Medical & Neurological
Complications after Stroke
Presented by:
Fawn Covert RN, BSN
Neurological Complications
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Reduced Level of Consciousness (↓LOC)
Worsening of neurological/physical deficits
New deficits indicating dysfunction in another part of the brain
Epileptic seizures
Reduction in LOC
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Occurring in approximately 15% of stroke patients
Most likely to occur within the first few days after stroke
Important indicator of the severity of the stroke
Potential causes:
– Direct damage
• Hemorrhage or infarction of the brainstem
– Indirect damage
• Supratentorial lesions associated with brain swelling and midline
shift
– Combination
• Global hemispheric ischemia and
• Increased intra-cranial pressure (ICP)
Worsening Neurological/Physical
Deficits
• Common with initial stroke
• Can worsen hours, days or, rarely weeks after the initial assessment
• The earlier the stroke is diagnosed, there is an increase in the likelihood
the worsening deficits will be recognized
• Within the first couple of days the worsening effects most likely have a
neurological cause/origin
• Beyond the first couple days, non-neurological causes must be considered
Neurological Causes
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Progression/completion of stroke
Extension/early recurrence
Hemorrhagic transformation of an
infarct
Development of edema around the
infarct or hemorrhage
Obstructive hydrocephalus inpatients
with stroke in the posterior fossa
Epileptic seizures
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Delayed ischemia (in subarachnoid
hemorrhage)
Incorrect diagnosis:
– Intracranial tumor
– Cerebral abscess
– Encephalitis
– Chronic subdural hematoma
– Subdural empyema
The above may cause new deficits
Non-Neurological Causes
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Infection:
– Respiratory
– Urinary
– Septicemia
Metabolic
– Dehydration
– Electrolyte imbalances
– Hypoglycemia
Drugs:
– Major and minor tranquilizers
– Baclofen
– Lithium toxicity
– Anti-epileptic drug toxicity
– Anti-emetics
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Hypoxia:
– Pneumonia/chest infection
– Pulmonary embolism
– Chronic pulmonary disease
– Pulmonary edema
Hypercapnea
– Chronic pulmonary disease
Limb or bowel ischemia in patients with a
cardiac or aortic arch source of embolism
The above may cause new deficits
Epileptic Seizures
• Occurring in approximately 5% of stroke patients, most occurring within
24 hours
• The highest overall risk population includes those who have hemorrhagic
strokes and infarcts involving the cerebral cortex
• Most seizures begin as partial (focal) although with secondary
generalization
• Diagnostics:
– Clinical assessment (witnessed seizure)
– Electroencephalography (EEG)
• Determine cause:
– Neurological
– General
Neurological Causes (Epilepsy)
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Primary stroke lesion location
Hemorrhagic transformation of infarction
Arteriovenous malformation
Intracranial venous thrombosis
Mitochondiral cytopathy
Hypertensive encephalopathy
Wrong diagnosis:
– Herpes simplex encephalitis
– Cerebral abscess
– Intracranial tumor
– Subdural empyema
General Causes (Epilepsy)
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Alcohol withdrawal
Anti-epileptic drug withdrawal
Hypoglycemia
Hyperglycemia, non-ketotic
Hyper/hyponatremia
Hypocalcemia
Hypomagnesemia
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Drugs:
– Baclofen (for spasticity)
– Antibiotics
– Antidepressants
– Phenothiazines (for agitation
hiccups)
– Anti-arrhythmics (for atrial
fibrillation)
Medical Complications
• Medical complications are believed to be an important problem after
acute stroke and present potential barriers to optimal recovery.
• Studies have suggested that complications not only are common, with
estimates of frequency ranging from 40%-96% of patients, but also are
related to poor outcomes (Langhorne, 2000).
• Many of the complications described are potentially preventable or
treatable if recognized.
