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STROKE SERIES · ARTICLE 5 OF 12
What happens at the hospital
Emergency treatment from ambulance to stroke unit.
You called 10177. The ambulance is on its way. What happens next? This article walks through the hospital journey of an acute stroke — from the moment the paramedics arrive at your door to the day you are transferred from the stroke unit to a general ward or home. Understanding what is coming makes the journey less frightening, both for the patient and for the family, and helps you ask the right questions at the right times.
South African stroke care has improved significantly in the last 15 years. Most large public hospitals can give clot-busting drugs. Several major centres can do mechanical clot retrieval. Dedicated stroke units exist in many of the bigger hospitals. The system is uneven, but it is far better than people often realise.
If you skipped article 2
This article assumes the F.A.S.T. check has been done and the ambulance has been called. If you are reading this because a stroke is happening right now — go back to article 2 first. Then come back here once help is on the way.
Step 1 — The ambulance arrives
Paramedics at the scene
USUALLY 8 – 30 MINUTES AFTER THE 10177 CALL
The paramedics will quickly do a stroke assessment of their own — usually a variant of F.A.S.T. They will check vital signs (BP, pulse, oxygen, blood sugar) and look for any other obvious problems.
They will ask: when did the symptoms start? If you know, give the exact time. If the patient woke up with the symptoms, give the last time the patient was clearly well — for example, “He was talking normally to me at 22:00 last night. I found him at 06:00 unable to speak.” This is the single most useful piece of information you can give them.
The paramedics will also ask: any current medications? Any allergies? Any recent surgery? Any history of bleeding? These questions matter because they affect which treatments can be given.
The ride to hospital
USUALLY 10 – 30 MINUTES
The paramedics will take the patient to a hospital that can manage acute stroke — not always the nearest one. A hospital with a CT scanner is essential; a hospital with a dedicated stroke unit is ideal. The paramedics know which hospitals in your area do what.
While the ambulance is moving, they may put up an IV line, give oxygen if needed, and contact the hospital ahead to alert the emergency department that a possible stroke patient is incoming. This “pre-notification” is one of the strongest predictors of fast hospital treatment.
Step 2 — Arrival at the emergency department
Triage and initial assessment
FIRST 5 – 15 MINUTES AT HOSPITAL
Suspected stroke is one of the highest triage priorities in any emergency department — equivalent to a heart attack or major trauma. The patient will usually skip the queue and go straight to a resuscitation cubicle.
A doctor will do a more detailed stroke assessment using a scoring system called the NIHSS (National Institutes of Health Stroke Scale). This scores the severity of the stroke on a 0 – 42 scale and helps decide which treatments to consider.
Blood will be drawn — full blood count, clotting, glucose, kidney function. Vital signs will be re-checked.
The CT scan
USUALLY WITHIN 30 – 60 MINUTES OF ARRIVAL
The CT scan is the single most important test in the first hour. It tells the team whether the stroke is ischaemic (a blockage) or haemorrhagic (a bleed) — and that decides almost everything that happens next.
A fresh bleed shows up as a bright white area on the CT scan. A fresh ischaemic stroke usually shows nothing — but the absence of bleeding allows clot-busting drugs to be given safely.
Some hospitals will also do a CT angiogram (CTA) at the same time — a more detailed scan of the arteries — to see exactly where the blockage is and whether thrombectomy is possible.
Step 3 — The treatment fork
This is where the path splits based on what the CT showed.
If the stroke is ischaemic (blockage)
Two treatments are possible — sometimes both:
Thrombolysis — clot-busting drugs
A medication called alteplase (or the newer drug tenecteplase) is given as a drip over about an hour. It dissolves the clot that is blocking the brain artery. If it works, blood flow to the at-risk brain tissue is restored before the cells die.
The catch: thrombolysis only works inside specific time windows.
• Within 3 hours of symptom onset — best results. Roughly 1 in 4 patients treated walks away without disability.
• 3 to 4.5 hours — still useful but smaller effect.
• After 4.5 hours — generally not given. The risks (bleeding) outweigh the benefits.
This is why the “when did symptoms start” question matters so much. Without that information, the team cannot decide whether thrombolysis is an option.
