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Stroke care in low-income settings 189

Case Report
Challenges of stroke management in resource-limited
settings: A case-based reflection
Yohane G. Gadama1, Gloria Mwangalika2, Louis B. Kinley3, Beth Jackson1,
Henry C. Mwandumba2,4, Jane Mallewa5, Tom Solomon6, Rob Simister7, Laura A. Benjamin6,7,
Maria I. Vargas8, Joseph Kamtchum-Tatuene2,6, Tamara Phiri5
1. Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
2. Malawi–Liverpool–Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi
3. Department of Radiology, Queen Elizabeth Central Hospital, Blantyre, Malawi
4. Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
5. Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
6. Liverpool Brain Infections Group, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
7. Hyper-acute Stroke Unit, University College Hospital, London, United Kingdom
8. Department of Neuroradiology, Geneva University Hospital, Geneva, Switzerland
Correspondence: Dr Joseph Kamtchum-Tatuene (tatuene@liverpool.ac.uk)

Abstract

A 19-year-old man presented with a 1-year history of headache, generalised body weakness, progressive memory loss, and disorientation.
One month prior to admission, there was aggravation of the weakness of the right upper limb, with new-onset difficulty with
mastication, speech impairment, apathy, and urinary incontinence. On clinical examination, the patient had a motor aphasia and a rightsided hemiparesis with increased muscle tone and hyperreflexia. A noncontrast computed tomography (CT) scan of the brain revealed
large ischaemic strokes extending beyond the classical vascular territories. Cerebrospinal fluid analysis showed a mildly increased protein
level. The electrocardiogram revealed an irregular sinus bradycardia. The remainder of the cardiovascular and laboratory workup was
unremarkable. Considering a working diagnosis of central nervous system vasculitis, the patient was treated with aspirin, prednisolone,
and physiotherapy. However, he died suddenly a few weeks later. Based on this case, we discuss the challenges of stroke management in
resource-limited settings, provide practical tips for general practitioners, reflect on the potential avenues for short- and long-term action,
and introduce the budding collaboration platform between the University College London, the University of Liverpool, the Queen
Elizabeth Central Hospital, and the Malawi–Liverpool–Wellcome Trust Clinical Research Programme.

Introduction

Stroke is the most common cause of disability and the
second most common cause of death worldwide, after
ischaemic heart diseases.1 In Malawi, it is the 6th biggest
killer after infectious diseases.2 Although more common
in the elderly, stroke also affects young adults and recent
data suggest an increasing incidence of ischaemic stroke
in young adults, with significant adverse socioeconomic
consequences.3 Furthermore, stroke in young adults (those
younger than 45 years of age) is often initially misdiagnosed
by inexperienced clinicians because of its unexpectedness,
leading to lost opportunities for intervention.4,5 In highincome countries, stroke is labelled as cryptogenic in up to
one-third of cases.6–8 The challenge of appropriate diagnosis
and management of stroke is even greater in low-income
countries where there is a dearth of basic equipment, trained
personnel, and specific drugs. In this paper, through a case
managed at Queen Elizabeth Central Hospital (QECH) in
Blantyre, we discuss the challenges of stroke management
in resource-limited settings, provide practical tips for general
practitioners, and reflect on the potential avenues for shortand long-term action.
QECH, which is Malawi’s largest referral hospital, does not
house a stroke unit; therefore, all stroke cases are managed
within the internal medicine department. The hospital has
a Magnetic Resonance Imaging (MRI) department, the
construction of which was funded by the Blantyre Malaria
Project.9 However, computed tomography (CT) is only
accessible in Lilongwe, the capital city, which is over 350
km away. There are in-house radiologists but neurology,
neurosonology, and neuroradiology expertise is only
provided sporadically by visiting researchers.

Case presentation

A 19-year-old man presented with a 1-year history of
persistent headache of variable intensity, associated with
generalised body weakness, progressive memory loss and
disorientation, with the patient being unable to find his way
back home whenever he went out of the house. One month
prior to admission, he experienced an aggravation of the
weakness of the right upper limb, with new-onset difficulty
with mastication, speech impairment, excessive sleepiness,
and urinary incontinence. During the course of his illness,
the patient had been hospitalised several times and treated
for meningitis, cerebral malaria, and psychosis, without
clear evidence for these diagnoses. There was no fever, no
seizures, no vomiting, and no visual symptoms. There was no
history of hypertension, diabetes mellitus, or consumption
of tobacco, alcohol, or drugs.
On clinical examination, the patient was found apathetic
with a Glasgow Coma Scale score of 14 (eye opening to
verbal command). He had a motor aphasia with right-sided
hemiparesis, increased muscle tone and brisk reflexes without
clonus or Babinski’s sign.
A noncontrast CT scan of the brain revealed multiple large,
hypodense lesions, extending beyond the classical vascular
territories and involving the lenticular nucleus and the frontal
operculum on the right, the insula and the frontal lobe on the
left, and both putamina and temporal lobes. The lesions were
suggestive of recurrent ischaemic strokes and the one in the
left frontal lobe seemed more recent and associated with a
mild haemorrhagic transformation (Figure 1).

