Managing acute stroke in low-resource settings

Perspectives Providing appropriate management to patients with acute stroke depends on the underlying etiology of the stroke. Current guidelines from the American Heart Association and American Stroke Association rely on computed tomogra-phy (CT) scans to distinguish between acute ischaemic stroke 1 and acute intracerebral haemorrhage. 2 Yet the majority of strokes worldwide (around 70% of approximately 17 million per an-num) occur in low-and middle-income countries 3 with limited access to CT. Global data on the availability of medical devices in 2014 estimated the number of CT scanners per 1 million population as only 0.32 in low-income countries compared with 42 in high-income countries. 4 Moreover, neurodiagnostic tests are often inaccessible or unaffordable to many patients in low-income settings. 5 Stroke-related disability and mortality are higher in low-and middle income countries compared with high-income countries 3 One potential reason for these poorer outcomes may be uncertainty among physicians about how best to manage patients presenting with acute stroke when CT is unavailable to distinguish ischaemic from haemor-rhagic stroke. This paper outlines some considerations in treating patients with acute stroke of unknown etiology in settings where CT is unavailable. These recommendations are based on existing data regarding management of acute ischaemic stroke and acute intracerebral haemorrhage in high-resource settings, epidemiological data, data from decision analyses, and clinical decision rules. Many aspects of supportive care are the same for acute ischaemic stroke and acute intracerebral haemorrhage, including maintenance of euglycemia and euthermia, provision of adequate hydration and nutrition, treatment of seizures if they occur, prevention of aspiration, prevention of deep-vein thrombosis, and early mobilization of the patient. Where pneumatic compression is unavailable, prophylaxis of deep-vein thrombosis with low-dose heparin appears to be safe to initiate as early as day 2 after acute intracerebral haemorrhage, 6 and so could likely be safely initiated at this time in patients with stroke of unknown etiology. Improving these basic aspects of comprehensive stroke care could be achieved through educational initiatives for front-line providers in low-resource settings. In such settings, these basic aspects of supportive care may be more important for stroke outcomes than the two aspects of acute stroke management that differ between haemorrhagic and ischaemic stroke: blood pressure management and use of antithrombotic therapy. Lowering systolic blood pressure is recommended for patients with acute intracerebral haemorrhage who present with elevated blood pressure; 2 reduction to below 140 mmHg appears safe but is of uncertain benefit. 7 …