Objective. To describe the prevention, management and rehabilitation of stroke in South Africa as provided by a range of caregivers. Options. Emphasis should predominantly be on finding the cause, preventing, and treating stroke in the transient and mild stroke group. Moderate stroke patients require maximal rehabilitation and secondary prevention. Severe disabling stroke patients require home and community care. Outcomes. The most effective use of resources (personnel and facilities) in relation to the different types of stroke. These should be used to decrease stroke incidence, increase stroke awareness, improve acute stroke therapy, and improve access to rehabilitation. Evidence. Based on international reports and research. Meta-analyses were used when the topic warranted such specific literature review. Stroke consensus has been achieved internationally and widely reported. A wide range of South African reviewers from various health fields, including representatives of local and national health groups, were consulted. Evidence-based documents were considered and incorporated. Values. As far as possible, cultural and economic preferences were given major emphasis. The aim of the guideline is to optimise stroke care from the point of view of individual patients, health practitioners, reimbursing agencies and society as a whole. Where possible, best-practice stroke care of international standard has been used in this document. However, at no stage has the Working Group deviated from the unique set of South African stroke problems, namely differing risk and preventive factors, multicultural, genetic and traditional practices and the problems of cost saving from best-practice funding for stroke care. Benefits, harms, costs. It is difficult to assess the local situation without prospective research. However, stroke causes the following in South Africa: - between 8% and 10% of all reported deaths; - 7.5% of deaths in the workforce (25-64 years of age); - age-standardised mortality rate of 125-175/100,000. More can be done to improve the cost-effectiveness of available resources by increasing education of health care professionals and patients. Recommendations. Assess and treat all cerebral vascular events within 6 hours if possible; categorise the stroke into mild, moderate or severe; transient ischaemic attack (TIA), minor or reversible stroke should be intensively investigated to find the cause and this should be treated vigorously; all risk factors should be treated; moderate strokes require active rehabilitation; secondary prevention is required to prevent another stroke; when vegetative symptoms persist after 7 days, therapy should be supportive. Validation. This guideline is similar to others produced in other countries but with reference to South Africa, and has been developed in collaboration with the Neurological Association of South Africa. The initial document was developed in 1997 with a multidisciplinary group with special interest in the management of stroke. In July 1998 a nationally representative stroke consensus meeting was held and the document was widely scrutinised. The guideline is endorsed by the South African Medical Association.
