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Complications

There are several complications that can arise after a stroke and prevention and treatment of these complications is a very important component of stroke care. People who are at higher risk of complications are the elderly, patients with severe stroke, patients with diabetes or other pre existing illness and patients who need prolonged hospitalisation. Here is a brief description of the common complications.

Pneumonia

Chest infections can occur in 20% or more of stroke patients within the first few weeks. It can be due to difficulty swallowing and material such as food, fluids and saliva getting into the lungs. There is difficulty with coughing and clearing secretions after a stroke and this contributes to infections. Immobility and reduced chest wall movements also increases the risk. The risks may be minimised by careful positioning, assessment of swallowing and use of tubes for feeding if necessary (tube feeding can also be associated with aspiration and infections) and chest physiotherapy. Treatment is by antibiotics, oxygen and chest physiotherapy if needed.

Urinary Tract Infections

Urine infections can occur in about 25% of hospitalised stroke patients in the first 2 months. The risk is increased by incontinence and the use of urinary catheters. The risk can be minimised by ensuring an adequate fluid intake and avoiding unnecessary catheterisation. Antibiotics are neede for the treatment of urine infections.

Pressure sores

The skin is at risk of damage after a stroke because of immobility, lack of sensation, being wet due to urinary incontinence and lack of nutrition. Pressure sores can be prevented by good nursing practices such as regular turning, assessment of risk and use of appropriate cushions and mattresses. If pressure sores have occurred, treatment is by the use of pressure relieving cushions or beds, local dressing, use of painkillers, antibiotics if infection supervenes and attention to nutrition.

Epileptic fits

Epileptic fits occur in about 5% of patients in the first 2 weeks after a stroke. Fits or seizures consist of uncontrollable jerking movements of the limbs which may begin with one limb and then spread to all the limbs and cause unconsciousness. There are 2 forms of seizures, early onset (within the first week or two) and later seizures with a risk of about 5% in the first year. The risk is higher in haemorrhagic strokes and larger ischaemic strokes. They are treated by drugs called anticonvulsants and the dose of the drug may have to be increased till the fits are controlled. People who have had fits are not allowed to drive for a period of time and the DVLA (Driver and Vehicle Licensing Agency) has to be informed.

Deep Vein Thrombosis (DVT and Pulmonary Embolism

Weakness of the legs and immobility can cause clots in the veins of the legs. This is a fairly common complication but can often produce no symptoms. In about 5% of people after a stroke, the DVT can cause pain, swelling and redness of the leg. The main danger from DVT is that clots may enlarge, travel upwards and float off into the circulation and move to the lungs where it causes a condition called pulmonary embolism. This can sometimes be fatal. Pulmonary embolism (PE) can cause shortness of breath, sharp chest pain and coughing up of blood. The diagnosis of DVT is made by blood tests and ultrasound scans of the legs. PE is diagnosed by special lung scans. Other tests done include ECG, x-rays and blood tests. Prevention is by early mobilisation, aspirin, hydration and the use of compression stockings. Our stroke unit is participating in a clinical trial called the CLOTS3 Trial which is testing the effectiveness of intermittent pneumatic compression in DVT prevention after a stroke. Treatment is by thinning the blood down with injections of heparin and later warfarin tablets. Treatment with warfarin is usually continued for 3 -6 months depending on the severity of the condition and other circumstances. If a person has a history of DVT or PE in the past, the treatment may have to be continued lifelong.

Shoulder and other joint problems

The shoulder on the paralysed side can often cause problems after a stroke. The most common symptom is pain. Features that increase the risk of problems include severe weakness of the arm, sensory loss, neglect and low tone allowing shoulder dislocation. Pain can also be due to frozen shoulder and rotator cuff tears. Other joints may become painful after a stroke but only if there is pre existing joint disease such as osteoarthritis. prevention is by careful positioning and avoidance of stretching of the joint by pulling on the arm. Treatment of pain is by positioning and mobilisation, exercises, support (such as slings and other appliances) and painkillers. Other forms of treatment such as injections, TENS (trans cutaneous electrical nerve stimulation) and surgery may occasionally be needed

Swollen and cold limbs

Swelling of the paralysed limbs is a common problem after a stroke. Lack of muscle contraction and pooling of fluid due to gravity are the main causes. The limb can sometimes feel cold as well. Treatment is by elevation, encouragement of movement, stockings and painkillrs if the limb is painful.

