By Oluwasola Samuel, Freelance Writer. Medically reviewed by Dr. Seyi Roberts, Consultant Neurologist, Lagos, Nigeria. With editorial support from The DLHA Team.
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Stroke patients in Africa face many treatment challenges.
When a stroke occurs, there is a need for a quick response to ensure proper medical evaluation and prompt treatment to aid recovery. Every moment wasted harms the brain, and it could be lost if there is no quick intervention.
Living with a stroke can be tough. It's a life-threatening neurological condition that affects millions of people worldwide, including a significant number in Africa.
On the one hand, we have seen remarkable progress in recent years. Health professionals and researchers have worked tirelessly to improve and develop innovative treatment options. However, there are still significant hurdles to overcome, especially in Africa.
In Africa, there is a significant burden on stroke patients and the healthcare system due to a lack of or limited access to advanced medical facilities and specialized stroke centres. This means that a lot of stroke victims in Africa won't receive timely care. Furthermore, there are limited healthcare workers with expertise in stroke treatment, which worsens the problem. [4. 5]
Despite these obstacles, efforts are being made by healthcare providers and organisations to bridge the care gap and ensure stroke patients in Africa receive the best treatment possible.
As the treatment options available for the treatment of stroke vary with its types, this report will first discuss the different types of stroke and other important information. So pull up a chair and get comfortable while you learn more on how stroke is treated.
Figure 1: Stroke types. Click on image to enlarge
According to the National Heart, Lungs, and Blood Institute (NIH) , there are two major types of stroke namely; Ischemic and haemorrhagic strokes respectively (See figure 1). [1}
This type of stroke occurs when the blood supply channel to the brain is blocked. This cut-off or blockage of oxygenated blood to the brain is caused by a plaque or blood clot in the blood vessels.
A plaque is a semi-hardened or hardened accumulation of substances in the inner lining of blood vessels that build and block the vessels at location or break off to block the vessel at a different location.
When the blood supply is cut off to the brain, the brain cells begin to die almost immediately.
About 87% of strokes are ischemic. When there is a shortage of blood occurs in the brain due to a plaque in the arteries, this condition is called "thrombotic stroke". [2} If a blood clot occurs somewhere else in the body but finds its way through the bloodstream to the brain, it's referred to as an "embolic stroke".
The haemorrhagic stroke is less common than the ischemic stroke, but it tends to be deadlier when compared to the ischemic stroke.
People who suffer from haemorrhagic stroke tend to die or suffer long-term disabilities unless there is a timely intervention to save the situation. A haemorrhagic stroke is a type of stroke that occurs when the blood vessel in or around the brain ruptures and bleeds, causing a leak of blood in or around the brain.
Haemorrhagic stroke can happen in two different forms that are called:
• Intracerebral haemorrhagic (ICH): This is the most common type of haemorrhagic stroke, where a blood vessel inside the brain breaks (ruptures) and bleeds. Around two-thirds of haemorrhagic strokes are due to ICH
• Subarachnoid haemorrhagic (SAH): This is the rupture of the blood vessels outside or on the surface of the brain, causing bleeding into a space that is called the subarachnoid space. This space contains fluid that buffers the jelly-like brain from the bony skull among other functions. A bleed into the subarachnoid space puts sudden pressure on the brain tissue underneath.
Lastly, there is another less popular type of stroke called the "Transient Ischemic Attack" (TIA). [3] This stroke is similar to an ischemic stroke but they are different. The TIA is caused by a temporary blockage of the flow of blood to the brain. This type of stroke usually lasts for a few minutes and reverses itself causing no permanent damage to the brain.
However, a TIA is often a warning sign that you are likely to have a full-blown stroke in the future. This can be more life-threatening.
One of the common causes of ischemic stroke is the buildup of plaque in the arteries of the brain that narrows the blood passage. This process is called "atherosclerosis", and it causes a reduction in the flow of blood supply to the brain (see figure 2).
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Besides atherosclerosis, there are other causes of ischemic stroke, which include:
• Heart attack
• Blood vessel injury around the neck
• Blood clotting disorder
• Fat emboli (floating fat particles in the blood)
• Atrial fibrillation(AFib) – an irregular and often rapid beating of a part of the heart)
• Heart disease
• Over age 60
• Smoking
• Family history of stroke
• Being obese
• High cholesterol
• Diabetes
• High blood pressure
• Irregular heartbeat
You can be susceptible to haemorrhagic stroke due to the following reasons:
• If you are over age 64
• If you are obese
• Lack of exercise
• Certain medical conditions (e.g., liver disease or leukemia)
• Smoking
• Eating unhealthy food
• High cholesterol
• Use of illicit drugs
• If you have an aneurysm
• Head injury/trauma
• Family history of stroke
• Arteriovenous malformations(AVMs)
• High blood pressure
If you have any of these risk factors for stroke, it's very important that you to talk to your medical professional about how you can manage or limit your risk.