© 2017 The College of Medicine and the Medical Association of Malawi. This work is licensed under the Creative Commons Attribution 4.0 International License.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
http://dx.doi.org/10.4314/mmj.v29i2.21

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Stroke care in low-income settings 190

Figure 1: Brain imaging findings
A –D: Axial non-contrast brain CT scan slices showing the ischaemic lesions affecting both temporal lobes
(white vertical arrows – A), the right lenticular nucleus (white triangle – B), the left insula and putamen
(white star – B), the right frontal operculum (white asterisk –C) and the left frontal lobe (white “plus” sign –
D). There is a hyperdense dot at the margin of the left frontal infarct, corresponding to a small haemorrhagic
transformation (horizontal white arrow – D).
E –H: Axial T2 brain MRI slices showing the ischaemic lesions affecting both temporal lobes (black vertical
arrows – E), the right lenticular nucleus (black triangle – F), the left insula and putamen (black star – F), the
right frontal operculum (black asterisk – G) and the left frontal lobe (black “plus” sign – H).

The full blood count, liver function tests, random blood
sugar, and the HIV and syphilis tests were unremarkable.
Cerebrospinal fluid analysis revealed a mild increase of
the protein level (0.66 g/L; normal range: 0.2–0.4) but a
normal white blood cell count (1/mm3; normal range: 0–5).
The carotid–vertebral ultrasound was unremarkable. The
transcranial Doppler could not be performed because there
was no temporal window. The electrocardiogram revealed a
sinus bradycardia (56 beats per minute), with supraventricular
extrasystoles. The transthoracic cardiac ultrasound showed
a mild dilatation of the right atrium but there was no
valvulopathy, myxoma, or intracardiac thrombus. There
was no sign of right-to-left shunt, even after microbubble
injection at rest (the patient could not perform the Valsalva
manoeuvre).
Considering a working diagnosis of recurrent strokes
secondary to central nervous system vasculitis, the patient
was started on oral low-dose aspirin (75 mg/day) and
prednisolone (60 mg/day). He was also offered some
physiotherapy. A noncontrast brain MRI (0.35 T) performed
2 weeks after admission did not show any additional lesions.
He was discharged with a schedule for close neurological
follow-up. However, the patient’s parents reported his
sudden death 2 weeks later.

Discussion

The patient described in this report was diagnosed with
recurrent strokes, but the young age, the atypical presentation
(chronic headache and alteration of cognitive function,
with focal neurological symptoms only appearing at a later
stage), the absence of cardiovascular risk factors (diabetes
mellitus, hypertension, obesity, smoking, dyslipidaemia), the
absence of HIV infection, and the limited accessibility of
brain imaging techniques led to recurrent misdiagnosis with
ensuing failure to initiate adequate preventive therapy. At first
sight, given the distribution of lesions in space (bilateral with
cortical involvement) and time (lesions of different ages), one
http://dx.doi.org/10.4314/mmj.v29i2.21

could think of cardioembolism as the primary mechanism of
the ischaemic lesions. However, their size, confluence, and
extension beyond classical vascular territories speak against
this hypothesis and instead suggest either a primary or
secondary central nervous system vasculitis, a coagulopathy,
or a metabolic or mitochondrial encephalopathy.
Besides the radiological findings, other arguments in favour
of a primary central nervous system vasculitis would be the
presence of a chronic headache (which is the most common
symptom), the insidious progression of disease, the presence
of cognitive impairment (which is the second most common
symptom), the absence of constitutional symptoms (fever,
weight loss, night sweats—as would be seen in systemic
vasculitides), and the high protein level in the cerebrospinal
fluid.10,11 A coagulopathy seems less probable in the absence
of past or present thrombotic events in other organs, or
episodes of abnormal bleeding—but a definitive conclusion
would require a comprehensive assessment of the
coagulation profile. The negative family history, the absence
of myopathy, and the normal psychomotor development do
not support the diagnosis of mitochondrial encephalopathy,
but genetic tests would be needed to formally rule out a
sporadic case with atypical presentation. Thus, given the
limited diagnostic resources, the final cause of the recurrent
strokes remains uncertain. The irregular bradycardia found
on admission could be related to the lesions of the left
insula. Association between insular lesions and arrhythmias
have been consistently demonstrated, with left insular lesions
most often causing bradycardia.12 These perturbations of the
cardiac rhythm may explain the patient’s sudden death (in the
absence of a pacemaker).
This case illustrates a few of the numerous diagnostic
and therapeutic challenges related to stroke diagnosis and
management in resource-limited settings, as summarised
in Table 1. A few practical messages could be formulated
for clinicians on the frontline. First, strokes may occur at all
ages and should not be considered as only a disease of the
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Stroke care in low-income settings 191

