Aroor S, Singh R, Goldstein LB BE-FAST (balance, eyes, face, arm, speech, time): reducing the proportion of strokes missed using the FAST mnemonic. Stroke. 2017; 48:(2)479-481

Brandt T, Steinke W, Thie A, Pessin MS, Caplan LR Posterior cerebral artery territory infarcts: clinical features, infarct topography, causes and outcome. Multicenter results and a review of the literature. Cerebrovasc Dis. 2000; 10:(3)170-182

Brotons AA, Motola I, Rivera HF, Soto RE, Schwemmer S, Issenberg SB Correlation of the Miami Emergency Neurologic Deficit (MEND) exam performed in the field by paramedics with an abnormal nihss and final diagnosis of stroke for patients airlifted from the scene. Stroke. 2018; 43:(S1)

Casswell EJ, Huwez F The fast screening tool in the early recognition of strokes involving the posterior circulation. Eur J Intern Med. 2011; 22:(S1)

Cohen JF, Korevaar DA, Altman DG 2016. STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration. BMJ Open. 2016; 6:(11)

Gadi N, Huwez F ABCD-E2 for fast negative TIAs/strokes in middle aged and elderly patients (abstract). Aging Clin Exp Res. 2011; 23

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. 2012; 83:(2)228-229

Hepworth LR, Rowe FJ Visual impairment following stroke—the impact on quality of life: A systematic review. Ophthalmol Res. 2016; 5:(2)1-15

Huwez F, Casswell EJ FAST-AV or FAST-AB tool improves the sensitivity of FAST screening for detection of posterior circulation strokes. Int J Stroke. 2013; 8:(3)

Isaeff WB, Wallar PH, Duncan G Ophthalmic findings in 322 patients with a cerebral vascular accident. Ann Ophthalmol. 1974; 6:(10)1059-1069

Jones SA, Shinton RA Improving outcome in stroke patients with visual problems. Age Ageing. 2006; 35:(6)560-565

Mingfeng H, Zhixin W, Qihong G, Lianda L, Yanbin Y, Jinfang F Validation of the use of the ROSIER scale in prehospital assessment of stroke. Ann Indian Acad Neurol. 2012; 15:(3)191-195

V-FAST. 2020. http// (accessed 31 July 2020)

Rowe FJ Vision in stroke cohort: profile overview of visual impairment. Brain Behav. 2017; 7:(11)

Rowe FJ, Hepworth LR, Howard C, Hanna KL, Cheyne CP, Currie J High incidence and prevalence of visual problems after acute stroke: an epidemiology study with implications for service delivery. PLoS One. 2019; 14:(3)

Rowe FJ, Hepworth LR, Dent J Pre-hospital detection of post-stroke visual impairment. Int J Stroke. 2017; 12:(5S)51-52

Rudd M, Buck D, Ford GA, Price CI A systematic review of stroke recognition instruments in hospital and prehospital settings. Emerg Med J. 2016; 33:(11)818-822

Stroke Association. State of the nation: stroke statistics. 2018. https// (accessed 9 July 2020)

The Stroke Collaborative; American Academy of Neurology, American College of Emergency Physicians, American Heart Association and American Stroke Association. The Stroke Collaborative and Give Me 5 For Stroke. Frequently Asked Questions. 2008. https// (accessed 31 July 2020)

Tong A, Sainsbury P, Craig J Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007; 19:(6)349-357

West Midlands Ambulance Service. Stroke guidelines: Cln-pro-027. 2016. https// (accessed 31 July 2020)

Development of V-FAST: a vision screening tool for ambulance staff

02 August 2020
Volume 12 · Issue 8



About two-thirds of stroke survivors experience visual problems and most patients who have a stroke limited to the occipital lobe will have visual impairments only.


The V-FAST screening tool, which assesses visual symptoms, eye movements, visual field and visual extinction, and a training package to improve diagnostic accuracy of identifying visual impairment in hyperacute strokes were developed and evaluated.


The educational package was developed through focus groups. The pilot study screened patients with suspected strokes in prehospital settings; the V-FAST tool was used with 43 of these patients. Each participant was also assessed in hospital using the National Institutes of Health Stroke Scale (NIHSS) and the score compared to V-FAST screening results to determine sensitivity and specificity.


The education package includes detailed instructions with video. In the pilot study, V-FAST detected visual impairment in 75.9% of FAST-positive and 80% of FAST-negative strokes. Sensitivity and specificity compared to NIHSS were 85.7% and 42.1% respectively.


V-FAST has good sensitivity to detect vision impairment when screening for possible strokes. The added education package facilitates greater knowledge and understanding of potential visual problems caused by stroke.

Visual impairment following stroke is common and estimated to affect two-thirds of all stroke survivors (Rowe et al, 2019). However, there is no standardised screening for visual impairment for ambulance services.

A particular issue is posterior circulation stroke, in which visual impairments such as visual field loss, visual inattention and eye movement disorders are common and are often FAST-negative (FAST stands for signs of a stroke, including facial drooping, arm weakness and speech difficulties, as well as time to call emergency services) (Rowe and VIS Writing Group, 2017). No ambulance service screening is provided for all these visual problems so there is the potential for misdiagnosis or missed diagnosis.

Where strokes affect the occipital lobe only, around 90% of patients will have only visual complaints (Isaeff, 1974). It is therefore important to assess specifically for this. Furthermore, although stroke is more likely to be considered as a diagnosis for older people, one in four stroke survivors are of working age (Stroke Association, 2018); they are often easily misdiagnosed where their primary complaint is visual, typically as migraine.

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