The best way to tackle stroke is to prevent it through being aware of its risk factors, and undertaking both lifestyle modifications and treatment to reduce the chances of the risk factors leading to a stroke.
Notwithstanding, when stroke occurs, it is a medical emergency that needs both immediate (acute) care and long term (chronic) care.
The different types of stroke have their special and unique treatment methods based on the peculiarities of the stroke.
Before treatment is administered, your doctor or emergency care provider will make efforts to clinically determine the kind of stroke you have and for how long. This is because the sooner this important information is known, the better it will be for your doctor to give the correct treatment that will increase your chances of recovery or survival.
Here are some of the treatment options you can get depending on the kind of stroke that you have:
When treating acute ischemic stroke, the aim is to unblock the blood vessels and restore the flow of blood to the brain as fast as possible. This may be done through any of the following treatments:
This drug type is administered through a major blood vessel in the body using a tube-like device called a catheter.
The drug helps to dissolve the clot that has blocked the flow of blood to the brain and must be administered between 3–4.5 hours after an ischaemic stroke event to increase your chances of survival and also to help reverse stroke symptoms and reduce complications.
The thrombolytic agent is called Tissue Plasminogen Activator or TPA.
This treatment is carried out when the giving a thrombolytic drug is no longer an option, i.e., the window of opportunity to give the drug is long gone or the clot is too big to be dissolved.
Figure 3: Treatment of stroke: Mechanical thrombectomy device in a brain vessel.
Mechanical thrombectomy involves the use of a special tube or catheter. The action steps (procedure) is carried out within 24 hours after exhibiting symptoms of stroke. It involves inserting a tube-like device (see figure 3) into a major blood vessel and then pushing or steering it up to where the clot is situated in the brain. A tool attached to the top of the catheter is then used to remove the clot.
A surgeon threads a catheter with a balloon attachment at the tip through a blood vessel in the body to where there is a narrowing of the blood vessel in the brain. At the location of the narrowing, the balloon at the tip of the catheter is then inflated to widen the narrowed artery, and a stent (a mesh scaffold-like device) is then placed inside the artery to hold it open and support the opened artery (see figure 4).
This treatment is carried out when using a catheter isn't an option. This is a surgery carried out to clear out the blocked carotid artery that has been blocked due to fat or cholesterol buildup over a period. This procedure reduces your risk of ischemic or transient ischemic attack.
Figure 5: Forms of blood thinners.
These medications are administered to stroke patients or people with stroke symptoms to ensure their blood does not clot and ensure the blood flows freely without getting stuck or sticking together. Depending on conditions, they are available for use as injections or as oral tablets (see figure 5). Blood thinners reduce your chances of having an ischemic stroke.
When treating haemorrhagic stroke, the aim is to stop the bleeding, reduce pressure on the brain, and seal off ruptured blood vessels. This can be carried out through the following treatment methods:
High blood pressure puts excessive pressure on the blood vessel which can result in a break (rupture) with bleeding of the blood vessel. This is the most common cause of a haemorrhagic stroke. Your doctor will give you blood pressure-reducing medication(s) to reduce your blood pressure and keep it at a safe level. This makes it easier for blood to clot and seal off the damaged blood vessel which then reduces or stops bleeding in the brain.
This procedure is done to close off an aneurysm in the brain. An aneurysm is a small balloon or pouch that develops from a weakened wall in a blood vessel in the brain. The clipping procedure is done by a neurosurgeon who makes an incision in the skull to access the aneurysm. Once located, a small clip is placed around the neck of the aneurysm to stop blood from getting into it, preventing rupture of the blood vessel or further bleeding. This procedure is carried out on people with ruptured aneurysms or people with haemorrhagic stroke caused by an aneurysm.
Surgery may be advised by your neurosurgeon to repair the blood vessels that lead to a haemorrhagic stroke. This procedure is done to repair a ruptured blood vessel that has an aneurysm, arteriovenous malfunction(AVM), or other types of blood vessel problem that have caused a haemorrhagic stroke. This procedure reduces the pressure that has built up in the brain and also removes accumulated blood in the brain.