Urinary Tract Infection
• Occurs in approximately 25% of hospitalized stroke patients within the
first two months after stroke
• Prevention:
– Maintaining adequate hydration and thus urine output
– Avoid unnecessary bladder catheterization
– Avoid constipation (will assist with complete bladder emptying)
– Avoid drugs with anticholinergic effects
– Assess for fever, investigate cause if present in combination with broad
spectrum antibiotics*
* With an increasing risk of Costridium difficile toxin-associated diarrhea, the
risks of early use of broad spectrum antibiotics must be carefully weighed
against the potential benefits.
Chest Infection
• Occurring in approximately 20% of stroke patients during the acute stage
• Increased incidence in tube fed patients or with alterations in the mouth’s
bacterial flora
• Probable causes:
– Aspiration
– Failure to clear secretions
– Patient immobility
– Reduced chest wall or diaphragmatic movement on the hemiparetic
side
– Comorbidities:
• Chronic airway disease
Chest Infections (cont.)
• Prevention:
– Careful positioning (HOB at 30˚)
– Oral care, using peridex every 12 hours for those on ventilators
– Physiotherapy and suction to avoid accumulation of secretions
– Aspiration precautions
Falls
• Very common after stroke
• Patient’s with lessened deficits after stroke are more likely to fall, because
the patient’s with more severe deficits are mobilized less decreasing their
likelihood of fall
• Often associated with an increased risk of intracranial hemorrhage
associated with anticoagulation (atrial fibrillation population)
• Risk reduction:
– Mobilize patients with adequate supervision and support
– Utilization of bed alarms
– Safety alert/Fall risk
– Withdrawal of unnecessary diuretics and psychotropic drugs
– Convenient room set up
Pressure Ulcers
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Most common in patients that are immobile and unable to redistribute their own
weight when lying or sitting
Increased risk factors:
– Malnourishment
– Infection
– Incontinence
– Serious underlying illnesses
Prevention:
– Accurate skin assessment daily and as needed (with removal of the graded
compression stockings)
– Frequent repositioning
– Pressure relieving mattresses
– Nutrition support
– Local treatments (creams, lotions etc.)
Pressure Ulcers (cont.)
Pressure Ulcer behind the knee from
graded compression stockings
Necrotic skin over tibia and ankle from
improperly fitting stockings
Thromboembolism
• Common in the legs of patients with a recent stroke, particularly older
patients with a severe hemiplegia
• In approximately 10% of cases deep vein thrombosis (DVT) progresses to
pulmonary embolism (PE)
• Pulmonary embolism is an important cause of preventable death after
stroke and is a frequent finding at autopsy
Thromboembolism (cont.)
• Assessment
– Deep Vein Thrombosis (DVT):
• Edema
• Hot or painful extremity
• Fever development
“Stroke patients who have communication difficulties, sensory loss or
neglect may well not complain of discomfort or swelling associated
with deep venous thrombosis, so that clinical detection will depend on
the vigilance of members of the multidisciplinary team. If a patient
develops a swollen leg on a stroke unit, deep venous thrombosis has to
be actively excluded” (Warlow et al., 2007).
Thromboembolism (cont.)
• Assessment
– Pulmonary Embolism (PE):
• Breathlessness and/or
• Tachypnea
• Pleuritic chest pain
• Hemoptysis (without any
other reasonable clinical
explanation)
• Prevention of DVT/PE
– Early mobilization
– Hydration/fluids
– Graduated compression
stockings
– Heparin
– Pneumatic compression
References
Warlow et al. (Eds.). (2007). Stroke practical management. Malden: Blackwell
Publishing.
Johnson, K.C., Li, J.Y. et al. (1998). Medical and neurological complication of
ischemic stroke: Experience from the RANTTAS trial. Stroke, 29, 447-453.
Dromerick, A. & Reding, M. (1994). Medical and neurological complications
during inpatient stroke rehabilitation. Stroke, 25, 358-361.
Langhorne, P., Stott, D.J., et al. (2000). Medical complications after stroke: A
multicenter study. Stroke, 31, 1223-1229.