Cerebrovascular Disease

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Click here to access the Adult Hospital Level Chapter 14: Neurological Disorders with Supporting NEMLC Report-2020-4-Review-Version-3.0-22-November-2025

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Stroke

Transient ischaemic attack (TIA)

Subarachnoid haemorrhage

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STROKE

I61.0-6/I61.8-9/I63.0-6/I63.8-9/I64 + (G46.0-8*)

GENERAL MEASURES

• Optimise hydration and nutrition; insert nasogastric tube if patient cannot swallow. Take precautions to ensure an open airway if patient is unconscious.
• Physiotherapy and good nursing care. Consider rehabilitation for suitable patients, refer if necessary.
• Do an ECG to rule out an acute coronary event or atrial fibrillation as precipitants.
• Do an ECG to rule out an acute coronary event or atrial fibrillation as precipitants. Do serology to exclude meningovascular syphilis (in patients <45 years old who do not have risk factors for stroke).
• Check lipid profile in ischaemic strokes.
• Ischaemic stroke in young adults (< 45 years of age) may be due to atherosclerosis, but also consider:
  • Embolic: e.g. rheumatic heart disease, atrial fibrillation, cardiomyopathy, previous myocardial infarction, and, very rarely, patent foramen ovale: history, careful clinical cardiac examination, ECG/CXR, and echocardiography.
  • Vessel wall disease: e.g. syphilis HIV infection, collagen-vascular diseases, TB or bacterial meningitis and extracranial arterial dissection. Investigate as guided by clinical presentation, but at least perform syphilis and HIV serology, urinalysis (haematuria and/or proteinuria), and ANF/RF. ANCA, and cerebral angiography or carotid Doppler may be indicated. Note that absence of a carotid bruit does not exclude significant carotid stenosis.
  • Hypercoagulable states: e.g. antiphospholipid antibody syndrome, thrombotic thrombocytopenic purpura. Useful screening investigations are FBC and, in women, PTT/Anti-phospholipid Ab. Testing and management of thrombophilias should be done in consultation with an expert.
• Initiate a palliative care approach if the patient’s condition is deteriorating / in case of a massive stroke (See Chapter: Medicines Used in Palliative Care). Ensure adequacy of swallowing ability by dietician or by asking the patient to swallow 10 mL of water.

MEDICINE TREATMENT

Hyper-acute management:

Symptom onset ≤ 3 hours:

• Do not give aspirin.
• Refer immediately to hospital that can provide thrombolytic therapy:
• Alteplase, IV, 0.9 mg/kg. Total dose should not exceed 90 mg.
  • 10 % of total dose given as a bolus and the remainder continued as an infusion over an hour.

LoE:Ibⁱ

Symptoms >3 hours:

• Aspirin, oral, 300 mg, immediately. 

LoE:Iaⁱⁱ

Followed by:

• Aspirin, oral, 150 mg daily.
  • If patient is unable to swallow, administer through a naso-gastric tube

Do not administer aspirin if there are symptoms suggestive of a sub-arachnoid bleed, e.g. headache, stiff neck etc.

AND

For DVT prophylaxis, see Venous thrombo-embolism.

Treat secondary pulmonary and urinary tract infections appropriately.

Secondary prevention:

Measures for secondary prevention may not be appropriate for patients with severe disability.

All patients with a thrombotic stroke, not on anticoagulation and irrespective of the LDL level:

• Aspirin, oral, 150 mg daily.

LoE:Iaⁱⁱⁱ

AND

• HMGCoA reductase inhibitors (statins), e.g.:
  • Simvastatin, oral, 40 mg at night 

LoE:IIb^iv

Patients on protease inhibitor:

• Atorvastatin, oral, 10 mg at night. 

LoE:IIb^v

Patients on amlodipine (and not on a protease inhibitor):

• Simvastatin, oral, 10 mg at night. 

LoE:IVb^vi

If patient complains of muscle pain:

Reduce dose:

• HMGCoA reductase inhibitors (statins), e.g.:
  • Simvastatin, oral, 10 mg at night.

OR

• Consult with specialist for further management. 

LoE:IVb^vii

Anticoagulation:

• In patients with cardioembolic strokes (e.g. secondary to atrial fibrillation) with no evidence of haemorrhage on CT scan, the optimal time to start anticoagulation therapy is likely to vary among individual patients; this can be from 7 to 14 days and up to 21 days and is dependent on the infarct size (>1/3 of the hemisphere) and the patient's risk factors for recurrent events. 

LoE:IIIb^viii

• Bridging the anticoagulation with heparin, or earlier initiation of warfarin is not recommended because, although it reduces ischaemic stroke recurrence, it increases symptomatic intracranial haemorrhage. 

LoE:IVb

Blood pressure management

• A transient increase in BP is common after an acute stroke. Lowering BP during the acute phase of stroke (within 6 hours of onset) may not improve morbidity.
• Do not actively lower a systolic BP <220 mm Hg or diastolic BP <120 mm Hg is the first few days after stroke as this may be associated with an increased risk of death.
• In patients presenting with stroke and BP >220/120 mm Hg, lower BP to about 180/110 mm Hg in the first 24 hours.
• Antihypertensive medicines may be withheld until patients have suitable oral or enteral access.
• Cautious incremental reintroduction of treatment is advised to achieve long-term standard BP control.
• See Hypertensive crisis, hypertensive emergency. 

