Stroke Complications

Learning objectives

Introduction

Complications after stroke can greatly affect outcome. They can be divided into those that occur from onset of the stroke are early complications as seen below and those more likely to occur during the first few weeks and later. They can affect the opportunities and stamina needed for therapy and rehabilitation. They can affect swallowing and nutritional status and add to the psychological post stroke burden. They can be life-threatening and affect short and long-term outlook. It is important to not only predict or at least react to diagnose issues but to have protocols in place to address particular problems. Most medical complications are seen within the first month. In the early days swallowing, fever, coma, cerebral oedema and sepsis are all major factors and patients are most vulnerable. Later as mobility is gained issue such as falling, ongoing continence issues and venous thromboembolism are more concerning. All the members of the multidisciplinary team play a role in minimising and pre-empting complications. Stroke renders patients weak with sensory loss, visual and cognitive and psychological and other issues. The main complication is simply the results of profound immobility and others which are listed below. It is important to have a plan to prevent and manage complications. Stroke renders patients weak with sensory loss, visual and cognitive and psychological and other issues. The main complication is simply the results of profound immobility and others which are listed below. It is important to have a plan to prevent as well as to detect and manage complications.

Hydrocephalus

An obstructive hydrocephalus can be seen after both ischaemic and haemorrhagic strokes and may need urgent neurosurgical intervention both for the stroke itself and the insertion of an external drain into the lateral ventricle to allow the external drainage of CSF so that intracranial pressure falls. It is dealt with in more detail. It usually presents with a general worsening and a fall in GCS which should initiate a new clinical reassessment and CT scan. This subject is dealt with in more detail here

Fever

Fever may be seen post stroke and can be multifactorial. Fever is associated with worsened outcomes. Pyrexia correlates with infarct size and severity. Infective causes should be explored and treated. General examination and bloods such as WCC, Urinalysis, CRP and blood cultures can be helpful. Anecdotally pontine lesions appear to cause pyrexia. Treatment should be with antipyretics such as IV/PO paracetamol and ensure euvolemia. Caution with overhydration and worsening cerebral oedema.

Heart Failure

Many patients are elderly and frail and may have co-existing ischaemic or valvular heart disease, hypertension or diabetes and be at high risk for heart failure. Both systolic and diastolic heart failure are common, and it is important to keep a close watch on input and output especially as this can change after stroke and decide on whether to continue routine diuretics or other heart failure medications. If there is diagnostic uncertainty the CXR may show cardiomegaly, upper lobe diversion and pleural effusion, the ECG will often be abnormal with LVH, old MI and dynamic changes and screening tests such as BNP will be abnormal too. An echocardiogram can often give a good assessment of LV contractile function as well as valve issues. Acute symptomatic management involves IV or oral loop diuretics and long-term prognosis is improved with use of ACE inhibitors and beta blockers. Ischaemic and valvular heart disease and Hypertension should be managed. Saline is the fluid of choice immediately post stroke, but care must be taken to avoid overload and pulmonary oedema particularly seen in the frail older patients with cardiac and renal disease. Weekly weights if possible, can give a good idea of short term changes in fluid balance.

Atrial Fibrillation

AF is seen in 10% of those over 80 and is a common cause of stroke. They may also have tachyarrhythmias such as Fast AF and maybe compromised. Usually the AF predates the stroke, but any form of sepsis or other problem can potentially precipitate AF. More information here. These patients will need CHADS-VASC and HASBLED score and consideration for anticoagulation.

Post Stroke seizures

Seizures after stroke are uncommon and seen in about 5%. They may be early or late. Early may occur within the first 1-2 days after a stroke. Usually, the stroke is large and cortical. There may be anything from a single seizure to status epilepticus. Early seizures can be one-off events in the acute stroke period and do not always herald a diagnosis of epilepsy and can quickly settle and may not need long-term anticonvulsants. Late onset seizures several months or even years post-stroke is treated as epilepsy. The underlying aetiology for seizures is complex but one suggestion is an excess of the excitatory neurotransmitter glutamate. Locally our first line therapy is often levetiracetam (Keppra) but Valproate is often used. Phenytoin is restricted for status epilepticus.

Venous Thromboembolism

VTE covers the incidences of Deep vein thrombosis and pulmonary embolism. DVT is common in those who are mobile in the hospital and is often asymptomatic. The more immobile the greater the risk. There are various strategies to try to prevent VTE and these are discussed below. If one performs venography at Day 10 in stroke patients a great deal of small and distal clots can be found of uncertain risk. The main preventative strategy is early mobilisation, hydration and intermittent pneumatic compression (IPC).

Aspiration can result from impaired swallowing and so an initial swallowing assessment is key, and this helps to prevent inappropriate oral intake. A bedside swallow should be performed on all new stroke patients within the first few hours. If this fails, then patients should remain NBM and have IV fluids or consideration for an NG tube. The neurology of swallowing involves centres in the frontal lobe and brainstem. Swallowing is a complex neurological function that depends on multiple muscle groups acting together to direct food from the oral cavity into the upper oesophagus allowing and avoiding and aspiration. It is not surprising that in many patients with stroke that it often parallels initial drowsiness. Swallowing is often the dominant disability in those with a Lateral medullary syndrome. An excellent paper is available here. Risk Factors Reported in the Literature for Development of Post Stroke Pneumonia.

Prophylactic antibiotics have been shown to be useful in animal models this has not translated fully into the human experience with a small reduction in infections and no effect on mortality.

