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.
Pneumonia (chest infections)
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 (UTIs)
Urine infections can occur in about 25% of hospitalised stroke patients in the first two 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 may be needed for the treatment of urine infections particularly when the patient is symptomatic.
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 occur in about five percent of patients in the first two 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 two forms of seizures, early onset (within the first week or two) and later seizures with a risk of about five percent 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 Driver and Vehicle Licensing Agency DVLA has to be informed.
Deep Vein Thrombosis (DVT)
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 of DVT and PE is by early mobilisation, aspirin and hydration.
A recent clinical trial called the CLOTS Trial showed that compression stockings were not useful in DVT prevention after a stroke as the benefits were outweighed by the complications of stocking use. Our stroke unit participated in the CLOTS 3 Trial which showed that intermittent pneumatic compression (IPC) was effective in DVT prevention after a stroke. Most immobile stroke patients are offered IPC unless there are any contraindications.
Treatment of DVT and PE is by thinning the blood down with injections of heparin and later warfarin tablets. Treatment with warfarin is usually continued for three - six 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 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, other 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.
Spacicity 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
Depression and anxiety are common after a stroke and it has been shown that about 25% of patients are clinically depressed four months after a stroke. People with severe strokes and those with previous depression are more likely to be depressed after a stroke. There is no link between the site of a stroke and depression.
Detecting depression after a stroke may be difficult if the patient cannot communicate. Lack of progress, change in personality, low mood, loss of weight and poor sleep may point towards depression.
Depression can impede the process of rehabilitation because the patient might not be motivated to participate in rehabilitation and may wish to remain in bed. Treatment is with psychological support and antidepressants.
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.
Delirium is managed by treating any underlying cause such as an infection.The patient is nursed in a side room if possible and with a reality orientation approach.
Extra nursing staff for 'one to one' nursing and close supervision are often needed. Sedative drugs are sometimes used as a last resort. Family members are often encouraged to sit with the patient and help calm them down.
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.