Dr Chaitanya Vemuri Internal Medicine Post Graduate Student

Improves both short term and long term prognosis

Classified as :

General Medical Complications Neurological Complications

 Reported in 85 % of hospitalized patients with stroke

They negatively impact short term functional outcomes

and mortality

 Complications of Immobility :
Deep Vein Thrombosis / Pulmonary Embolism
Falls Pressure sores / ulceration

Infections :
Chest Infection Urinary Tract Infection Other Infections

 Malnutrition :
Dysphagia
Dehydration

Pain :
Shoulder pain ( subluxation in the paretic limb ) Miscellaneous pain ( headache, musculoskeletal )

Neuropsychiatric Disturbances :
Depression Acute Confusional States ( Delirium )

 Miscellaneous :
Cardiac Complications ( Arrhythmias, Myocardial Infarction ) Gastrointestinal Bleed Constipation

 Lower Extremity DVT : in up to 1/2 of patients with

hemiplegic stroke without use of heparin prophylaxis

Highest incidence is b/w 2nd and 7th day poststroke High risk factors : Elderly patients

Immobilization after stroke

Dehydration also predisposes to DVT.

 Post thrombotic Syndrome : pain, edema, heaviness and

skin changes in affected limb.

It develops in about 50 % of patients with symptomatic

DVT.
Proximal DVT is more associated with Fatal Pulmonary

Embolism

 Early Mobilization Mechanical Compressive Devices : Antiembolic stockings

Sequential Pneumatic Compression Devices

Subcutaneous Unfractionated Heparin Low molecular weight Heparin

 Early mobilization after stroke is an effective measure to

reduce incidence of DVT

Contraindications : hemodynamically unstable patients

patients with fluctuating symptoms patients treated with thrombolytics - in first 24 hrs.

 Antiembolic Stockings : Knee high or Thigh high : reduce

venous stasis in legs Sequential Pneumatic Compression Devices

Prophylaxis in those with

contraindications for antithrombotic therapy in first 24 hrs post thrombolysis hemorrhagic infarcts
Caution : patients with Peripheral arterial disease

Peripheral Neuropathy

 Subcutaneous administration of Unfractionated Heparin &

Low molecular weight Heparin

LMWH has more favourable risk-benefit profile for

reduction of DVT & PE after ischemic stroke

Contraindication : for 24 hours after thrombolytic therapy

 DVT : Asymptomatic / Symptomatic Edema of lower limbs Pain

Acute onset of breathlessness : Pul embolism

Invg : Doppler of Lower limbs

Echocardiogram MDCT Pulmonary Angiogram Anticoagulants

 Fall prevention should be an important part of initial

mobilization Patients with stroke during hospitalization : high risk for falls Incidence of second falls is almost twice that of first falls Risk factors : Heart disease Pre stroke cognitive impairment Urinary incontinence Most happen during day ( 45 % ) patients room ( 51 % ) during visits to bath room ( 20 % )

 Measures to prevent falls in hospitalized paitents with

stroke :
Use adult assistive walking devices Motion detectors

Bed alarms
Use of convex mirrors to enable nursing staff to view

hallways from nursing stations Continuing staff education Minimal use of sedative medications

 In dependent areas ( sacrum , greater trochanter ) Measures to reduce the incidence : Early mobilization of neurologically stable patients Those who cannot be mobilized, routine assessment of skin

breakdown is to be made Frequent Turning Keep skin dry and free of moisture Use oscillating mattresses to minimize the pressure on susceptible areas ( sacrum , greater trochanter ) Antibiotics and debridement

 Poststroke infection is common during first 5 days after

admission
Fever : Heralding sign of infection High risk factors : Age > 65 yrs

Patients with dysphagia Patients with dysarthria Failure of bedside water swallow test

 Measures to prevent pneumonia : Airway Suctioning Aggressive Pulmonary Toilet

especially in patients with reduced level of consciousness Incentive Spirometry : to facilitate air movement and prevent ateclectasis at lung bases Mobilization and Frequent changes in position
A study of Prophylatic antibiotics to prevent infection after stroke

does not support their routine use

( Chamorro et al 2005 )

Prompt antibiotic therapy is warranted in patients with

radiographically confirmed chest infecion and in those where clinical suspicion is high
Empiric coverage for both aerobic and anaerobic pathogens should

be used until cultures reports are available

 Urinary Tract Infection : a common infection in hospitalized

patient with stroke Associated with use of indwelling bladder catheter Preventive measures : Intermittent catheterization Anticholinergic drugs Peform Urine analysis on routine basis Prompt antibiotic therapy : helps to prevent bacteremia, sepsis

Less common infections : Cellulitis

Cholecystitis Infective Endocarditis (s/p IV drugs)

 Clinically apparent dysphagia after stroke : 51 55 % Diagnosis : clinical screening

videofluroscopy
A diverse array of stroke localizations may result in dysphagia
Hemispheric lesions : motor impairment of face, lips, tongue

attention deficit Brain stem lesions : impair normal pharyngeal swallow laryngeal elevation glottic closure cricopharyngeal relaxation

 Consequences : Aspiration pneumonia

Dehydration Malnutrition Difficulty in administring drugs

High risk presentations for dysphagia :

Brain stem stroke Impaired consciouness Difficulty / Inability to sit upright Shortness of breath Slurred speech Facial weakness Wet cough Weak cough Hoarse voice

