialinsight

One evening I had a stroke. Half my sight vanished overnight. Adapting made me grasp how amazing the visual system and brain are. It also taught me to understand disability completely differently and I'm grateful for the lesson.
This entry was posted in Blindness and visual impairment, Stroke, Disability, Cognition, Uncategorized and tagged , , , , , , , , , , , , , . Bookmark the permalink.

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