Is the ‘Act FAST’ stroke campaign lobeist? The implications of including symptoms of occipital lobe and eye stroke in public education campaigns

The ‘Act FAST’ public education campaign was introduced to reduce the time to presentation of patients with stroke, and thereby increase the opportunity for thrombolysis and rapid initiation of secondary prevention. The campaign was launched in the UK in February 2009 and has subsequently been adopted in a number of other countries, including the USA and Australia. One significant limitation of the ‘Act FAST’ campaign, however, is that the acronym excludes any reference to the symptoms of sudden visual loss, which may be a manifestation of embolic disease either in the anterior or posterior circulation. One solution would be to modify the acronym to include vision: ‘Act VFAST’ (act very fast). FAST has been shown to have good diagnostic sensitivity (>75%) when used by ambulance staff, and other authors have suggested alternative acronyms to further increase this sensitivity. However, these study designs involve patients who have already been presented to hospital and it is therefore not possible to determine false-negative rates: in the case of vision, it is not known how many patients with embolic visual changes do not make it to acute services for review. If patients with vision loss are not aware that this can be a symptom of stroke, they may not present in the first place. One potential way to improve this is to increase recognition within the community that vision loss can be a manifestation of stroke. Interestingly, there is also evidence that when matching descriptions of stroke symptoms to patient experience of those symptoms, ‘loss of vision’ or ‘sudden decrease in vision’ had much higher rates of patients identifying that this description exactly matched their experience. Visual symptoms from embolic disease may manifest through occlusion of the retinal or posterior circulation vessels: 5– 10% of ischaemic strokes in the USA involve the posterior cerebral artery (PCA) or its branches. A population-based study on all types of TIA using active ascertainment of the secondary event found the risk of subsequent stroke was 9.9% at 2 days and 13.4% at 30 days. Further, the subset of patients with visual manifestations of embolic disease experience a longer delay in diagnosis: this often precludes thrombolysis and delays the initiation of secondary prevention. This is in part because screening tools used in emergency departments are less sensitive for posterior circulation than anterior circulation events, but also because poor public awareness of the visual manifestations of stroke results in patients being less likely to present urgently. Binocular visual loss from embolic disease relates to occlusion of the posterior circulation; although mortality from PCA stroke is low, morbidity is high. Cortical blindness is as disabling as any other cause of blindness, and hemifield visual field loss often precludes driving and may significantly impair reading, activities that are strong influences on independence and quality of life. Unless patients are aware that sudden visual loss can be caused by stroke, the delay in presentation will preclude thrombolytic treatment, and yet evidence is now emerging that those with posterior circulation strokes benefit from this treatment. 10 Monocular visual change from embolic disease relates to occlusion of the retinal arteries. While there is limited evidence for thrombolysis for this indication, early investigation and diagnosis would allow prompt initiation of secondary prevention. This is particularly important given that