 3-oz water swallow test For those who fail in swallow test : to keep NPO

Nasogastric tube / Nasoduodenal tube

Dont delay antiplatelet therapy as per rectal preparations

of aspirin are available

 Hemiplegic shoulder pain : a common complication in

patients with significant proximal muscle weakness

Measures : Functional electric stimulation Positioning External shoulder support devices Intraarticular steroid injections Therapeutic strapping of at risk hemiplegic shoulder

 Headache : in acute / subacute phase

in approximately 25 % of patients
Discomfort involving cervical and lumbar spine, hip, knee

Treatment

Anti inflammatory drugs

Use of orthotic devices

 Depression : 60 % of patients within 3 months of stroke

onset Severity of depression : lesion volume functional impairment Degree of overall cognitive impairment
Systematic review of nine prevention trials provided little

support for prophylactic use of antidepressants to prevent depression

 Acute confusional states (Delirium)

Emotional lability
Anxiety Fatigue Differential diagnosis of delirium is broad. Causative factor must be aggressively searched Predisposing factors : advanced age

preexisting cognitive impairment malnutrition

 Cardiac : Paroxysmal arrhythmias

Concurrent myocardial ischemia

GIT : Gastrointestinal bleeding Currently Stroke Guidelines do not recommend routine GI

Prophylaxis But practically use of H2 antagonists / PPI is useful to prevent episodes of GI bleed

 Cerebral edema Mass effect and herniation Hemorrhagic transformation Seizures Progressing ischemia Recurrent stroke

 Complications resulting in measurable deterioration of

neurological function occurred in 13 % of patients within 48 72 hrs of hospitalization for acute ischemic stroke
Deterioration : Progressive stroke ( 33 % ) Increased intracranial pressure ( 27 % ) ( mc in 1st wk ) Recurrent cerebral ischemia ( 11 % ) ( mc in 1st wk ) Secondary parenchymal hemorrhage ( 11 % )

 Large infarctions involving cerebral hemispheres or cerebellum

result in space occupying mass effect d/t cerebral edema

Neurological deterioration d/t Transtentorial / Uncal Herniation

Extension of ischemia into adjacent vascular territories occur as

tissue shifts compress anterior cerebral artery against ipsilateral falx posterior cerebral artery against incisura
Cerebellar infarction can result in Brainstem compression &

Obstructive Hydrocephalus when significant edema occurs

 Factors heralding onset of cerebral edema / mass effect :

Drowsiness ( earliest )
Progressive decline in level of consciouness Worsening neurological deficit Headache Nausea & Vomiting Life threatening cerebral edema associated with massive

MCA infarction becomes evident b/w 2 and 5 days after stroke onset

 High risk factors :

Hypertension Heart failure Leucocytosis Retrospective study : incidence of cerebral edema &

herniation high : young female absence of prior h/o stroke carotid artery occlusion
Hypodensity > 50 % of MCA Territory

Hyperdense MCA sign on non contrast CT : neurologic deterioration

 IV Mannitol : 1 g/kg intial bolus

maintainence : 0.25 0.5 g/kg every 4-6 hrs target s.osmolality : 310-320 mosm/L Hypertonic Saline : 3 % NaCl target : S.Na+ : 145 mmol/L Barbiturates Hyperventilation : target Pa Co2 : 30 mm Hg Elevated Head Position : head of bed kept at 30 degrees

 Hemicraniectomy & Duraplasty : definitive therapy for life

threatening space occupying edema

Clear benefit of surgery on mortality with a 49 % absolute risk

reduction for fatal outcome favouring the surgical group

But does not appear to increase the likelihood of severe disability in

those who survive

Obstructive hydrocephalus : ventriculostomy Massive cerebellar infarction : ventriculostomy and

sub occipital craniectomy

 Exact frequency and risk factors that predispose to hemorrhagic

transformation remain unclear

Frequency of hemorrhagic transformation in untreated patients : 8.5

%
Accompanied by neurological deterioration or frank hematoma

formation

Risk factors : Patients treated with antithrombotic and thrombolytic therapy Large infarct with mass effect Advanced age ( > 70 yrs ) Low platelet count Elevated Blood Pressure

 Progressive neurological deterioration d/t hematoma

related mass effect : emergency clot evacuation

Most patients are managed conservatively with short term

discontinuation of antithrombotic agents & careful control of blood pressure

If symptomatic intracerebral bleed is diagnosed , emergent

transfusion of Fresh Frozen Plasma ( 5-10 ml/kg ) and Cryoprecipitate ( 0.1bag/kg ) is recommended.

 Estimates of seizure frequency after stroke based on retrospective analyses

range from 2 23 %

Seizure occurrence due to Cortical irritation due to ischemic

injury
Early onset seizures ( < 14 days post stroke ) are at lower risk of seizure

recurrence than late onset seizures

Status epilepticus occurs in small fraction : indicates poor prognosis Antiepileptic medication is to be initiated in patients with witnessed or

suspected seizures after stroke

Optimal duration of therapy has not been established Prophylactic antiepileptic therapy is not recommended

 Worse outcomes have been reported in patients with elevated

blood sugars at admission

Hyperglycemia is associated with higher incidence of Increased cerebral edema Hemorrhagic transformation with / without tPA administration Recommendations :

Avoid dextrose containing IV solutions

Glycemic control with short acting insulin

 Cost effective

Reduce mortality
Improve functional outcomes