The effect of stroke worldwide and in South Africa is well known. It remains, however, the highest cause of death in patients more than 50 years of age in South Africa, and the fourth highest cause of death overall.¹ The impact on surviving patients, their families and support systems is considerable. To alter the course of this burden, it is first necessary to know the disease profile in the local population, which will aid in identifying reversible factors in those at risk. Similar socio-demographic and risk profile studies have been conducted in South Africa^2,3,4 but research of this nature is lacking in the Free State Province. In addition, literature evaluating the various time parameters influencing stroke imaging and patient treatment is also deficient in South Africa.

The aim of the present study was to assess the stroke profile of patients referred for computed tomography (CT) imaging to our institution and to evaluate factors that could improve stroke management.

This prospective descriptive study was conducted at the Department of Clinical Imaging Sciences, Pelonomi Regional Hospital, Bloemfontein. The study period was one year, starting 01 July 2014.

Ethics approval was obtained from the Ethics Committee of the Faculty of Health Sciences of the University of the Free State prior to the study initiation date. As imaging and interpretation of results were performed according to existing departmental guidelines, informed consent was not needed prior to imaging. All data were noted confidentially by using the patients’ hospital number as identification. Permission was also obtained from the chief medical officer of Pelonomi Regional Hospital.

The patient mean age of 59 years was similar to that found by Connor et al. in a study conducted in Johannesburg published in 2009.³ Hypertension (83.7%), smoking (20.3%) and diabetes (15.0%) as the leading risk factors correlate with those observed in other studies conducted in the African continent. The meta-analysis published in 2015 by Owolabi et al. established that hypertension was present in 98% of stroke sufferers in Africa and was identified as the strongest modifiable risk factor.⁹ Closer to home, Connor et al. also identified hypertension as the leading risk factor (70% of patients), followed by current smoking (30%) and alcohol consumption (26%).³ The prevalence of diabetes in their study was similar to that in our population group (14%).

Assessing the management of such medical conditions and advocating lifestyle modification by reinforcing public awareness is pivotal in addressing stroke management. The prevalence of HIV infection could not be assessed, as this was inconsistently recorded; this was unfortunate as it would have been an interesting contribution to the study. Tipping et al. found in their 2007 study that of 1087 stroke patients, 6.1% were HIV infected. The majority of the 67 patients were younger than 46 years, and had ischaemic strokes (96%). Infectious meningitis or vasculitides (28%) and HIV vasculopathy (20%) were more common underlying aetiologies. The more traditionally accepted risk factors (hypertension, diabetes, etc.) were not significant risk factors in this young stroke group.¹⁰ HIV infection and antiretroviral treatment contribute to accelerated atherosclerosis and aneurysmal changes, thus increasing the risk of stroke. As found by Benjamin et al., it would be difficult to identify HIV as a stand-alone risk factor in our population group, considering the high prevalence of hypertension.¹¹

The stroke distribution (ischaemic 67.8%, haemorrhagic 32.2%) is in line with that of other population groups in Africa, where the incidence of haemorrhagic stroke ranged between 29% and 57%.^3,9,12 Owing to unretrievable clinical records, transient ischaemic attacks could not be ascertained in terms of a cause in three of the four patients previously mentioned with normal CT findings. As stated in our imaging protocol, these patients could have benefited from additional CT perfusion studies but, owing to technical difficulties at the time (non-functional injection pump), this was not possible. A routine MRI service was also not yet available.

Given that 52.4% of the patients with acute ischaemic strokes had ASPECT scores ≥ 7, but only 7.5% presented within four-and-a-half hours from symptom onset, expediting the referral and transport process would significantly increase the number of patients qualifying for rtPA. Understandably, there are contributing factors beyond our control, such as the distance from hospital at the time of symptom onset. It should also be noted that our institution has an ever-enlarging catchment area owing to loss of resources in peripheral hospitals. In-hospital delays are not unique to our situation, as other developing countries experience similar problems, which was evident from an article published by Gurav et al. in May 2015.¹³

Many factors can, however, be addressed as outlined in the Target stroke campaign manual released by the American Heart Association (AHA).⁸ These include early notification of emergency departments by emergency medical services (EMS), education of the EMS personnel on appropriate triage of patients eligible for intravenous treatment, expedited in-hospital assessment and improved guidelines and protocols to minimise uncertainty by the treating physicians. Such guidelines, specifically designed for the South African setting, have already been established.¹⁴ The treating physician could also accompany appropriately selected patients to the scanner; this would shorten the door-to-needle time as drug administration could then commence as soon as a relevant ischaemic stroke pattern is identified.

Another recommendation is to make use of a ‘single-call activation system’. This was implemented with good effect by Nolte et al.¹⁵ at their institution in the form of an all-points alarm. The entire stroke team was notified simultaneously by means of an SMS-based system. This method reduced their median in-hospital delay time from 54 min to 35 min and increased the number of patients treated with rtPA by 24%.

As time intervals were deduced from the RIS, the time of arrival in hospital and ‘door to physician time’ were unknown. We therefore used the ORT, as previously defined under methodology. This is an obvious underestimation but nonetheless is still longer than recommended by international guidelines.⁸ Our median ORT was 61 min, with the recommended ‘door to report time’ being 45 min.

The median reporting time of 32 min should also be addressed, as the AHA recommendations permit 20 min (door-to-scan report time: 45 min; door-to-scan time: 25 min). Comparison of our time parameters with AHA guidelines is depicted in Table 2. This period could be improved by clear interpretation protocols and increased awareness on utilising tools such as the ASPECT score. The effect of delayed reporting time on treatment is crucial.

When applicable, the referring physician was telephonically informed of the CT findings immediately. A formal report was only released after a protracted period, which could explain the wide interquartile ranges. Measuring these variables was not practically possible and could not be assumed.

The fact that almost two-thirds of the scan requests occurred after hours is not surprising, as a working day consists of 8 hours. It is also a reflection of functionality of the after-hours services.

Following the outcome of the present study, it is our intention to reconvene with our Internal Medicine Department about implementing the above-mentioned plans and determining further progress.

Our stroke population did not differ significantly from those documented in the rest of South Africa and Africa as a whole. Pre- and in-hospital delays contributed significantly to patient numbers qualifying for thrombolytic treatment.