Research
Thrombolysis for acute ischemic stroke in South Africa
Alan Bryer1,2* and Sean Wasserman2
Background Stroke is an important cause of death and disabil-
ity in sub-Saharan Africa. Thrombolysis with recombinant
tissue plasminogen activator (tPA) is the only effective therapy
for acute ischaemic stroke. Essential requirements for stroke
thrombolysis include availability of CT scanning and arrival at
hospital within 4.5 hours of symptom onset. However, in
developing countries where the prerequisites are met at
certain centres, the efficacy and safety of thrombolysis have
not been firmly established.
Aims We aimed to evaluate the early outcomes and safety of
stroke thrombolysis in a South African setting.
Method We conducted a prospective observational study of
all stroke patients receiving tPA for thrombolysis over the
period January 2000 to February 2011. The primary outcome
measure was the proportion of patients achieving significant
early neurological recovery defined as an improvement of four
or more points on the NIHSS score at discharge. The safety
endpoint was the rate of symptomatic intracranial haemor-
rhage (SICH) and death.
Results Forty-two patients received thrombolysis over the
study period. Sixty-seven percent achieved significant neuro-
logical improvement. The majority of patients (53.8%) were
discharged home, and by the time of discharge 17 (40.5%)
were functionally independent. SICH occurred in 2 (4.8%)
patients with an overall mortality rate of 7.1%.
Conclusions Our findings indicate that the use of thrombolysis
in routine clinical practice in a South African setting has similar
safety and early efficacy outcomes to developed and other
developing countries.
Key words: acute stroke therapy, African, developing countries, ischemic
stroke, sub-Saharan Africa, thrombolysis
Method
We undertook a prospective, observational study of all stroke
patients receiving tissue plasminogen activator (tPA) for acute
ischemic stroke at a tertiary academic hospital (Groote Schuur
Hospital) (1). Eligibility for the study was defined by the Stroke
Unit Protocol and included patients with a clinical diagnosis of
acute stroke who presented within three-hours of symptom onset.
After publication of the ECASS III trial in 2008, this time window
was extended to 4·5 hours (2). Neurological impairment and
functional disability were assessed on arrival and at discharge
using the National Institutes of Health Stroke Scale (NIHSS) score
and the modified Rankin Scale (mRS), respectively. Computed
tomography (CT) scans were performed at baseline and within
Correspondence: Alan Bryer*, E8 Room 64, Division of Neurology,
Groote Schuur Hospital, Cape Town 7925, South Africa.
E-mail: alan.bryer@uct.ac.za
1
Stroke Unit, Division of Neurology, Groote Schuur Hospital, Cape
Town, South Africa
2
Department of Medicine, University of Cape Town, Cape Town, South
Africa
Conflict of interest: The authors declare no potential conflict of interest.
DOI: 10.1111/ijs.12059
112 Vol 8, October 2013, 112–113
36 h of thrombolysis, or if there was any evidence of clinical
deterioration. The primary outcome measure was the proportion
of patients achieving significant early neurological recovery
defined as an improvement of four or more points on the NIHSS
score at the time of discharge. The safety endpoint was the rate of
symptomatic intracranial hemorrhage (SICH) and death. Symp-
tomatic intracranial hemorrhage was defined as any new intrac-
ranial bleed on CT or magnetic resonance imaging accompanied
by a neurological deterioration of four or more points on the
NIHSS score from baseline. Secondary outcomes were functional
independence (i.e. an mRS score of 0–2) or an improvement of
two or more points on the mRS achieved at discharge.
Results
Forty-two patients were thrombolysed between January 2000 and
February 2011. The patients had a mean age of 60 (SD 12·26; range
24 to 79) and a median baseline NIHSS score of 14 [interquartile
range (IQR) 10·5 to 17]. Approximately 60% (n = 25) were clini-
cally assessed to have large vessel atheroembolic etiologies. Thirty-
six patients (85·7%), received intravenous (IV) tPA, four (9·5%)
received intra-arterial (IA) tPA and two (4·8%) received bridging
treatment with IV tPA followed by an endovascular procedure
including IA tPA. The mean time to tPA infusion was 160 mins
(SD 50; range 60 to 270). Most patients (29, 72·5%) were throm-
bolysed within 180 mins. The median duration of hospital stay
was 12 days (IQR 8 to 15·8). Over half of the patients who received
thrombolysis (25/42, 59·5%) arrived at the hospital using their
own transport. The median NIHSS score fell to 7·5 (IQR 1 to 15)
by the time of discharge. Forty-eight percent of patients scored in
the mild range (0 to 7), compared with only 5% on arrival. At
discharge, 18 (42·9%) patients had improved their mRS by two or
more points and 17 (40·5%) were functionally independent. The
majority of our patients (53·8%) were discharged home. Only two
(4·8%) patients in our cohort suffered SICH. Adverse effects were
not significantly related to time of tPA infusion, age, or stroke
severity. At the time of discharge, a total of three (7·1%) patients
had died, all of whom had admission Rankin scores of 5. Of these,
two deaths were unrelated to treatment.
The thrombolysis rates for patients admitted to our acute
stroke unit were consistently less than 6% per annum. There was
a small increase in the thrombolysis rates during the period of
study (0·6% in the year 2000, 2·3% in year 2005, 5·4% in year
2010, with mean of 175 patients treated in the stroke unit per
annum). However, these thrombolytic rates pertain only to
patients treated in the acute stroke unit and do not reflect the rates
for whole tertiary hospital as some patients with stroke that were
not thrombolysed were treated in the general medical wards when
our stroke unit was full (and these patients were not captured on
our database).
© 2013 The Authors.
International Journal of Stroke © 2013 World Stroke Organization
 A. Bryer and S. Wasserman
Discussion
Two thirds of our patients achieved significant neurological
improvement after receiving tPA. Small studies from other devel-
oping countries have reported similar results (3–7). Less than 2%
of patients with ischemic stroke in our hospital drainage area
received thrombolysis. This seems to be comparable with data
from other developing countries. Most of the patients who quali-
fied for tPA arrived at hospital using their own transport. A
greater proportion of patients who received thrombolysis were
employed, and lived in brick houses compared with those who
were managed conservatively, suggesting that those with higher
incomes are more likely to arrive at hospital within the narrow
time window required for this intervention. The implementation
of the stroke unit model of care across the healthcare system in
South Africa is the top priority for the stroke service in order to
achieve a significant impact on outcome. Nevertheless, our
limited data thus far indicate that the use of thrombolysis in
routine clinical practice in a South African setting has similar
early efficacy and safety outcomes to both developed and other
developing countries. However, the majority of patients with
acute stroke in South Africa are managed in public healthcare
facilities where thrombolysis is not available including some of
our tertiary hospitals where such treatment is feasible. The imple-
mentation of an acute stroke response network in the emergency
services should be considered to facilitate early arrival and assess-
© 2013 The Authors.
International Journal of Stroke © 2013 World Stroke Organization
Research
ment at designated stroke centres in tertiary hospitals in the
public sector where facilities for thrombolysis are available par-
ticularly in large metropolitan areas.
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