LoE:IIb^ix

If BP > 220/120 mm Hg: 

• Long-acting calcium channel blocker, e.g.:
  • Amlodipine, oral, 5 mg daily. 

LoE:IIb^x

OR

If adequate fluid intake can be ensured:

• Hydrochlorothiazide, oral, 12.5 mg daily.

LoE:IVb

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Note

- There is some evidence of harm from BP reduction within 7 days of acute stroke; after 7 days cautious incremental re-introduction of treatment is advised to achieve long term standard BP control.
LoE:IIb^xi 

- Antihypertensive medicines should be stopped in acute stroke unless the BP >220/120 mm Hg (see above).
- Reassess the need for re-initiation of patients’ previous antihypertensive medication. See Hypertension.  
LoE:IIb^xii 

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REFERRAL

• Patients with aspirin intolerance.
• To a facility with a CT scan:
  • Patients with atypical clinical presentation.
  • Selected patients with suspected ischaemic stroke who may benefit from thrombolysis with tissue plasminogen activator if initiated within 3 hours of onset of symptoms.
  • Patients with suspected posterior cerebral fossa haemorrhage who may require surgical decompression.
  • If there is a history suggestive of subarachnoid haemorrhage or if there is neck stiffness.

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TRANSIENT ISCHAEMIC ATTACK (TIA)

G45.0-4/G45.8-9

DESCRIPTION

• A transient ischaemic attack is an episode of brain, spinal cord, or retinal ischaemia causing focal neurological dysfunction usually for less than one hour.
• Risk of subsequent stroke is highest in the week after a TIA.
• Consider hypoglycaemia, epilepsy, and migraine as alternative causes for the symptoms.

Table 14.1: The ABCD² scoring system:

Feature	Points
Age ≥ 60 years	1
BP ≥ 140/90 mmHg	1
Clinical features:   speech disturbance without weakness OR   unilateral weakness	1 2
Diabetes	1
Duration:   10 to­ 59 minutes   ≥ 1 hour	1 2

Reference: Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, Sidney S. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007 Jan 27;369(9558):283-92. doi: 10.1016/S0140-6736(07)60150-0. PMID: 17258668.

ABCD² score of ≥4 is regarded as high risk and warrants urgent investigation and management as the risk of stroke within the next week is ≥4%.

MEDICINE TREATMENT

Cardioembolic disease:

• Warfarin, oral, 5 mg daily.
  • Measure INR after 48 hours, then every 1 to 2 days until within the therapeutic range of 2 to 3 (refer to Initiation dosing tables in Prescribing Information for Specific Medicines).
  • Adjust dose to keep INR within therapeutic range (refer to Maintenance dosing tables in Prescribing Information for Specific Medicines ).

LoE:IVb^xiii

Other patients:

• Aspirin, oral, 150 mg daily.

LoE:IIIb^xiv

Lipid control (all patients):

• HMGCoA reductase inhibitors (statins) e.g.:
  • Simvastatin, oral, 40 mg at night. 

LoE:IIb^xv

Patients on protease inhibitor:

• Atorvastatin, oral, 10 mg at night. 

LoE:IIb^xvi

Patients on amlodipine (and not on a protease inhibitor):

• Simvastatin, oral, 10 mg at night. 

LoE:IVb^xvii

If patient complains of muscle pain:

Reduce dose:

• HMGCoA reductase inhibitors (statins), e.g.:
  • Simvastatin, oral, 10 mg at night.

OR

• Consult specialist for further management. 

LoE:IVb^xviii

Manage hypertension - see Hypertension.

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SUBARACHNOID HAEMORRHAGE

I60.0-9

DESCRIPTION

• Bleeding into the subarachnoid space, most commonly due to the rupture of a vascular aneurysm. 
• Patients typically present with an acute onset of severe headache and may have additional neurological symptoms and signs. 
• Diagnosis is confirmed preferably by neurological imaging and, when this is not available, by demonstrating CSF xanthochromia on lumbar puncture.

GENERAL MEASURES

• Maintain normal hydration and electrolyte status.
• Control blood pressure.

MEDICINE TREATMENT

Analgesia if level of consciousness is not impaired:

Avoid NSAIDs.

• Paracetamol, oral, 500 mg–1 g, 4–6 hourly as required (to a maximum of 4 g in 24 hours).
  • Maximum dose: 15 mg/kg/dose.

If no response to paracetamol:

• Morphine, IV, to a total maximum dose of 10 mg (See Prescribing Information for Specific Medicines, for individual dosing and monitoring for response and toxicity).

In all patients presenting with aneurysmal subarachnoid haemorrhage while waiting for transfer to neurosurgical facility and in consultation with neurosurgeon:

• Nimodipine, oral, 60 mg 4 hourly for 21 days.

REFERRAL

• All patients with minimal impairment of consciousness level for angiography and appropriate neurosurgical management.
• Patients initially deemed unsuitable for further investigation, may be referred at a later stage, should their condition improve.

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-4_Version 2.0_6 June 2025

Chapter 14 Neurological Disorders_14.1 Cerebrovascular Disease