Complications of Ischemic Stroke

8/13/2019 Complications of Ischemic Stroke

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Dr Chaitanya Vemuri

Internal Medicine Post Graduate Student


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Improves both short term and long term prognosis

Classified as :

General Medical Complications

Neurological Complications


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Reported in 85 % of hospitalized patients with stroke

They negatively impact short term functional outcomes

and mortality


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Complications of Immobility :

Deep Vein Thrombosis / Pulmonary Embolism

Falls

Pressure sores / ulceration

Infections :

Chest Infection

Urinary Tract Infection

Other Infections


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Malnutrition :

Dysphagia

Dehydration

Pain :

Shoulder pain ( subluxation in the paretic limb )

Miscellaneous pain ( headache, musculoskeletal )

Neuropsychiatric Disturbances :

Depression

Acute Confusional States ( Delirium )


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Miscellaneous : Cardiac Complications ( Arrhythmias, Myocardial Infarction )

Gastrointestinal Bleed

Constipation


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

hemiplegic stroke without use of heparin prophylaxis

Highest incidence is b/w 2ndand 7thday poststroke

High risk factors : Elderly patients

Immobilization after stroke

Dehydration also predisposes to DVT.


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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


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Early Mobilization

Mechanical Compressive Devices :

Antiembolic stockings

Sequential Pneumatic Compression Devices

Subcutaneous Unfractionated Heparin

Low molecular weight Heparin


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Early mobilization after stroke is an effective measure to

reduce incidence of DVT

Contraindications : hemodynamically unstable patientspatients with fluctuating symptoms

patients treated with thrombolytics

- in first 24 hrs.


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Antiembolic Stockings : Kneehigh or Thighhigh : reduce

venous stasis in legs

Sequential Pneumatic Compression Devices

Prophylaxis in those withcontraindications for antithrombotic therapy

in first 24 hrs post thrombolysis

hemorrhagic infarcts

Caution :patients with Peripheral arterial disease

Peripheral Neuropathy


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Subcutaneous administration of Unfractionated Heparin &

Low molecular weight Heparin

LMWH has more favourable risk-benefit profile forreduction of DVT & PE after ischemic stroke

Contraindication : for 24 hours after thrombolytic therapy


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DVT : Asymptomatic / Symptomatic

Edema of lower limbs

Pain Acute onset of breathlessness : Pul embolism

Invg : Doppler of Lower limbs

Echocardiogram

MDCT Pulmonary Angiogram

Anticoagulants


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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 % )


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Measures to prevent falls in hospitalized paitents withstroke :

Use adult assistive walking devices

Motion detectors

Bed alarms

Use of convex mirrors to enable nursing staff to viewhallways from nursing stations

Continuing staff education

Minimal use of sedative medications


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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 skinbreakdown 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


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Measures to prevent pneumonia :

Airway Suctioning

Aggressive Pulmonary Toiletespecially in patients with reduced level of consciousness

Incentive Spirometry : to facilitate air movement and preventateclectasis at lung bases

Mobilization and Frequent changes in position

A study of Prophylatic antibiotics to prevent infection after strokedoes 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 clinicalsuspicion is high

Empiric coverage for both aerobic and anaerobic pathogens shouldbe used until cultures reports are available


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Urinary Tract Infection : a common infection in hospitalizedpatient 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 : CellulitisCholecystitis

Infective Endocarditis (s/p IV drugs)


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Clinically apparent dysphagia after stroke : 5155 %

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 swallowlaryngeal elevation

glottic closure

cricopharyngeal relaxation


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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


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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


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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


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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


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Depression : 60 % of patients within 3 months of strokeonset

Severity of depression :

lesion volume

functional impairment

Degree of overall cognitive impairment

Systematic review of nine prevention trials provided littlesupport for prophylactic use of antidepressants to preventdepression


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Cardiac : Paroxysmal arrhythmias

Concurrent myocardial ischemia

GIT : Gastrointestinal bleeding

Currently Stroke Guidelines do not recommend routine GI

ProphylaxisBut practically use of H2 antagonists / PPI is useful to

prevent episodes of GI bleed


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Complications resulting in measurable deterioration of

neurological function occurred in 13 % of patients within

4872 hrs of hospitalization for acute ischemic stroke

Deterioration :

Progressive stroke ( 33 % )

Increased intracranial pressure ( 27 % ) ( mc in 1stwk )

Recurrent cerebral ischemia ( 11 % ) ( mc in 1stwk )

Secondary parenchymal hemorrhage ( 11 % )


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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 astissue 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


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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 massiveMCA infarction becomes evident b/w 2 and 5 days afterstroke onset


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High risk factors :

Hypertension

Heart failureLeucocytosis

Retrospective study : incidence of cerebral edema &herniation high : young

femaleabsence of prior h/o stroke

carotid artery occlusion

Hypodensity > 50 % of MCA Territory

Hyperdense MCA sign on non contrast CT : neurologicdeterioration


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IV Mannitol : 1 g/kg intial bolus

maintainence : 0.250.5 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


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Hemicraniectomy & Duraplasty : definitive therapy for lifethreatening space occupying edema

Clear benefit of surgery on mortality with a 49 % absolute riskreduction for fatal outcome favouring the surgical group

But does not appear to increase the likelihood of severe disability inthose who survive

Obstructive hydrocephalus : ventriculostomy

Massive cerebellar infarction : ventriculostomy and

sub occipital craniectomy


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Exact frequency and risk factors that predispose to hemorrhagictransformation remain unclear

Frequency of hemorrhagic transformation in untreated patients : 8.5%

Accompanied by neurological deterioration or frank hematomaformation

Risk factors :

Patients treated with antithrombotic and thrombolytic therapy Large infarct with mass effect

Advanced age ( > 70 yrs )

Low platelet count

Elevated Blood Pressure


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Progressive neurological deterioration d/t hematomarelated mass effect : emergency clot evacuation

Most patients are managed conservatively with short termdiscontinuation of antithrombotic agents &careful control of blood pressure

If symptomatic intracerebral bleed is diagnosed , emergenttransfusion of Fresh Frozen Plasma ( 5-10 ml/kg ) andCryoprecipitate( 0.1bag/kg ) is recommended.


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Estimates of seizure frequency after stroke based on retrospective analysesrange from 223 %

Seizure occurrence due to Cortical irritation due to ischemic

injury

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


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Worse outcomes have been reported in patients with elevatedblood 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


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Cost effective

Reduce mortality

Improve functional outcomes


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Documents

Complications of Ischemic Stroke