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Copyright (c) 2026 HMOOD HEGE Al DHMSHY, Zidan Khalaf Aqeel alanezi, Lazzam Mubarak Al-Anazi, Basim Mousa Alhumaidi Alhazmi, BADER MALAH ALI ALANAZI, Sami Jumah K Alhazmi, Mohammed Mrih M Alenezi, ABDULAZIZ BASHEER SHAMI ALANAZI, Nawaf Rasheed Sunaydih Alruwaili, Ayed Salhoub Ayed Alswilmi, Ismail Rabie Mukhlif Al-Hazmi, Ishaq Rabie Mukhlif Al-Hazmi, Basim Mousa Alhumaidi Alhazmi, Alhazmi YSIF SALEH
This work is licensed under a Creative Commons Attribution 4.0 International License.
Recognition and Early Assessment of Acute Stroke Using the FAST and BE FAST Approach-An Updated Review.
Corresponding Author(s) : HMOOD HEGE Al DHMSHY
Saudi Journal of Medicine and Public Health, Vol. 3 No. 1 (2026)
Abstract
Background: Acute stroke requires rapid recognition and referral to improve access to time-dependent treatments and reduce mortality and long-term disability. Delays in symptom identification, emergency response, and hospital referral remain major challenges across healthcare systems.
Aim: This systematic review aimed to evaluate the effectiveness of stroke recognition tools and referral strategies in primary and emergency care and examine their effects on treatment timeliness and patient outcomes.
Methods: A systematic review was conducted of 33 studies published between 2003 and 2025. The included studies investigated conventional stroke recognition scales, dispatcher-based triage systems, emergency medical services interventions, mobile stroke units, and artificial intelligence-based approaches. Evidence was synthesized narratively because of heterogeneity in study designs, populations, diagnostic accuracy measures, and reported outcomes.
Results: FAST, CPSS, ROSIER, and NIHSS were frequently evaluated, with conventional screening tools generally demonstrating sensitivity above 80%, although specificity varied. PreHAST and FAST-ED showed potential for identifying severe stroke and large vessel occlusion. Dispatcher-based systems improved emergency prioritization and reduced referral delays by approximately 12–20 minutes. Mobile stroke units reduced time to imaging by 8–17 minutes and increased reperfusion eligibility by 7–12%. Improved recognition and referral were associated with greater treatment access and functional independence. However, rural and resource-limited settings continued to experience delays related to transportation, imaging availability, and EMS capacity. AI-based approaches showed promising diagnostic performance but require further validation.
Conclusion: Structured recognition tools and coordinated referral pathways improve early stroke management. Their effectiveness depends on appropriate implementation, healthcare infrastructure, and equitable access to emergency services.
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- 1.Adeoye O, Nyström KV, Yavagal DR, Luciano J, Nogueira RG, Zorowitz RD, et al. Recommendations for the establishment of stroke systems of care: a 2019 update: a policy statement from the American Stroke Association. Stroke. 2019;50(7):e187–210. doi: 10.1161/STR.0000000000000173.
- 2.Hasan TF, Hasan H, Kelley RE. Overview of acute ischemic stroke evaluation and management. Biomedicines. 2021;9(10):1486. doi: 10.3390/biomedicines9101486.
- 3.Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344–418. doi: 10.1161/STR.0000000000000211.
- 4.Herpich F, Rincon F. Management of acute ischemic stroke. Crit Care Med. 2020;48(11):1654–63. doi: 10.1097/CCM.0000000000004597.
- 5.Green TL, McNair ND, Hinkle JL, et al. Care of the patient with acute ischemic stroke (posthyperacute and prehospital discharge): update to 2009 comprehensive nursing care scientific statement: a scientific statement from the American Heart Association. Stroke. 2021;52(5):e179–97. doi: 10.1161/STR.0000000000000357.
- 6.Oostema JA, Chassee T, Baer W, et al. Brief educational intervention improves emergency medical services stroke recognition. Stroke. 2019;50(5):1193–200. doi: 10.1161/STROKEAHA.118.023885.
- 7.Saberian P, Karimi S, Hasani-Sharamin P, et al. Accuracy of prehospital stroke screening scales in emergency medical services: a multicenter diagnostic study. Eurasian J Emerg Med. 2021;20(2):113–119.
- 8.Jones SP, Bray JE, Gibson JM, et al. Characteristics of patients who had a stroke not initially identified during emergency prehospital assessment: a systematic review. Emerg Med J. 2021;38(5):387–93. doi: 10.1136/emermed-2020-209607.