Generally in humans, when there is a cut on any part of the body and bleeding occurs, after some time, you notice some form of clot over the bleeding. This clot is caused by a process called hemostasis. One of the treatments used to stop bleeding in haemorrhagic stroke patients is to administer hemostasis enabling drugs to help form a clot where there is a rupture in the blood vessel reducing your chances of brain damage or death.
This is an effective procedure used to treat haemorrhagic stroke. It's safe and can be used to stop bleeding from a ruptured aneurysm or arteriovenous malfunction (AVM) in the brain.
During this procedure, a flexible tiny coil (catheter) is passed through one of your arteries and guided to the site where the aneurysm is located in your brain. Once on site, the catheter then inserts detachable coils into the aneurysm or AVM to fill it. This blocks blood flow to the aneurysm and stops bleeding.
An AVM is a type of childbirth defect that causes abnormal connections between arteries and veins in the brain which can result in the rupture of the poorly formed network of blood vessels in the brain leading to a haemorrhagic stroke.
This surgical procedure is done by making a cut in the scalp, removing a piece of the skull, and locating the AVM which the surgeon removes carefully. After the surgery, the bone is returned and the scalp is then closed. However, some AVM can be located in a part of the brain that might be dangerous to operate on.
When it comes to the outcome of stroke treatment in sub-Saharan Africa, the data are scarce, [5] making it difficult to know if many of the acute interventions detailed above result in optimal care.
Sub-Saharan African countries generally fall short of the recommended standard for stroke care as each of the countries within the region have their own peculiar problems that hinder the best stroke care.
According to studies carried out in 14-54 African countries between January 2006 – June 2017, the percentage of stroke patients who arrived at the hospital within 3 hours of their stroke, ranged from 10% – 43%. [4] While half of the people in the study waited 31 hours or more before arriving at the hospital after they had a stroke.
The delay in reporting to the hospital is caused by many factors that include, lack of public awareness and poor knowledge of stroke signs and symptoms amongst the public, cultural and religious beliefs and practices, funding and transport issues, etc. Also, in Africa adherence to recommended treatments protocol is low because of limited resources.
A 2021 study, identified that in-hospital death rate during acute care of stroke varies from region to region in Africa. On an average, approximately 1 in 5 patients admitted into hospital following acute stroke across African countries, die from the condition. The factors influencing this death rate include; time of arrival in hospital following the stroke, the level of consciousness at admission, level of skilled care available, sex, age, other pre-existing conditions like hypertension, renal disease and diabetes. [6]
The current state of outcome can be improved through the collaborative efforts of policymakers and healthcare professionals to ensure effective and improved access to organized stroke care in as many locations as possible. Also, adoption of telemedicine can help improve public awareness and treatment.
After acute stroke treatment has been carried out, it's common for stroke patients to have lingering effects. These effects could be for days or months. After a stroke episode, part of the brain cells may have been damaged causing loss of ability to carry out certain activities of daily living and movements.
A few days following acute stroke treatment, rehabilitation plans are put in place to help you recover and also help you as much as possible become the person you were before the stroke episode so you can fit into society again.
Depending on the severity of the lingering effects certain post-stroke therapies can be adopted and these include:
Physical therapy helps stroke patients adapt to their new disabilities or help them recover the use of their body. Depending on the severity of the stroke, intensity, and duration, physical therapy may be advised.
Physical therapy can help you recover from a stroke in many ways including:
• Improve your strength and movement
• Improve your balance and coordination
• Improve your cognitive (mental) function, and
• Reduce the stiffness of your muscles.
Some of the physical activities that might be included in your physical therapy include:
• Motion Exercises: Joint mobilization exercises or stretching exercises.
• Balance and Coordination Exercises: Walking on a balance beam, standing on one leg, heel-to-heel walks.
• Strength Training Exercises: Weight lifting, resistance band exercise, and body weight exercise.
• Gait Training Exercise: Walking over obstacles, walking with a walker, and walking on different surfaces.
This form of therapy focuses on strengthening your mental abilities. It helps to improve your concentration, thinking, and memory abilities. Your emotional and psychological abilities are improved through some cognitive therapy.
Cognitive therapy can be used to help you if you have any of the following cognitive issues:
• Memory problems
• Speech problem
• Executive function problems
• Attention problems
• Problem-solving problems
The following activities can be used to revive your cognitive abilities:
• For retention problems: Use a mnemonic device or keep a journal for retentive memory.