Pain

Pain is a common problem after strokes. The pain may be due to shoulder problems (see above), coexisting arthritis, due to spasticity (see below) and central post stroke pain.

Central post stroke pain occurs in strokes that affect the sensory pathways in the brain. The pain may develop some time after the stroke. The pain is due to the brain misinterpreting normal sensory signals as pain. The pain is described as burning, shooting or sharp and can be made worse by movement, touch and anxiety. It is often associated with altered sensation and can affect one side of the body (the side affected by the stroke) or the limbs or face on that side. It can sometimes be difficult to treat and normal painkillers are usually ineffective. Drugs that have proven useful include some antidepressants (mainly tricyclic antidepressants), gabapentin, some anticonvulsants (carbamazepine, valproate and others). Patients may be referred to pain clinics if the pain proves difficult to control. TENS and surgical techniques are sometimes needed for symptom control.

Spasticity and Contractures

Spasticity is increased resistance to stretch in affected muscles. It is caused by damage to the nerves controlling voluntary movements in the brain. The muscles are at first weak and floppy. Later on, the muscles become stiff and difficult to stretch (spastic). Spasticity may not be present all the time. It may be triggered by pain, pressure sores, infections or constipation. Spasticity may range from slight muscle stiffness to permanent shortening of the muscle. It may cause pain, especially if it pulls joints into abnormal positions and or prevents normal movement of the joints. When the muscle is permanently shortened, the joint becomes misshapen. This is called a contracture and is one of the most significant consequences of spasticity. There may also be painful spasms of the spastic limbs. One of the aims of rehabilitation is to prevent unwanted increases in tone and spasticity. Precipitating factors such as infections and sores are prevented or treated. Proper positioning, seating, passive movements and physiotherapy are useful. Use of splints may be necessary. Tablets such as baclofen or tizanidine are sometimes needed. One potential problem of this treatment is sedation and generalised weakness. Injections of botulinum toxin into spastic muscles may be needed to overcome specific problems.

Depression and anxiety

Approximately 25% of people can experience depression in the first four months following a stroke; this is commonly associated with the severity of the stroke, previous episodes of depression and communication difficulties resulting from the stroke. Depression is not related to the location of the stroke. Feeling socially isolated can also contribute to feelings of depression, making it important for family and friends to visit during the person's hospital admission and when they leave hospital.

Some of the effects of stroke can be very similar to signs of depression. For example, indicators of depression, such as sleep disturbance, loss of appetite, reduced concentration and reduced social interaction can also result from the stroke. Because of these similarities, if family members and stroke unit staff members become concerned that a person may be depressed, it may be necessary to refer to a trained mental health professional, such as a Clinical Psychologist, to carry out a detailed assessment of mood. Because anxiety and depression can limit a person's ability to engage in rehabilitation, it is important to assess, monitor and manage these feelings. Management may include prescribing antidepressants combined with support from a Clinical Psychologist.

Confusion and dementia

Patients can become confused after a stroke and this condition is called delirium (acute confusional state). It can be due to the effects of the stroke itself or due to other factors such as infections. People who are older, have pre-existing memory problems or more severe strokes are at greater risk. Patients with delirium can become disorientated, have memory problems and exhibit agitation and disruptive behaviour. There progress is often slow and they may need to stay longer in hospital.

Strokes are a cause of dementia. This condition is called vascular dementia or vascular cognitive impairment. Dementia is diagnosed on the basis of cognitive problems (difficulty with thought, memory and reasoning) which persist beyond 6 months or more and prevent the patient from functioning normally. Dementia can occur as the result of a single large stroke or after multiple smaller strokes. It can also occur as a result of narrowing of small arteries in the brain without obvious stroke like episodes. People with vascular dementia may find it very difficult to participate in rehabilitation and may not progress. In such cases, the only option may be to get them home with a care package if possible or recommend placement in a care home.

 

Falls and fractures

Falls are common after a stroke. As many as 25% or more may fall while undergoing rehabilitation in hospital. A large proportion are at risk of falling after returning home. A small proportion of these falls may result in injuries and fractures. Factors that cause falls are muscle weakness, poor balance, poor vision and confusion. Falls are very difficult to prevent but can be minimised by close supervision when mobilising, avoidance of unnecessary medication and attention to the environment.