Medical complications of stroke

Introduction
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By Adrian Marchidann MD

Overview. Medical complications following stroke account for significant morbidity and mortality. These clinical conditions need to be recognized and managed effectively for a more favorable outcome. Direct effects of ischemic stroke, like hemorrhagic conversion or cerebral edema, account for the majority of deaths within the first week, but other medical complications that include cardiac causes (arrhythmias, myocardial infarction), infections (pneumonia, urosepsis), and venous thromboembolism account for at least 50% of mortality thereafter. In this clinical summary, Dr. Adrian Marchidann of SUNY Downstate Health Science Center discusses the medical complications of stroke-related deficits, their workup, and treatment modalities. Venous thromboembolism care information was updated according to the 9th edition of the American College of Chest Physicians guidelines.

Key Points

  • Venous thromboembolism is one of the most common and potentially dangerous complications in patients with stroke because of limitations of limb mobility, and in the case of intracerebral hemorrhage, of concerns regarding early anticoagulation.
  • Although promising, the newer oral anticoagulation agents like rivaroxaban and dabigatran need further testing before stronger recommendations are made for their use as anticoagulants of choice.
  • In the context of acute ischemic or hemorrhagic stroke, treatment of hemodynamically unstable pulmonary embolism requires specialized care and resources because the treatment of choice, intravenous thrombolysis, is contraindicated.
  • Due to limited mobility, stroke is associated with increased risk of osteoporosis, fractures, pressure sores, painful arthritis, and peripheral neuropathy.

Introduction. Medical complications following stroke account for significant morbidity and mortality. For a more favorable outcome, these clinical conditions need to be recognized and managed. In this section, the complications are listed and treatment described.

Prospective studies suggest that direct effects of ischemic stroke, such as hemorrhagic conversion or cerebral edema, account for the majority of deaths within the first week, but medical complications account for at least 50% of mortality thereafter (Silver et al 1984; Johnston et al 1998). With the advent of stroke units and more organized inpatient care, complications secondary to immobilization are being prevented. The only statistically significant finding in the Stroke Unit Trialist Collaboration study was that stroke units minimized complications of immobility and reduced deaths that usually occurred between 1 and 4 weeks of an index stroke (Anonymous 1997). These complications may be countered in part by simple interventions such as careful speech and swallow evaluations to minimize aspiration, reduction in the use of urinary catheters, and anticoagulation to prevent deep venous thrombosis. In the later months after stroke, the most frequent complications, significant in terms of mortality, are: cardiac issues (arrhythmias, myocardial infarction), infections (pneumonia, urosepsis), and venous thromboembolism (pulmonary embolus); the less morbid complications are psychiatric disorders, central post-stroke pain, falls, and pressure sores (Silver et al 1984).

In the Copenhagen Stroke study, cardiovascular risk factors and 5-year mortality were assessed. The conclusions were that atrial fibrillation, diabetes, smoking, and previous stroke significantly affect long-term survival. Smoking and daily alcohol consumption were associated with improved survival in the univariate analyses, but with adjustment for other factors, especially age, the lethality of smoking was exposed, and the positive effect of alcohol disappeared. This shows that secondary preventive measures such as anticoagulation for atrial fibrillation, smoking cessation, and proper treatment of diabetes may significantly improve long-term survival (Kammersgaard and Olsen 2006).

A reasonable grouping of post-stroke medical complications, which includes the neurologic sequelae (recurrent stroke, post-stroke seizures), is provided in Table 1 (Langhorne et al 2000). Several of these topics (sleep apnea, vascular dementia, depression, dysphagia, normal pressure hydrocephalus) are discussed in other clinical summaries. The topics discussed in this clinical article are listed in Table 2.

Table 1. Medical Complications of Stroke: A Classification Scheme

I. Neurologic complications

(A) Seizures
(B) Vascular dementia

II. Infections

(A) Urinary tract infection, urosepsis
(B) Dysphagia, aspiration pneumonia

III. Complications of immobility

(A) Falls
(B) Hemiosteoporosis, fractures
(C) Pressure ulcer
(D) Spasticity

IV. Thromboembolism

(A) Deep venous thrombosis
(B) Pulmonary embolism

V. Pain

(A) Shoulder pain
(B) Central post-stroke pain

VI. Psychological complications

(A) Depression
(B) Anxiety
(C) Confusion
(D) Emotional incontinence

VII. Miscellaneous

(A) Gastrointestinal hemorrhage
(B) Constipation
(C) Cardiac failure, arrhythmias
(D) Arthritis
(E) Sleep apnea
(F) Nutritional deficiencies

Adapted from (Langhorne et al 2000).

Table 2. Medical Complications of Stroke

I. Disorders of immobility

(A) Deep venous thrombosis and pulmonary embolus
(B) Hemiosteoporosis and hip fractures
(C) Falls
(D) Pressure sores, skin ulcers
(E) Peripheral nerve injury

II. Pain

(A) Shoulder pain
(B) Central post-stroke pain

III. Incontinence

In This Article

Introduction
Deep venous thrombosis and pulmonary embolism
Bone disease: osteoporosis and fractures
Complications of stroke
Pain syndromes
References cited
Contributors