Post on 03-Jun-2018
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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