Complications Of Ischemic Stroke: Prevention Management

1. Dr Chaitanya Vemuri Internal Medicine Post Graduate Student Complications Of Ischemic Stroke: Prevention & Management

2. Improves both short term and long term prognosis Classified as : General Medical Complications Neurological Complications Introduction

3. Reported in 85 % of hospitalized patients with stroke They negatively impact short term functional outcomes and mortality Medical Complications

4. Complications of Immobility : Deep Vein Thrombosis / Pulmonary Embolism Falls Pressure sores / ulceration Infections : Chest Infection Urinary Tract Infection Other Infections Medical Complications

5. Malnutrition : Dysphagia Dehydration Pain : Shoulder pain ( subluxation in the paretic limb ) Miscellaneous pain ( headache, musculoskeletal ) Neuropsychiatric Disturbances : Depression Acute Confusional States ( Delirium ) Medical Complications

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

7. 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. Deep Vein Thrombosis / Pulmonary Embolism

8. 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

9. Early Mobilization Mechanical Compressive Devices : Antiembolic stockings Sequential Pneumatic Compression Devices Subcutaneous Unfractionated Heparin Low molecular weight Heparin DVT Prophylaxis

10. 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.

11. 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

12. 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

13. DVT : Asymptomatic / Symptomatic Edema of lower limbs Pain Acute onset of breathlessness : Pul embolism Invg : Doppler of Lower limbs Echocardiogram MDCT Pulmonary Angiogram Anticoagulants

14. 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 % ) patient�s room ( 51 % ) during visits to bath room ( 20 % ) Falls

15. 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

16. 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 Pressure sores and Ulceration

17. 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 Infections : Pneumonia & UTI

18. 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

19. 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)

20. 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 Dysphagia

21. 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

22. 3-oz water swallow test For those who fail in swallow test : to keep NPO Nasogastric tube / Nasoduodenal tube Don�t delay antiplatelet therapy as per rectal preparations of aspirin are available

23. 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 Pain

24. 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

25. 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 Neuropsychiatric Disturbances

26. 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

27. 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 Miscellaneous Medical Complications :

28. Cerebral edema Mass effect and herniation Hemorrhagic transformation Seizures Progressing ischemia Recurrent stroke Neurological Complications

29. 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 % )

30. 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 Cerebral edema & Mass effect

31. 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

32. 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

33. 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 Medical Therapies

34. 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

35. 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 Hemorrhagic Transformation

36. 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. Hemorrhagic Transformation

37. 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 Seizures

38. 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 Hyperglycemia

39. Cost effective Reduce mortality Improve functional outcomes Stroke Unit

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