Table
challenges
on the
to better
strokestroke
management
in low-resource
settings settings
Table1a:
1a:Diagnostic
Diagnostic
challenges
on path
the path
to better
management
in low-resource
Challenges

Relevance for this case

Staff
Improve the availability of neurologists, stroke
physicians and stroke nurses in order to reduce the
frequency of misdiagnoses and poor follow-up.

The diagnosis of stroke could have been made earlier, with
earlier initiation of preventative therapies.

Cardiology
Improve the availability of cardiologist, ECG and
cardiac monitoring device (in-hospital and
ambulatory), and transoesophageal echography.

- Prolonged in-hospital ECG monitoring interpreted by
qualified cardiologists could have helped to identify
transient but more serious dysrhythmias (including
paroxysmal atrial fibrillation).
- Transoesophageal echography is more sensitive than
transthoracic echocardiography for the identification of
patent foramen ovale and intracardiac thrombi.

Neuroimaging
Improve the availability of neuroradiologists, high
quality brain imaging (Computed Tomography,
Magnetic Resonance Angiography, Digital
Subtraction Angiography, and Neurovascular
Ultrasound).

- A better access to brain imaging might have contributed
to reduce the diagnostic delay.
- Vascular imaging (angioCT-scan and contrast-enhanced
transcranial Doppler; gadolinium-enhanced T1, 3D TOF,
and black-blood MRI sequences) could have highlighted
segmental stenosis of large intracranial arteries or areas of
contrast enhancement suggesting an ongoing inflammatory
process.

Biology and pathology
Improve the availability of:
Any of these conditions could have been the cause of the
- Immunoassays for autoimmune diseases,
recurrent strokes and the availability of appropriate tests
- Genetic and biochemical tests for congenital/
would have facilitated the diagnostic discussion.
inherited or acquired coagulation disorders as well as
collagen and mitochondrial diseases,
- CSF serologies and PCR for viral and bacterial
pathogens that frequently cause infectious vasculitis,
- Equipment for stereotactic biopsy,
- Trained staff for appropriate use of laboratory tests
and timely processing of specimens (blood, CSF,
urine, biopsies).
Table
challenges
on the
to better
stroke stroke
management
in low-resource
settings settings
Table1b:
1b:Therapeutic
Therapeutic
challenges
onpath
the path
to better
management
in low-resource
Challenges

Relevance for this case

Medical
Improve the availability and diversity of key
therapeutic agents: statins, antihypertensives
(including injectable preparations), oral
antidiabetics, oral/injectable antithrombotic agents
(antiplatelets and anticoagulants with associated tests
for monitoring activity - anti-Xa, INR), recombinant
tissue plasminogen activator, methylprednisolone
and steroid sparing agents for optimal acute and
long-term management of autoimmune vasculitis.

High dose methylprednisolone if frequently used for
treatment initiation in a patient with CNS vasculitis,
followed by long-term immunosuppression by
cyclophosphamide or other steroid-sparing agents.

Improve the availability of adequately staffed and
equipped stroke units for optimal monitoring of key
prognostic parameters during the acute phase, better
management of cases and early onset rehabilitation.

This might have improved the outcome in this case,
especially if the diagnosis had been made earlier.

Interventional
Improve the availability of:
A pacemaker could have been useful in this patient with
- Staff trained for the insertion and surveillance of
persistent irregular bradycardia and might have prevented
pacemakers
sudden death
- Equipment and trained staff for endovascular
interventions (endarterectomy, stenting, angioplasty)
Rehabilitation
Improve the availability of:
- Neuropsychologists for specific neurocognitive
rehabilitation,
- Occupational therapist for optimal organization of
post-stroke social and professional reinsertion
http://dx.doi.org/10.4314/mmj.v29i2.21

There was a clear indication for neuropsychological
rehabilitation and occupational therapy.

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Stroke care in low-income settings 192

Table
Epidemiologicand
and
public
health
challenges
onpath
thetopath
to stroke
bettermanagement
stroke management
Table 1c:
1c: Epidemiologic
public
health
challenges
on the
better
in low- in
low-resource
settings
resource settings
Challenges

Relevance for this case

Implementation of proper stroke registers that could A better awareness of stroke symptoms could have reduced
help for real-time monitoring of stroke incidence and the time to consultation, thus allowing earlier diagnosis and
risk factors and inform the planning of public health treatment.
interventions.
Improve population awareness about stroke risk
factors and symptoms and also the necessity to seek
medical advice as soon as possible.

