Mediclinic Bloemfontein Brings Stroke Treatment into the Future

Posted on 4 September 2018

The hospital’s dedicated stroke unit offers patients specialised care – and gives other facilities an example to follow.

Stroke remains a leading killer in South Africa. The Heart & Stroke Foundation: South Africa estimates that as many as 240 South Africans suffer a stroke each day, and 70 of those will succumb to the related injuries.

Dr Erna Pretorius, a neurologist at Mediclinic Bloemfontein, is on a mission to change that.

New treatment guidelines recently released by the SA Stroke Society (SASS) aim to address this pressing issue, by recommending a series of standardised best practices for healthcare workers, in both pre-hospital and emergency centre environments.

These new guidelines also fall within proposals made by the Health Professionals Council of SA (HPCSA), which recognises the hours immediately after a stroke as a hyperacute phase of care, during which standard protocols can be greatly beneficial to a patient’s chances of recovery.

The HPCSA notes that “growing evidence [shows] good early stroke management can reduce damage to the brain and minimise the effects of stroke. Because of this early recognition of stroke, the subsequent response of individuals to having a stroke, and the timing and method by which people are transferred to hospital are important to ensure optimal outcomes.”

The Council recommends that all patients with acute stroke should be managed in a stroke unit: a protocol-driven multidisciplinary team within a hospital dedicated to improving recovery from stroke. Ideally, this unit should consist of trained pre-hospital staff, post-acute care and effective rehabilitation measures.

Dr Pretorius says she has spent two years developing just such a unit at Mediclinic Bloemfontein, the first of its kind in the area. This unit follows a set of protocols that are designed to diagnose, manage and treat stroke patients in line with the new guidelines.

“There are different kinds of stroke hospitals,” she explains. “An entry-level hospital can receive and refer a patient, whereas other hospitals will have a thrombologist on standby – while some hospitals can take a patient all the way through to neurological interventions. And these hospitals are graded according to their stroke-readiness as per their resources and expertise.”

Traditional stroke treatment follows the routine of an ordinary admission process: after being triaged, a patient would have a CT scan, and once those results indicate signs of a stroke, the condition is managed accordingly. All of this occurs within a reasonable amount of time, says Dr Pretorius – but for most stroke patients, even these few hours can have catastrophic effects.

“Proper stroke guidelines have been in place and followed since the 1970s,” she says. “But now the emphasis in changing. We’re now looking at treatment as revolving around a timeframe.

SASS advocates that a large part of reducing stroke fatalities begins with recognising stroke as a medical emergency: it should be evaluated and managed with minimum delay. This should involve both healthcare professionals, including pre-hospital ambulatory services, as the general public, too.

Dr Pretorius is a member of the Angels Initiative, a global body of stroke doctors and stroke survivors whose aim is to foster a community of stroke centres and stroke-ready hospitals, as a means to improve the treatment – and potential outcomes – for stroke patients around the world. She was recently presented with the Angels Excellence Award, in recognition of the work she is doing to spread stroke awareness in her area.

“Stroke treatment starts at home,” she emphasises. “We want people to know what a stroke looks like, and to understand that the patient needs to be transferred to the nearest stroke-ready hospital, or dedicated stroke unit, as soon as possible.”

Emergency services and triage nurses are also encouraged to determine without delay whether their stroke patients could benefit from thrombolysis. “The sooner you can get a stroke patient to a clinical thrombologist, the better – we want to restore blood and oxygen diffusion in the brain as quickly as we can.”

“Time is brain,” says Dr Pretorius. “Every minute that blood flow is interrupted, two million neurons will die inside the brain.”

Other recommendations of the SA Stroke Society treatment guidelines include:

  • 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 perioperative 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-oriented 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.

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