Medical & Neurological Complications after Stroke

1. Medical & Neurological Complications after Stroke Presented by: Fawn Covert RN, BSN

2. Neurological Complications • Reduced Level of Consciousness (↓LOC) • Worsening of neurological/physical deficits • New deficits indicating dysfunction in another part of the brain • Epileptic seizures

3. Reduction in LOC • 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)

4. 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

5. 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 Delayed ischemia (in subarachnoid hemorrhage) Incorrect diagnosis: Intracranial tumor Cerebral abscess Encephalitis Chronic subdural hematoma Subdural empyema Neurological Causes The above may cause new deficits

6. Infection: Respiratory Urinary Septicemia Metabolic Dehydration Electrolyte imbalances Hypoglycemia Drugs: Major and minor tranquilizers Baclofen Lithium toxicity Anti-epileptic drug toxicity Anti-emetics 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 Non-Neurological Causes The above may cause new deficits

7. 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

8. Neurological Causes (Epilepsy) • 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

9. Alcohol withdrawal Anti-epileptic drug withdrawal Hypoglycemia Hyperglycemia, non-ketotic Hyper/hyponatremia Hypocalcemia Hypomagnesemia Drugs: Baclofen (for spasticity) Antibiotics Antidepressants Phenothiazines (for agitation hiccups) Anti-arrhythmics (for atrial fibrillation) General Causes (Epilepsy)

10. 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.

11. 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.

12. 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

13. 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

14. 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

15. Pressure Ulcers • 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.)

16. Pressure Ulcer behind the knee from graded compression stockings Necrotic skin over tibia and ankle from improperly fitting stockings Pressure Ulcers (cont.)

17. 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

18. 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).

19. 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 Thromboembolism (cont.)

20. 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.