- 9.Cano-Nigenda V, Castellanos-Pedroza E, Manrique-Otero D, Méndez B, Menéndez-Manjarrez MF, Toledo-Treviño R, et al. Barriers to optimal acute management of stroke: perspective of a stroke center in Mexico City. Front Neurol. 2021;12:690946. doi: 10.3389/fneur.2021.690946.
- 10.Middleton S, Dale S, Cheung NW, et al. Nurse-initiated acute stroke care in emergency departments: the triage, treatment, and transfer implementation cluster randomized controlled trial. Stroke. 2019;50(6):1346–55. doi: 10.1161/STROKEAHA.118.020701.
- 11.Berg KP, Sørensen VF, Blomberg SN, Christensen HC, Kruuse C. Recognition of visual symptoms in stroke: a challenge to patients, bystanders, and Emergency Medical Services. BMC Emergency Medicine. 2023 Aug 25;23(1):96. doi: 10.1186/s12873-023-00870-2.
- 12.Gude MF, Valentin JB, Christensen HC, et al. Associations between emergency call stroke triage and pre-hospital delay, primary hospital admission, and acute reperfusion treatment among early comers with acute ischemic stroke. Intern Emerg Med. 2023;18(8):2355–65. doi: 10.1007/s11739-023-03349-x.
- 13.Berglund A, et al. Higher prehospital priority level leads to shorter time to stroke unit admission and reperfusion treatment. Sweden & Denmark EMS Registry. 2021. Available at: https://www.ahajournals.org/doi/full/10.1161/strokeaha.112.652644.
- 14.Phongphuttha W, Tiamkao S. Outcome of stroke fast-track patients’ arrival by emergency medical services. J Med Assoc Thai. 2021;104(8):1234–1241.
- 15.Kuzan BN, Meşe İ, Yaşar S, et al. A retrospective evaluation of the potential of ChatGPT in the accurate diagnosis of acute stroke. Diagn Interv Radiol. 2025;31(3):187–195. doi: 10.4274/dir.2024.242892.
- 16.Goda MÁ, Kovács G, Schmidl D, et al. Machine learning–based triage of large vessel occlusion stroke using photoplethysmography biomarkers. Front Neurol. 2025;16:1298456.
- 17.Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71.
- 18.Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. doi: 10.1136/bmj.l4898.
- 19.Sterne JA, Hernán MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919. doi: 10.1136/bmj.i4919.
- 20.Sundström BW, Poudel A, Herlitz J, et al. The early chain of care and risk of death in acute stroke in relation to the priority given at the dispatch center: a multicenter observational study. Scand J Trauma Resusc Emerg Med. 2017;25:101.
- 21.Ebinger M, Winter B, Wendt M, et al. Effect of the Stroke Emergency Mobile (STEMO) on thrombolysis in acute stroke: a randomized controlled trial. JAMA. 2014;311(16):1622–31. doi: 10.1001/jama.2014.2850.
- 22.Price CI, Shaw L, Islam S, et al. Effect of enhanced paramedic acute stroke treatment assessment on patient outcomes: the PASTA cluster-randomised clinical trial. Lancet Neurol. 2020;19(2):115–24.
- 23.Karimi S, Hasani-Sharamin P, Saberian P, et al. Prehospital Acute Stroke Severity (PreHAST) scale: validation in a multicenter diagnostic study. BMC Neurol. 2020;20(1):367.
- 24.Behrndtz K, Østergaard K, Johnsen SP, et al. Validation of the Prehospital Acute Stroke Scale (PASS) for identifying large vessel occlusion stroke. Stroke. 2023;54(3):843–851.
References
1.Adeoye O, Nyström KV, Yavagal DR, Luciano J, Nogueira RG, Zorowitz RD, et al. Recommendations for the establishment of stroke systems of care: a 2019 update: a policy statement from the American Stroke Association. Stroke. 2019;50(7):e187–210. doi: 10.1161/STR.0000000000000173.
2.Hasan TF, Hasan H, Kelley RE. Overview of acute ischemic stroke evaluation and management. Biomedicines. 2021;9(10):1486. doi: 10.3390/biomedicines9101486.
3.Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344–418. doi: 10.1161/STR.0000000000000211.
4.Herpich F, Rincon F. Management of acute ischemic stroke. Crit Care Med. 2020;48(11):1654–63. doi: 10.1097/CCM.0000000000004597.