• For Attention problems: Break down tasks into smaller steps and eliminate distractions.
• For Problem-Solving problems: Brainstorming solutions and identifying potential obstacles.
• For Speech problem: Use gesture or facial expression to communicate.
This type of therapy focuses on the part of the brain that aids you in speaking and understanding other people when they speak. This therapy helps you to recover your speaking, swallowing, eating, and drinking abilities. It can also help improve the ways you talk and speak with others.
Some examples of specific speech therapy that can help you recover from speech problems include:
• Speech Exercises: Use of gesture or writing test.
• Listening Exercises: A person speaks and you are asked to listen and give feedback, listening to music, audiobooks, or nature.
• Reading Exercises: Using finger pointers or breaking down words into syllables for easy reading and comprehension.
• Writing Exercises: Using a computer or Word processor to type words.
• Swallow Exercises: Engaging tongue, jaw, and swallow exercises.
The indications are that the outcome of chronic stroke care in Africa also varies from region to region, but is generally poor. The disability rate following a stroke is high. In one study in Ethiopia, about 45% of stroke patients discharged from hospital had residual physical disability. [7] Nearly 86% of stroke patients die within 3 years of their initial stroke.
Factors contributing to the high mortality and disabilitiy rates during chronic stroke care inclclude, cost, low standard of care, compliance with care protocols, etc.
Improvement in standard of care, public health awareness for stroke prevention, and funding support for stroke care will go a long way to reduce the short and long term human cost in death and disability following a stroke in sub Saharan Africa.
Stroke is of public health concern in sub-Saharan Africa. It is one of the leading causes of death and disability in the region. Treatment of stroke is the same in Africa as in other parts of the world. There are many challenges in providing optimal stroke care in Africa due to limited infrastructure and resources. Despite these challenges, some initiatives are being put in place to improve stroke care in Africa.
It's important to be aware of the symptoms of stroke because being aware enables you to detect it early, and this is essential for improving stroke outcomes. If you or anyone else has stroke symptoms, you must seek medical help immediately. Timely intervention or treatment helps give stroke patients higher chances of recovery.
There are several stroke treatments and they are carried out based on the type of stroke a patient has. Healthcare professionals need to ascertain the type of stroke before commencing treatment. Medical treatment and rehabilitation are important for helping stroke patients recover and fit into society again. There are several rehabilitation services in Africa and these services play a vital role in helping stroke patients recover fully.
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2. Stroke - causes and risk factors. NHLBI, NIH [Internet]. Last updated May 23 2023.2023. Available from: https://www.nhlbi.nih.gov/health/stroke/causes. Accessed October 23, 2023.
3. American Stroke Association. [Internet, n.d.]. Transient ischemic attack(TIA). Available from: https://www.stroke.org/en/about-stroke/types-of-stroke/tia-transient-ischemic-attack. Accessed October 23, 2023.
4. Urimubenshi G, Cadilhac DA, Kagwiza JN, Wu O, Langhorne P. Stroke care in Africa: A systematic review of the literature. International Journal of Stroke. 2018 Oct [cited 2023 Oct 26];13(8):797–805. Abstract. Available from: http://journals.sagepub.com/doi/10.1177/1747493018772747.
5. Limbole E, Mipinda JB, Cavagna P, Hermann Y, Tchuente-Noutchogouin MT, Souleymane C, et al. Stroke care in 17 Sub-Saharan African countries: the FEBRUARY study (2016–2021) from African research network, European Heart Journal, Volume 43, Issue Supplement_2, October 2022, ehac544.1989. https://doi.org/10.1093/eurheartj/ehac544.1989.
6. Mohammed AS, Degu A, Woldekidan NA, Adem F, Edessa D. In-hospital mortality and its predictors among stroke patients in sub-Saharan Africa: A systemic review and meta-analysis. SAGE Open Med. 2021 Jul 31;9:20503121211036789. doi: 10.1177/20503121211036789
7. Zewudie AZ, Regasa T, Hambisa S, Nureye D, Mamo Y, Aferu T, Feyissa D, Yosef T. Treatment Outcome and Its Determinants among Patients Admitted to Stroke Unit of Jimma University Medical Center, Southwest Ethiopia. Stroke Res Treat. 2020 Dec 30;2020:8817948. doi: 10.1155/2020/8817948. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7790566/
Published: November 5, 2023
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