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Posterior circulation stroke: still a Cinderella disease

BMJ 2013; 346 doi: (Published 14 June 2013) Cite this as: BMJ 2013;346:f3552

Rapid Response:

Re: Posterior circulation stroke: still a Cinderella disease

The editorial by A Emsley on the Posterior circulation stroke as a Cinderella disease (1) is very welcomed as it is helping to increase the awareness of these strokes, and encouraging finding ways for earlier recognition and appropriate management. The FAST tool (Face, Arms, Speech & Time to call 999) developed at Newcastle (2) had contributed immensely to the hyperacute care of ischemic strokes . However, as highlighted by the editorial, FAST fails to detect and triage a significant proportion of acute ischemic strokes affecting the posterior fossa (1, 3). In addition, it does not detect ophthalmic TIAs and strokes.

The posterior fossa contains parts of the brain not represented in the FAST Tool such as the cerebellum and occipital cortex. In addition, many functions of the brain stem are also not included in the FAST Tool such as eye signs, swallowing and sudden impairment or loss of consciousness. Furthermore, sudden onset of impaired / loss of consciousness might be an important feature of basilar artery thrombosis, and this symptom is underscored by the ROSIER Tool (Recognition of Stroke in the Emergency Room) (4). Indeed, a study has recommended the simpler FAST tool has been to replace the ROSIER for initial assessment of patients with suspected acute stroke (5).

We had experienced these difficulties and through an audit a series of 36 consecutive patients, it became apparent to us that the addition of a cerebellar dysfunction (Ataxia- A) and an occipital lobe dysfunction (Vision or blindness) to the FAST Tool, would lead to increase the sensitivity of the FAST Tool for the detection of posterior fossa strokes. Therefore we suggested FAST-AV or FAST AB tool for FAST Negative patients; where A represents ataxia, and V or B represent visual disturbance or blindness whether partial or complete (6). We believe that such a tool would be easy and simple for use by the paramedics but further larger corroborative studies are needed.

The life threatening basilar artery thrombosis is often overlooked by the non-stroke physicians and neurologist and thus triaged to general wards where treatment is delayed. ROSIER will underscore the latter group of patients and for which we did attempt a new tool of diagnostic ABCD-E2 {A for ataxia; B for blindness; C for impaired consciousness; D for sudden dysphagia; and E2 comprises of E-1 for diplopia while E 2 representing pupillary abnormalities} (7, 8).

Therefore it seems that a supplementation to the FAST is really needed and the use of FAST-AV or FAST –AB for FAST negative patients might be helpful, while the Diagnostic ABCD-E2 might trigger thinking of basilar artery thrombosis.

Conflict of interest: None


1. Emsley HCA. Posterior circulation stroke: still a Cinderella disease, Editorial. BMJ 2013;346:f3552

2. Harbison J, Massey A, Barnett L, Hodge D, Ford GA. Rapid ambulance protocol for acute stroke. Lancet. 1999; 353: 1935.

3. Gulli. G, Markus HS. The use of FAST and ABCD2 scores in posterior circulation, compared with anterior circulation, stroke and transient ischemic attack J Neurol Neurosurg Psychiatry doi:10.1136/jnnp.2010.222091

4. Nor AM, Davis J, Sen B, et al.. The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. Lancet Neurol 2005;4:727–34

5. Whiteley WN, Ward law JM, Sandercock PAG. Clinical scores for the identification of stroke and transient ischaemic attack in the emergency department: a cross-sectional study. J Neurol Neurosurg Psychiatry i:10.1136/jnnp.2010.235010

6. Huwez, F. and Casswell, E. J. (2013), FAST-AV or FAST-AB tool improves the sensitivity of FAST screening for detection of posterior circulation strokes. Int J of Stroke, 8: E3. doi: 10.1111/ijs.12008

7. Huwez F. Management of TIAs: what are the costs of Failure to Recognise? Essex Stroke Meeting Regional Conference, April 16th, 2011.

8. Gadi N, F.Huwez. ABCD-E2 for Fast Negative TIAs/ Strokes in Middle Aged and Elderly Patients. Aging Clin Exp Res 2011; 23(1), 199 (Abstract)

Competing interests: No competing interests

27 June 2013
Farhad Umer Huwez
Consultant Phyysician
Southend University Hospital
Prittlewell Chase, Wescliff-)n-Sea, Essex SS0 0RY