The treatment can involve physiotherapy to aid expectoration, adequate hydration and regular sitting out to help ensure respiratory function. Pure aspiration is partially a chemical pneumonitis if low pH material is aspirated. One of the common issues is about NG feeding of patients with poor upper airway protection and the real risks of gastro-oesophageal reflux and aspiration of feeds. There are always the concerns of the never event where a patient is fed via NG, but the tip of the line is within a main bronchus. This should be preventable with pH testing and CXR if needed ensuring the NG tube remains in the midline in its passage though the chest. Avoid the "whoosh test" which is unreliable.

References

• Wartenberg, KE, Stoll A,Funk A, AndreasMeyer, Schmidt MJ, Berrouschot J. Infection after Acute Ischemic Stroke: Risk Factors, Biomarkers, and Outcome. Stroke Research and Treatment Volume 2011. doi:10.4061/2011/830614
• Sellars C, Bowie L, Bagg J, Sweeney, Miller H, Tilston J, Langhorne P, Stott DJ. Risk Factors for Chest Infection in Acute Stroke. Stroke. 2007;38:2284-2291

Continence

Bladder dysfunction is common after stroke. Continence issues are common in those with language and cognitive dysfunction associated with severe functional impairment. Continence issues greater with larger and cortical infarcts and there is no real lateralisation.

Falls

The only way to completely prevent falls in a patient recuperating following stroke is to not allow patients to walk but this creates a whole set of other problems. The aim of rehabilitation when possible is to enable a patient to walk safely. This may require the use of various walking aids. Falls without syncope may be due to many factors, weakness, poor vision, ataxia, apraxia, anxiety. Falls associated with low BP should be managed medically and the cause addressed as much as is possible prior to ongoing therapy.

Nutrition

The patient will enter a catabolic state if deprived of calories post stroke. The challenge is always how to give calories as safely as possible. In many frail older patients, there may already be some weight loss. Patients may have chronic illnesses associated with weight loss such as COPD or even known or occult malignancies. With dementia type processes the interest and desire to eat may be reduced. Patients may simply forget to eat and need support and prompting. Other issues in older patients include poor dentition, odynophagia, candidiasis, and oral issues. Some may have an undetected oesophageal malignancy, so an accurate history must be taken and an OGD may be needed in some. In some patients with lateral medullary syndromes where the issue is predominately a defective swallow then rapid NG to PEG will quickly resolve nutritional issues and the PEG can be removed when swallow is safe enough to allow normal intake. It is important that patients are evaluated for nutrition as part of the weekly MDT. Tools such as MUST below can help to identify at-risk patients.

Mood/Cognition

Strokes are often life-changing events and carry with them psychological trauma for the patient and those close to them. There is often a loss, physical, function and a loss of confidence and independence which can be devastating. It takes time for patients to readjust to new circumstances and many patients with time recover psychologically. Psychological treatment can include counselling or therapy for feelings that result from clinical depression. Types of treatment may include antidepressant medication, psychotherapy or both. You may also be referred to a local stroke support group. I will often discuss mood on more than one occasion with patients and discuss if they wish to consider antidepressants which is usually a six-month course and they can then withdraw gradually under supervision of their primary care physician.

There is available NICE guidance:psychological care after stroke. They pinpoint various times when psychological issues should be assessed.

• One month after stroke or just before discharge, or at six week follow-up
• Three months after stroke, usually post-discharge to judge persistence of early-onset problems and emergence of new problems
• Six months after stroke when much physical and social recovery has stabilised and likely longer-term problems can be assessed
• Assessment at six month and annual reviews will allow identification of those with long-term problem

Which cognitive assessment tools to use?

Assessment measures should only be carried out by staff trained to administer these tests. Some assessments require specific training from the company who provide the assessment, such as the AMPS. Assessment tools vary in purpose and should be selected according to need. Some assessment tools aim to give a broad picture of cognitive ability such as the MOCA, ACE-R or RBANS. Other assessments are targeted at specific cognitive skills for example:

• Attention: TEA
• Memory; Rivermead Behavioural Memory Test,
• Perceptual skills; BIT, RVPB
• Executive Functions; BADS

Links to Tests

• Addenbrookes cognitive Examination-III English Version A (2012)
• The Rivermead Behavioural Memory Test 3. Used to screen for memory problems and can measure changes over time. Used in those following Brain Injury, head Injury, stroke, neurological dysfunction. Takes 30 mins.

Skin Integrity issues

Poor skin care can lead to skin breaks and even pressure ulcers in vulnerable areas e.g. heals, buttocks. The problem is worse after stroke as there may be paralysis such that the patient cannot move the affected limb and so pressure points are not changed, and breakdown occurs. Also, patients may have sensory loss and so will not have any awareness or pain. Spasticity and contractures can distort normal anatomy and so cause skin pressure issues. Much of this is preventable from good nursing care. Most patients who are immobile are turned every 2 hours.

Shoulder syndromes

The integrity of the shoulder joint depends on the muscles surrounding it in terms of holding the joint together, the so-called rotator cuff group of muscles. Shoulder pain - stems from lack of support of an arm due to weakness or paralysis. This usually is caused when the affected arm hangs resulting in pulling of the arm on the shoulder.

References

• Medical complications after stroke Sandeep Kumar, Magdy H Selim, Louis R Caplan.Lancet Neurol 2010; 9: 105-18
• Spasticity after stroke: Physiology, assessment and treatment. Brain Inj, Early Online

  Last updated: 25/11/2018