News Release

Subtle stroke symptoms trigger fewer emergency calls

Peer-Reviewed Publication

American Heart Association

DALLAS, March 21 – Subtle warning signs of stroke such as dizziness, numbness or facial weakness, are less likely to prompt calls for emergency medical services (EMS) than are obvious symptoms, according to one of the first analyses of the nature of stroke emergency calls. The German study is reported in today's rapid access issue of Stroke: Journal of the American Heart Association.

Obvious and dramatic symptoms include sudden limb weakness or the inability to talk.

"Many patients wait to see if symptoms improve or disappear," says the study's lead author René Handschu, M.D., of the Freidrich-Alexander-Universitaet Urlangen-Nurnberg in Germany. "From the patient's point of view, numbness of one limb or even dizziness and nausea is not so bad that you will bother all your neighbors by calling an ambulance with lights and sirens."

But timing is crucial in stroke treatment. Some therapies like thrombolysis (clot busting) can only be administered within certain time windows. In the United States, tissue plasminogen activator (tPA) is the only Food and Drug Administration-approved drug available to treat the most common type of stroke. This clot buster can limit disability but must be given within three hours of stroke symptom onset.

"The main reason the vast majority of acute stroke patients do not receive effective treatment in time is because there is a prolonged time between onset of first symptoms and first attempts of seeking medical attention," Handschu says. "Immediately recognizing stroke symptoms and calling for emergency services is a crucial factor in improving outcome for acute stroke patients.

"There is a striking need for educational efforts to improve recognition of especially non- dramatic and atypical stroke symptoms in the general population but also in family members of patients at higher risk for stroke," he says.

Researchers analyzed the records of all patients admitted to the hospital's stroke unit through the city's EMS system in a year. They evaluated 141 EMS calls. Patients were average age 65.4.

Speech problems were reported in 25.5 percent of cases, limb weakness in 21.9 percent and an altered state of consciousness in 14.8 percent. In 21.2 percent of cases, a fall was the reason for the call. Subtle symptoms were rarely mentioned. Facial weakness was reported in 9.9 percent of cases, numbness in 7.8 percent of cases and dizziness in 5.6 percent of cases.

Only 19.8 percent of callers mentioned stroke or transient ischemic attack (TIA) as the possible cause of the health problem. Dispatchers suspected a stroke in 51.7 percent of all calls. They sent a high priority ambulance in 79.3 percent of all cases.

"The infrequent use of the phrase 'stroke' in calls to dispatchers is a hint for insufficient knowledge about stroke symptoms in the population of our study area," he says.

In this study, the average time between onset of symptoms to EMS call was 38 minutes. It took an average of 12 minutes for EMS to arrive and 51 minutes on average to arrival at the hospital. Time from hospital arrival to delivery of the clot buster was about 40 minutes, Handschu says.

"In sheer numbers, the biggest delay is prehospital. The important question is what part of the delay can we reduce," Handschu says. "We can work on further reduction of in-hospital delays of treatment but we reach limits. The most important factor in reducing delay is the patient himself."

The analysis found that patients who delayed calls were often older, living alone and were unaware of the severity of their problem or unable to call. Family and friends who called late tended to be those who arrived late on the scene, several hours after the onset of symptoms. Callers tended to be at least 10 years younger than the patient, and were typically the patient's spouse, children or close neighbors. "This could be one target group for public education," Handschu says.

Handschu says it also might help to train dispatchers in specific stroke symptoms and to provide them with a written questionnaire for responding to calls. For example, they might ask about the cause of a fall and whether symptoms preceded the fall.


Co-authors are Reinhard Poppe; Joachim Rauss; Bernhard Neundörfer, M.D. Ph.D.; and Frank Erbguth M.D., Ph.D.

NR03-1039 (Stroke/Handschu)

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