Table
2: Clinical
Clinicalclues
clues
associated
common
young adults
Table 2:
associated
withwith
somesome
common
causes causes
of strokeofinstroke
young in
adults
Possible aetiology

Clinical clues
Cervical artery
dissection

Neck pain, recent neck trauma or chiropractic manipulation, vigorous
exercise, recurrent cough, lifting up heavy charges or carrying heavy
charges on the shoulders, presence of Claude-Bernard-Horner syndrome
(myosis, ptosis, anhydrosis)

Noninfectious
vasculitis

Recurrent episodes of skin rashes, joint pains, unexplained fever as seen in
systemic lupus erythematous, weak pulse in Takayasu arteritis

Patent foramen
ovale

Onset of neurological deficit following Valsalva manoeuvres (push up
exercises, defecation, micturition, lifting up heavy loads), presence of
concurrent deep venous thrombosis

Genetic or acquired
arterial diseases6,7,13,18

Cardiac diseases7,19,20

Infections21–26

Coagulopathies27-29

Infectious
Fever, murmur on cardiac auscultation
endocarditis and
rheumatic heart
diseases
HIV infection

HIV infection is a risk factor for stroke and patients should be routinely
tested for the condition, especially when considering the persistently high
prevalence in low-resource settings.

Infectious
vasculitis (VZV,
HSV,
tuberculosis,
syphilis)

Recent episode of zoster (especially ophthalmic zoster), chickenpox, herpes
rash, or tuberculous meningitis.
Recurrent episodes of sexually transmitted diseases and reported risky
sexual behaviours

Sickle cell
disease

Personal and family history, chronic anaemia

Haemophilia

Recurrent episodes of prolonged bleeding

Drug and
alcohol abuse

Needle tracks on the skin, perforation of the nasal septum.
Delirium tremens, hypertrophy of parotid glands, macrocytic anaemia and
abnormal liver enzymes

Pregnancy

Recent episodes of preeclampsia or eclampsia

Other conditions24,30,31 Recent
infections
Typical
cardiovascular
risk factors

Flu-like symptoms, gastroenteritis, upper respiratory tract infection in the
14 days preceding stroke onset.
Hypertension, diabetes mellitus and smoking are possible causes of stroke
in young adults.
The presence of obesity, family history of diabetes, polyuria, polydipsia,
and polyphagia should prompt appropriate screening.

elderly. In children and young adults, the clinical presentation
is often atypical, with chronic headache, seizures, and
neurobehavioural symptoms.13 Hence, a thorough
neurological examination must always be performed to look
for discrete signs (for example, speech disturbances, sensory
deficits, or abnormal or asymmetric muscle tone or reflexes)
suggesting a structural brain lesion, and the threshold for brain
imaging should be low. The identification of the aetiology of
stroke in young adults is more challenging, because on one
hand, classical cardiovascular risk factors are usually absent,
and on the other hand, the numerous alternative causes are
rare conditions that are difficult to diagnose in low-to-middle
income countries. In order to get the best out of the limited
resources at their disposal, clinicians should use a stepwise
approach, based on epidemiologic data and specific clinical
clues (Table 2). Advice should be sought from a physician
with expertise in stroke medicine whenever possible,
especially for patients with recurrent or cryptogenic strokes.
http://dx.doi.org/10.4314/mmj.v29i2.21

While waiting for resource and infrastructure improvements,
low-to-middle income countries like Malawi can implement
some simple solutions to improve stroke care in their local
settings. These include raising population awareness about
stroke symptoms and risk factors using well-designed
communication strategies,14 investing in telemedicine for
teaching and case management,15,16 and strengthening
partnerships with high-income countries for the financial,
logistic, and training support. There are ongoing discussions
between Queen Elizabeth Central Hospital, the Malawi–
Liverpool–Wellcome Trust Clinical Research Programme,
and international partners (University College London
Hospitals and the University of Liverpool), in view of
initiating a collaborative platform to address some of these
challenges in the short term.17 The actions implemented
will aim to improve clinical care through the creation of a
stroke unit, as well as support local stroke research and staff
training.
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Malawi Medical Journal 29 (2): June 2017
Noncommunicable Diseases Special Issue

Acknowledgements
The authors are grateful to the patient and his parents for
granting the permission to use their medical information for
teaching and scientific publication.

Competing interests
All authors declare that they have no competing interests
related to this work.

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