Stroke

Description

General measures

Medicine treatment

Referral

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I61.0-6/I61.8-9/I63.0-6/I63.8-9/I64

DESCRIPTION

Stroke consists of rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting >24 hours or leading to death. Most strokes are ischaemic (embolism or thrombosis) whilst others may be caused by cerebral haemorrhage. A transient ischaemic attack (TIA) is defined as stroke symptoms and signs that resolve within 24 hours.

The diagnosis of stroke depends on the presentation of sudden onset of neurological loss, including:

• Weakness, numbness or paralysis of the face or limb/s.
• Sudden onset of blurred or decreased vision in one or both eyes; or double vision.
• Difficulty speaking or understanding.
• Dizziness, loss of balance or any unexplained fall or unsteady gait.
• Headache (severe, abrupt).

GENERAL MEASURES

Acute management

• Assess airway, breathing, circulation and disability.
• Measure blood glucose and treat hypoglycaemia if present. See: Hypoglycaemia and hypoglycaemic coma.
• BP is often elevated in acute stroke. Do not treat elevated BP at PHC, but refer patient urgently.
• Patients should be given nil by mouth until swallowing is formally assessed.

Long term management 

• Optimise treatment for existing medical conditions such as hypertension, diabetes mellitus, dyslipidaemia and cardiac conditions.
• Increase regular physical activity, aim for 30 minutes 5 times a week.
• Advise patient regarding appropriate weight loss, if weight exceeds ideal weight.
• Advise patient regarding smoking cessation.
• Refer for rehabilitative therapy including physiotherapy, occupational therapy and / or speech therapy if indicated.
• Initiate a palliative care approach if the patient’s condition is deteriorating / in case of a massive stroke (see Medicines used in palliative care).

LoE:IIb¹

MEDICINE TREATMENT

Acute treatment

• Aspirin, oral, 300 mg, as a pre-referral dose.

LoE:IIa²

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Note: 

Do not give aspirin if the patient:
- Is unconscious;
- Cannot swallow;
- Is on long-term anti-coagulation therapy;
- Has signs of a subarachnoid bleed: i.e. neck stiffness, headache;
- Will be transferred and treated with a thrombolytic within 3 hours.

LoE:IIa³

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Secondary prevention for adults (i.e. continuation of aftercare treatment initiated at higher level of care).

Antiplatelet therapy

All patients, if not contraindicated (e.g. haemorrhagic stroke, peptic ulcer, patients on anticoagulation therapy, etc.): 

• Aspirin, oral, 150 mg daily.

LoE:IIa⁴

Lipid-lowering therapy

See: Prevention of ischaemic heart disease and atherosclerosis.

Hypertensive therapy 

For blood pressure management, See: Hypertension in Adults.

Diabetes mellitus and dietary management information

See Chapter: Endocrine Conditions.

REFERRAL

Urgent 

• Refer all acute stroke cases for further management (preferably within 3 hours).

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4_Version 1.0_26 May 2025

Chapter 15: Central Nervous System Conditions_15.1 Stroke