Thrombolysis carries a small risk of bleeding — including bleeding in the brain itself, which can make the stroke worse. The doctors will weigh this against the expected benefit. They will explain the choice to the family before going ahead, where possible.
Thrombolysis is available at most large South African public and private hospitals. It is on the SA Essential Medicines List.
Thrombectomy — mechanical clot retrieval
For some patients with a large-artery blockage, a specialist interventional radiologist or neurosurgeon can physically pull the clot out of the brain. A thin catheter is threaded through a blood vessel — usually from the groin or the wrist — up into the brain artery, and a tiny mesh device grabs the clot and removes it.
Thrombectomy is much more effective than thrombolysis alone for large-vessel strokes. The two are often used together — thrombolysis first to start dissolving the clot, then thrombectomy to remove what’s left.
Time windows are wider for thrombectomy:
• Best results within 6 hours of symptom onset.
• In carefully selected patients with extra advanced imaging, can be done up to 24 hours.
Thrombectomy in South Africa is available at major centres — Groote Schuur (Cape Town), Tygerberg (Cape Town), Charlotte Maxeke (Johannesburg), Steve Biko (Pretoria), Inkosi Albert Luthuli (Durban), and several large private hospital groups (Netcare, Mediclinic, Life Healthcare).
If the stroke is haemorrhagic (bleed)
Thrombolysis is not given — it would make the bleeding worse. Treatment focuses on:
• Lowering BP carefully — usually with a drip medication, targeting a systolic BP around 140 mmHg. Lowering too fast or too far can starve the surrounding brain tissue.
• Reversing any blood-thinners the patient was on. Warfarin is reversed with vitamin K and clotting factors; DOACs (apixaban, rivaroxaban, dabigatran) have specific reversal drugs in some centres.
• Neurosurgery in some cases — for very large bleeds, bleeds causing severe pressure, or bleeds from a burst aneurysm (SAH). Surgical options include removing the blood clot, clipping or coiling an aneurysm, or relieving pressure with a temporary drain.
For subarachnoid haemorrhage from a burst aneurysm, the priority is identifying and securing the aneurysm — usually with endovascular coiling (a catheter procedure) or surgical clipping — to prevent a second, often fatal, re-bleed.
Asking about treatment decisions
It is completely reasonable to ask the team: “What treatments are being considered? What are the time windows? What are the risks and the benefits?” These conversations happen quickly under pressure, but the doctors are used to them and will appreciate clear, calm family questions. If you can’t be at the hospital, ask the doctor to phone you when decisions are being made.
Step 4 — The stroke unit
Admission to the stroke unit
AFTER INITIAL TREATMENT, USUALLY WITHIN HOURS
A stroke unit is a dedicated ward with specially-trained nurses, therapists and doctors. Patients admitted to stroke units do significantly better than patients admitted to general wards — about 1 in 20 patients goes home alive who would not have done so on a general ward. The benefit is large and well-established.
What the stroke unit does:
• Continuous monitoring of vital signs and neurological status.
• A formal swallow screen (see below) before any food or water by mouth.
• Early mobilisation — usually within 24 – 48 hours, even if the patient seems weak.
• Daily input from physiotherapy, occupational therapy and speech therapy.
• Investigations to find the cause of the stroke — heart monitoring for AFib, carotid Doppler ultrasound, sometimes an echocardiogram.
• Starting secondary prevention medications — usually aspirin, a statin, and (in time) BP medication.
The first 24 hours — what to expect
The first day is intense. Things move quickly and can feel chaotic to family members. A rough picture of what usually happens:
Hour Typical events 0 – 1 Ambulance → triage → CT scan → first treatment decision 1 – 4 Thrombolysis (if given), thrombectomy in selected cases, blood tests, ECG 4 – 12 Stabilisation, transfer to stroke unit, more imaging, family briefing 12 – 24 Swallow screen, first physiotherapy review, start of secondary prevention drugs 24 hours Repeat CT to check for bleeding or worsening; team review
The patient may seem better, the same, or temporarily worse over the first 24 hours. Sometimes there is a “stuttering” pattern — a bit better, then a bit worse, then better again. This is common in the first day and does not necessarily mean things are going badly.
