South African guideline for management of ischaemic stroke and transient ischaemic attack 2010: A guideline from the South African Stroke Society (SASS) and the SASS Writing Committee

Background. Stroke is a leading cause of death and disability in South Africa. An increase in the burden of stroke is predicted as the population is undergoing a rapid epidemiological transition with increased exposure to, and development of, stroke risk factors, together with aging of the population. Objective. The objective was to update the guideline published in 2000, to place the recommendations within the current South African context, and to grade evidence according to the level of scientific rigour. Recommendations. Ideally, all patients with acute stroke should be managed in a dedicated stroke unit. There is ample evidence that protocol-driven multidisciplinary stroke unit care within a hospital improves recovery from stroke. Treatment in a stroke unit has been shown to reduce mortality as well as reduce the likelihood of dependency after stroke. An effective stroke service requires the establishment of a seamless network consisting of acute stroke units, post-acute care and rehabilitation, and further care in the community. Primary preventive measures reduce stroke incidence and should be universally available and actively promoted at all levels of health care in South Africa. Successful care of a stroke patient begins with recognition by the public and health professionals that stroke should be considered an emergency. Avoiding delay should be the major aim of the prehospital phase of acute stroke care. Acute stroke or transient ischaemic attack (TIA) should be treated as a medical emergency and evaluated with minimum delay. General supportive treatment is emphasised and is directed at maintaining homeostasis and the treatment of complications. Intravenous thrombolytic therapy with recombinant tissue plasminogen activator (tPA) is an accepted therapy for acute ischaemic stroke within 4.5 hours of onset of symptoms, but can only be administered at centres with specific resources. Awareness and treatment of the neurological and systemic complications of acute stroke are an integral part of management. Patients with suspected TIA and minor stroke with early spontaneous recovery should be evaluated as soon as possible after an event. Brain imaging is recommended, and non-invasive imaging of the cervicocephalic vessels should be performed urgently and routinely as part of the evaluation. Carotid endarterectomy (CEA) is recommended for patients with severe (70 - 99%) ipsilateral stenosis, and the procedure should be performed as soon as possible after the last ischaemic event – ideally within 2 weeks – in centres with a peri-operative complication rate (all strokes and death) of less than 6%. Survivors of a TIA or stroke have an increased risk of another stroke, which is a major source of increased mortality and morbidity. Secondary prevention strategies are aimed at reducing this risk. Stroke rehabilitation is a goal-orientated process that attempts to obtain maximum function in patients who have had strokes and who suffer from a combination of physical, cognitive and language disabilities