You're discharging this acute ischemic stroke?!

Case: 45 y/o F with hx of DM, HTN presents with right sided weakness starting 2 hours prior to arrival. Pt on exam marked weakness on right side. Noticeable right sided facial droop with some dysarthria. GCS 14.

Vitals: Afebrile, Pulse 110, BP 190/110, RR 14
Glucose POC 110

So sounds like some kind of stroke.  Management usually starts with a CT to rule out hemorrhagic CVA (cerebrovascular accidents). Then if it is believed to be ischemic and their symptom onset is within the time window then we start TPA "clot busters". I'm excited because most strokes I have seen here are subacute and occur outside the treatment window, generally >4.5 hours. The risk of bleeding outweighs the potential benefit when it is outside the window. This one presented quickly and so I tried my best to get a CT as promptly as possible.

My eagerness was met with frustration when I realized (was told) they do not push TPA here. Either way if it is a hemorrhagic stroke, then maybe we can get neurosurgical involvement (if they are available, there is only neurosurgeon for all of Fiji) and possibly improve pt outcome. As much as I tried to expedite her CT. It took over 4 hours for the CT tech and the radiologist to get her CT completed. It was an ischemic stroke. When the medicine team finally evaluated her she had improving deficits and was able to ambulate with assistance. They did their own bedside swallow evaluation and she was able to swallow, so they discharged her. Well I have never discharged an acute ischemic stroke before. The medicine admit team said they would have her follow up closely.

In the states, strokes are generally admitted to evaluate the reason for their strokes. Thromboembolic strokes normally get a cardiac echo, cardiac monitoring, carotid duplexes etc to evaluate the reason for the thromboembolic insult. If the underlying reason isn't evaluated for the next stroke could be catastrophic. They are started on statins, aspirin, antihypertensives, counseled on smoking cessation, diabetes management, and get rehabilitation. This was very different.

The new trend for global health focuses more on NCD (non communicable diseases) with people living now more in urban than rural areas. Many more people around the world are overweight. The trend now is seeing more NCDs such as heart disease, stroke, cancers, diabetes and chronic lung disease. People globally now die more from NCDs than they do of infectious causes. This is direct from the Center for Disease Control. Before I did this rotation, I can't say that I knew that fact.

It is disconcerting to know that the major hospital in the capital city of Fiji does minimal for any kind of stroke. Residents tell me that most patients are lucky if they receive a CT within a day. If the patient could not maintain his airway and they were intubated, ventilators would be given precedence for patients that had potentially reversible causes of their pathology, most often sepsis. Management is often very conservative.

Hemorrhagic stroke management isn't much better. One neurosurgeon for all of Fiji and hope that it is not a bad brain bleed.

Hemorrhagic stroke

This patient was a 50 y/o M with sudden onset L sided hemiparesis. GCS 9 on arrival. Pt started vomiting so he was intubated for airway protection. Blood pressure was 250/160. They have no nicardipine here, no labetalol (only ICU use but they are out of stock). We tried blood pressure control with hydralazine, response limited. No neurosurgeon was readily available for an external ventricular drain (EVD).

We continued conservative management.

I hate strokes. It is NOT just a first world issue.