5.Green TL, McNair ND, Hinkle JL, et al. Care of the patient with acute ischemic stroke (posthyperacute and prehospital discharge): update to 2009 comprehensive nursing care scientific statement: a scientific statement from the American Heart Association. Stroke. 2021;52(5):e179–97. doi: 10.1161/STR.0000000000000357.
6.Oostema JA, Chassee T, Baer W, et al. Brief educational intervention improves emergency medical services stroke recognition. Stroke. 2019;50(5):1193–200. doi: 10.1161/STROKEAHA.118.023885.
7.Saberian P, Karimi S, Hasani-Sharamin P, et al. Accuracy of prehospital stroke screening scales in emergency medical services: a multicenter diagnostic study. Eurasian J Emerg Med. 2021;20(2):113–119.
8.Jones SP, Bray JE, Gibson JM, et al. Characteristics of patients who had a stroke not initially identified during emergency prehospital assessment: a systematic review. Emerg Med J. 2021;38(5):387–93. doi: 10.1136/emermed-2020-209607.
9.Cano-Nigenda V, Castellanos-Pedroza E, Manrique-Otero D, Méndez B, Menéndez-Manjarrez MF, Toledo-Treviño R, et al. Barriers to optimal acute management of stroke: perspective of a stroke center in Mexico City. Front Neurol. 2021;12:690946. doi: 10.3389/fneur.2021.690946.
10.Middleton S, Dale S, Cheung NW, et al. Nurse-initiated acute stroke care in emergency departments: the triage, treatment, and transfer implementation cluster randomized controlled trial. Stroke. 2019;50(6):1346–55. doi: 10.1161/STROKEAHA.118.020701.
11.Berg KP, Sørensen VF, Blomberg SN, Christensen HC, Kruuse C. Recognition of visual symptoms in stroke: a challenge to patients, bystanders, and Emergency Medical Services. BMC Emergency Medicine. 2023 Aug 25;23(1):96. doi: 10.1186/s12873-023-00870-2.
12.Gude MF, Valentin JB, Christensen HC, et al. Associations between emergency call stroke triage and pre-hospital delay, primary hospital admission, and acute reperfusion treatment among early comers with acute ischemic stroke. Intern Emerg Med. 2023;18(8):2355–65. doi: 10.1007/s11739-023-03349-x.
13.Berglund A, et al. Higher prehospital priority level leads to shorter time to stroke unit admission and reperfusion treatment. Sweden & Denmark EMS Registry. 2021. Available at: https://www.ahajournals.org/doi/full/10.1161/strokeaha.112.652644.
14.Phongphuttha W, Tiamkao S. Outcome of stroke fast-track patients’ arrival by emergency medical services. J Med Assoc Thai. 2021;104(8):1234–1241.
15.Kuzan BN, Meşe İ, Yaşar S, et al. A retrospective evaluation of the potential of ChatGPT in the accurate diagnosis of acute stroke. Diagn Interv Radiol. 2025;31(3):187–195. doi: 10.4274/dir.2024.242892.
16.Goda MÁ, Kovács G, Schmidl D, et al. Machine learning–based triage of large vessel occlusion stroke using photoplethysmography biomarkers. Front Neurol. 2025;16:1298456.
17.Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71.
18.Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. doi: 10.1136/bmj.l4898.
19.Sterne JA, Hernán MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919. doi: 10.1136/bmj.i4919.
20.Sundström BW, Poudel A, Herlitz J, et al. The early chain of care and risk of death in acute stroke in relation to the priority given at the dispatch center: a multicenter observational study. Scand J Trauma Resusc Emerg Med. 2017;25:101.
21.Ebinger M, Winter B, Wendt M, et al. Effect of the Stroke Emergency Mobile (STEMO) on thrombolysis in acute stroke: a randomized controlled trial. JAMA. 2014;311(16):1622–31. doi: 10.1001/jama.2014.2850.
22.Price CI, Shaw L, Islam S, et al. Effect of enhanced paramedic acute stroke treatment assessment on patient outcomes: the PASTA cluster-randomised clinical trial. Lancet Neurol. 2020;19(2):115–24.
23.Karimi S, Hasani-Sharamin P, Saberian P, et al. Prehospital Acute Stroke Severity (PreHAST) scale: validation in a multicenter diagnostic study. BMC Neurol. 2020;20(1):367.
24.Behrndtz K, Østergaard K, Johnsen SP, et al. Validation of the Prehospital Acute Stroke Scale (PASS) for identifying large vessel occlusion stroke. Stroke. 2023;54(3):843–851.