Stroke, or acute cerebrovascular disease, is divided into two categories: ischemic and hemorrhagic, with the former being the most common (accounting for about 75% to 85% of all stroke patients). Stroke is a common and frequent disease affecting human health and life, causing great suffering and heavy economic burden to patients, families and society. However, medicine is not completely helpless against stroke. If a patient with ischemic stroke can arrive at the hospital within 3-4.5 hours after the onset of the stroke, the doctor can “dissolve” the thrombus through thrombolysis. The patient will be safe.
I. Quick identification of stroke
In order to enable patients and their families to quickly identify stroke symptoms and get effective treatment as soon as possible, doctors have come up with many ways. The purpose of the proposed quick identification recipes is to educate the public on how to quickly identify a stroke.
1. Cincinnati Stroke Indicator (FAST mnemonic). The FAST phrase is a simple identification method for stroke proposed by the Cincinnati Stroke Center in the U.S. The contents of the FAST phrase are.
(1) F (Face): Ask the patient to smile and observe whether the corners of the mouth are asymmetrical.
(2)A(Arm): Ask the patient to close his eyes and raise his arms flat, and observe whether his arms will hang down due to weakness.
(3)S(Speech language): Ask the patient to speak a sentence and observe if there is slurring of speech.
(4)T(Time time): Record whether the onset is within 3 hours.
The initials of the four English words are combined to become a new English word FAST (Fast), which tells the public that once the above situation occurs, they must quickly call the emergency number and send them to the hospital for treatment.
2.Stroke simple judgment method – STR method. Some researchers have proposed a new simple judgment method for stroke according to the main symptoms of stroke – STR method.
(1) S (Smile smile): Ask the patient to smile. Look for any asymmetry of the corners of the mouth. If the corners of the mouth are asymmetrical on both sides, it suggests facial palsy.
(2) T(Talk): Ask the patient to say a simple sentence in an organized and coherent manner, e.g., it is a sunny day. If the sentence is slurred or incoherent, the patient has a speech impediment.
(3) R (Raise your hands): Ask the patient to raise his or her hands flat. See if one arm falls down uncontrollably within 10 seconds. If so, it suggests that a stroke may have occurred.
By remembering the three steps of STR, you can quickly identify a stroke with an accuracy rate of up to 90 percent. It can help stroke patients win treatment time and improve the treatment effect.
3. “Stroke 120” mnemonic. However, both the “FAST recipe” and the “STR recipe” are based on the initial spelling of English words, which is indeed very simple and easy to remember for the English-speaking public or the non-English-speaking public who know English. However, it is difficult for Chinese people who do not know English to understand and remember, and although it is very concise, it is not suitable for Chinese conditions. For this reason, Professor Liu Renyu of the University of Pennsylvania and Professor Zhao Jing of the Minhang Hospital of Fudan University have proposed a Chinese version of the “Stroke 120” mnemonic, which is very suitable for the Chinese context and was published on October 29, 2016 on World Stroke Day. The Chinese version of the “Stroke 120” was published in the Lancet Neurology journal on October 29, 2016. The recipe reads.
(1) Look at 1 face for asymmetry and crooked corners of the mouth (“1” stands for “see 1 asymmetrical face”)
(2) Checking 2 arms, holding both hands flat, to see if there is unilateral weakness and one arm falls down (“2” stands for “check if there is unilateral weakness in both arms”)
0 (Listening) Listen to language, ask the patient to say a complete sentence, such as it is a sunny day, see if there is unclear language, expression difficulties. (“0” is the harmonic sound of “listening”, which means “listening to the clarity of speech”)
The three items together form 120, which is the same as the Chinese national medical emergency number 120. This means that if you have any of the above three symptoms, call the 120 emergency number. Take the patient to a hospital that is equipped for stroke diagnosis and treatment.
Evaluation of the “Stroke 120” recipe
The “Stroke 120” recipe completely covers the contents of “FAST recipe” and “STR recipe” for stroke. That is
1. 1 face = F (Face face) = (Smile Smile)
2, 2 arms = A (Arm arm) = R (Raise your hand)
3. 0(Listen) = S(Speech language) = T(Talk speak)
A stroke rapid recognition technique must reflect both the motor and speech components of the primary impairment, must have a neurological basis, and must be very simple, easy to learn, easy to remember, and easy to use.
The main hallmark symptoms of stroke are sudden onset of motor impairment, sensory impairment, and speech impairment. The sensory examination is the least accurate and least reproducible part of the neurological examination overall, and it is clearly inappropriate to use it as a standard of identification technique. The “Stroke 120” includes the basic neurological signs and symptoms of stroke, such as cranial nerve, motor, and speech. It is easy to understand and remember by Chinese people, and is more in line with Chinese culture. Moreover, it has a solid neurological foundation.