The swallow screen — small but important
Stroke often affects swallowing. Food or water that goes into the lungs instead of the stomach can cause aspiration pneumonia — one of the most common causes of death in the days after a stroke. So no food or water is given by mouth until a formal swallow screen has been done — usually by a nurse or speech therapist, in the first 24 hours.
The screen is simple: the patient is given a sip of water and watched closely for coughing, choking, a wet voice, or trouble swallowing. If the screen is failed, the patient stays nil-by-mouth and a speech therapist does a more detailed assessment, sometimes including a special X-ray (videofluoroscopy).
If the patient can’t safely swallow, fluids and food are given through a thin tube down the nose (a nasogastric tube) until swallowing improves. This is uncomfortable but temporary — most stroke patients’ swallowing recovers within days to weeks.
Early mobilisation
For most stroke patients, getting out of bed within the first 24 – 48 hours improves recovery. Even sitting up in bed counts. Lying flat for days raises the risk of pneumonia, blood clots in the legs, pressure sores, and muscle deconditioning. Physiotherapists will usually start with passive movement of the limbs, then progress to sitting, standing, and walking with support over the first week.
What family members can do
The family role in the first days is enormous. Specific things that help:
• Bring the patient’s regular medication list — every tablet, every dose, every time. The hospital pharmacy can help if you bring the actual boxes.
• Bring the medical aid card or hospital file if there is one.
• Designate one family contact person for the medical team to communicate with. This stops mixed messages.
• Be there for the daily ward round if you can. Even 15 minutes is enough to ask the team three questions and get a clear picture.
• Talk to the patient. Even if they can’t talk back, they can often hear you. Familiar voices help orientation.
• Help with personal care — feeding (once swallowing is safe), washing, changing — if the ward allows. This eases the nursing load and helps the patient.
• Look after yourself. Sleep, eat properly, take breaks. You are useful only if you stay well.
How long is the hospital stay?
It varies enormously. As a rough guide:
• TIA (no permanent stroke): 1 – 2 days for investigation.
• Small ischaemic stroke, mild symptoms: 3 – 7 days.
• Moderate ischaemic stroke: 7 – 14 days.
• Major stroke or haemorrhagic stroke: 2 – 6 weeks, sometimes longer.
• Patients needing rehabilitation: often transferred to a rehabilitation ward or unit after the acute hospital stay, for further weeks of therapy.
Discharge planning
From day 3 or so onwards, the team starts thinking about discharge. They will assess:
• How much help the patient will need at home.
• Whether the home is safe — stairs, bathroom, doorways.
• Whether outpatient rehab is needed (physiotherapy, occupational therapy, speech therapy).
• What medications the patient needs going forward.
• Follow-up clinic appointments.
• Whether driving will be permitted (usually a 1-month restriction at minimum after any stroke).
You will be given a discharge summary — keep it. It contains the diagnosis, the medications, and the follow-up plan. Show it at every future clinic visit.
The bigger picture
Acute stroke care has been transformed over the last two decades. Thirty years ago, stroke patients were largely watched and supported; today, the first hours involve active treatments that genuinely reverse damage. South African public hospitals have been at the forefront of this change for the kinds of care that don’t require expensive equipment — thrombolysis, stroke units, careful nursing.
The system is uneven and there are real gaps — particularly in rural areas — but the trajectory is good. Knowing what to expect helps you and your family navigate the journey with less fear and more useful action.
The next article in the series moves from the hospital to the first six weeks of recovery — what to expect at home, common physical and emotional changes, and what is normal versus what needs medical attention.
A note on numbering
Article 4 of this series — the risk factors — is still in the queue. You can read this article first and come back to article 4 whenever it works for you; they don’t strictly depend on each other.
Where to get more help
Heart and Stroke Foundation South Africa — heartfoundation.co.za · 021 422 1586 — has lists of SA stroke units and information on what to expect.
StrokeSSA — Stroke Survivors South Africa — survivor and caregiver community.
Your hospital’s social worker — once admitted, ask to speak to the ward social worker for help with medical aid queries, transport, rehab referrals.
Phila Today Stroke Series — next: the first six weeks of recovery — what to expect.
Phila Today · Article 5 of 12 in the Stroke Series