CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 3, April 2013
86
AFRICA
Review Article
Management of ischaemic stroke in the acute setting:
review of the current status
KALPESH JIVAN, KAUSHIK RANCHOD, GIRISH MODI
Abstract
Acute ischaemic stroke can be treated by clot busting and
clot removal. Thrombolysis using intravenous recombinant-
tissue plasminogen activator (IV r-TPA) is the current gold
standard for the treatment of acute ischaemic stroke (AIS).
The main failure of this type of treatment is the short time
interval from stroke onset within which it has to be used for
any benefit. The evidence is that IV r-TPA has to be used
within 4.5 hours.
Other modalities of treatment are not as effective and
need more scrutiny and examination. The available modali-
ties are intra-arterial thrombolysis and clot-retrieval devices.
Not unexpectedly, recanalisation treatments have flourished
at a rapid rate. Although vessel recanalisation is vital to
increasing the possibility of significant tissue reperfusion,
clinical trials need to emphasise functional outcomes rather
than reperfusion/recanalisation rates to adequately assess
success of these devices/techniques.
Our view is that until these treatments become proven
in large-scale studies, a greater endeavour should be made
in resource-limited settings to expand facilities to enable
intravenous r-tPA treatment within the 4.5-hour period
following onset of stroke. The resources required are small
with the main costs being a CT scan of the brain and the
cost of r-tPA. This can easily be done in any emergency facil-
ity in any part of the world. What is needed is public aware-
ness, and campaigns of ‘stroke attack’ should be revisited,
especially in the resource-limited context. This approach at
present will halt to some extent the stroke pandemic that we
are facing.
Keywords:
stroke, intravenous r-tPA, recanalisation treatments
Submitted 5/3/12, accepted 11/1/13
Cardiovasc J Afr
2013;
24
: 88–94
DOI: 10.5830/CVJA-2013-001
Stroke is the third leading cause of death worldwide, resulting
in approximately 5.7 million deaths annually.
1
With current
treatment options, this number is projected to rise to 6.5 million
in 2015 and to 7.8 million in 2030. The global focus on stroke
treatment is based on these figures and reflects the impact stroke
has on society. In a recent review, taking into account 120 cost
studies in developed countries, the average costs of stroke ranged
from $468 to $146 149.
2
There is limited information regarding
the cost of stroke in developing countries. The approximate cost
of ischaemic stroke in Togo is EUR428.80.
3
Currently there is
inadequate information regarding the cost of stroke in South
Africa.
4
The main issue with regard to stroke is outcome. Clinical
outcomes of stroke have been reviewed in 174 acute stroke trials.
5
Death occurred in 76% of patients in the trials, impairment
of body function and structure in 76%, disability (activity
limitations) in 42%, and adverse social impact or restricted
quality of life occurred in only 2% of patients. Functional
outcomes are the main cause of stroke cost. Stroke is the eighth
most significant cause of life lost due to illness and the ninth
most important cause of disability in South Africa.
4
The ultimate goal in stroke management is to reverse the
stroke and leave no disability. This has however not been possible
to date. From a pathophysiological point of view, in the acute
setting, this could be achieved by improving perfusion in the
ischaemic area.
Current models of stroke pathology indicate the area of
infarction following a stroke is surrounded by an ischaemic
penumbra. Cerebral blood flow (CBF) of below 10–12 ml/100
g/min results in irreversible neuronal injury/infarction.
6
Within
an hour of hypoxic ischaemic insult, this core of infarction
is surrounded by an oligaemic zone called the ischaemic
penumbra where autoregulation is ineffective. The penumbra
phase generally begins when CBF flow falls below 20 ml/100
g/min.
6
Cellular integrity and function are preserved in this
potentially salvageable penumbra for variable periods of time.
Although little can be done to save the infarcted core, it is the
penumbra that is the target of salvage therapies.
Methods
A PUBMED search was conducted using the keywords ‘acute
stroke management’, ‘interventional devices for acute stroke’,
‘intravenous thrombolysis’, ‘intra-arterial thrombolysis’,
‘guidelines for stroke management’ and ‘prevention of strokes’
from 1995 to 2012.
Results
Three types of treatment in the acute setting have emerged to
salvage the penumbra, reduce the area of infarction and improve
Division of Neurology, Department of Neurosciences, School
of Clinical Medicine, Faculty of Health Sciences, University
of the Witwatersrand, Johannesburg, South Africa
KALPESH JIVAN, MB BCh (Wits), FC Neurol (SA)
KAUSHIK RANCHOD, MB BCh (Wits), FC Neurol (SA)
GIRISH MODI, MB BCh (Wits), MSc (Lond), PHD (Lond), FCP (SA),
FRCP (Lond),