The neurological basis of the “Stroke 120” recipe
1. Look at a face to see whether there is asymmetry and crookedness of the corners of the mouth, which reflects the cranial nerve disorder. Except for the periorbital area below, the facial innervation has two kinds of fibers: crossed and uncrossed. Therefore, lesions of facial nerve fibers above the cranial nerve nucleus will result in lesser facial dysfunction. Involvement of the facial nerve nucleus results in complete hemiparesis of the face.
To examine the facial nerve, the motor function function of the face is examined by observing the movement of the facial muscle tissue. When facial palsy is present, the nasolabial fold on the paralyzed side is shallow and the corners of the mouth are slightly deviated to the healthy side. Whether it is central facial palsy (lesions above the cerebral bridge) or peripheral facial palsy (when the cerebral bridge is lesioned), the corner of the mouth will be deviated.
2. Check 2 arms, hold both hands flat and see if there is unilateral weakness with one arm falling down. The main purpose is to check the patient’s motor disorder.
All purposeful movements in humans are done by the brain through the cone bundle to innervate muscle movements. After a stroke, movement disorders are manifested due to dysfunction of the cerebral cortex or the pyramidal tract (subcortex, brainstem). Therefore, it is important to examine and detect movement disorders. According to the degree of motor impairment, there are two types of paralysis: complete paralysis and incomplete paralysis. In complete paralysis, there is a complete loss of muscle strength and the limbs are in a state of complete inability to move at will. In incomplete paralysis, the muscle strength of the limb is somewhat reduced, so some random movement is still preserved. Either complete paralysis or paraplegia can be detected by asking the patient to raise his or her hands flat.
(1) Complete hemiparesis: The best aspect of the motor system to examine is observation. Complete and severe limb paralysis is evident due to the lack of limb movement. It is also not the target of the oral recipe.
(2) Mild hemiparesis: This is the main purpose of the “hands up” test, where the patient is asked to raise both hands flat and see if one arm falls due to weakness.
It is derived from the upper extremity mild hemiparesis test (upper extremity barley test) and the anterior rotator drift test (occult mild hemiparesis test).
(1) Upper extremity bradykinesia test (upper extremity barley test): The patient is asked to hold both upper extremities forward and maintain this position. In mild hemiplegia, the upper limb on the side can be flattened, but it cannot be sustained, and after a few seconds, it can be seen to droop and lower than the healthy side.
(2) Rotator anterior muscle drift test (occult hemiparesis test): Ask the patient to extend both upper limbs forward with palms upward, then close the eyes and maintain this posture. If the upper limbs remain extended without any deflection for 10 seconds when the eyes are closed, the test can be considered normal.
The limb on the mildly paralyzed side will slowly move down and the hand will begin to rotate forward. This is due to the heavier involvement of the posterior rotator muscle of the upper limb when the conus fasciculus is involved.
3, 0 (listening) listening to language, let the patient say a complete sentence, such as “Today is a sunny day”, to see if there is unclear language, expression difficulties. This is a reflection of the language barrier.
The expression of spoken language in humans requires the tight integration of multiple regions of the nervous system. Language is formed in the frontal lobe. The Broca area of the motor area directs specific directions of movement, and then information is transmitted through the cortical medullary tract to various brainstem nuclei that innervate the muscles that move the teeth, lips, tongue and soft palate to form language. The cerebellar conduction tracts tightly integrate these movements.
The major areas of reception, translation and movement of spoken language are located around the lateral fissure and central sulcus, which are primarily supplied with blood by the middle cerebral artery. Wernicke’s area, located in the primary auditory cortical area of the temporal lobe, receives spoken language and has a supervisory function. It then travels to the parietal angular gyrus, which translates and integrates auditory stimuli and relates them to other areas of the brain for comprehension. Arch fibre tracts connect these posterior language areas to Broca’s area in the motor tract, from which specific motor commands are issued and translated into actual spoken language.
The examination of language disorders is very complex. In practice, we are asking the patient to say a complete sentence, e.g., it is a sunny day, and see if he can speak it fluently. The oral test not only checks details about the cortical function of the language, but is able to check for such output incongruities as dysarthria. It is generally not necessary to examine any other specific aspects in patients who are articulate and can carry on a normal conversation. Fluent speech usually means that the motor system is normal.
Native speakers with any type of speech difficulty or slurred spelling should be considered abnormal.
Like the “FAST” and “STR” phrases, the “Stroke 120” phrase can teach people to quickly identify strokes with facial palsy, hemiparesis, mild hemiparesis or upper extremity paralysis and speech impairment. However, it does not include those with vertigo, sensory disorders, chorea, epilepsy as the first or only symptom, or those with blackness in one eye or partial blindness in the visual field. The good thing is that the number of stroke patients with these symptoms as the first or only symptom is only a small number of cases after all.
If “Stroke 120” can be popularized throughout China, it will greatly reduce the pre-hospital delay of stroke patients, win valuable rescue time, make thrombolysis and embolism retrieval within the time window a reality, and make it possible to save the ischemic semi-dark zone. This will significantly reduce the disability and mortality rate of stroke patients, extend the average life expectancy of patients, improve their quality of life, and reduce the economic burden of families and society.