Neurological and Medical Complication of Stroke

Harvey A. Drapkin, D.O. F.A.C.N.

Stroke is the third leading cause of death as well as the third leading cause of disability

in the United States.

Approximately 700,000 per year and

160,000 fatalities.

Mortality Predictors Include

Stroke severity; but older age, concomitant medical diseases, and recurrent stroke are also associated with poor short-term prognosis.

Condition is worsened by neurological and medical complications in up to 80% of patients.

Mortality Causes

• Week One – 90% of deaths are due directly to the Infarct (Edema, Extension, Herniation)

• Weeks 2-4 – Pulmonary Embolism is most common cause of death and risk remains high for 3 months

• Weeks 8-12 – Bronchopneumonia. Later Heart Disease.

Slide of Cerebral Infarct with Edema

Slide of Cerebral Infarct with Edema

Treatment of Increased Intracranial Pressure

• Osmotic Agents

• Hyperventilation

• External Ventricular Drainage

Hypoxia, Hypercapnia and Hyperthermia must be avoided.

Treatment of I I P

• Moderate hypothermia (32-34º) – May be helpful

• Hemicraniectomy and Duroplasty – Supratentorial

• Cerebellectomy and/or Evacuation/Decompression

Generally younger patient – better outcome.

Seizures and Stroke

Seizures at onset – often partial, may represent 4.4% of stroke patients. S.E. – 1%

Early seizures after stroke – within days 3-6%

Late seizures after stroke – after 14 days, more likely to recur without AED treatment.

Seizures and Stroke

More frequent occurrence in:

• Severe disabling stroke

• Hemorrhagic Strokes

• Stroke with Cortical Involvement

Stroke – Most common etiology for S.E. in Elderly.

Seizures and Stroke

Who to treat and how long?

One way is to exclude other causes for seizure, i.e. Hypoxia, Hypoglycemia, etc. and start AED’s

Most Neurologists treat for 2-3 years

EEG – Beneficial especially in Non Convulsive S.E.

Stroke and Seizure

• Do seizures affect stroke outcome? Yes.

“Prolonged focal motor seizure often cause worsening of the previous motor deficit” Bogousslauskt, et al.

• Which drugs – Classical or new?

Either but consider drug interactions of “classicals”, i.e. Warfarin.

DVT’s, VTE’s and Pulmonary Emboli

• One study of patients with stroke and confirmed P.E. showed that 50% of patients had sudden death

• Diagnosis of VTE is complicated by the stroke and its impairment. Noninvasive testing often very helpful

• Tx with Heparin/Warfarin – risk of bleed, death, etc. 3%.

Blood Pressure – ASA Guidelines

• High or Low may affect stroke outcome

• Early stage – systolic BP 150-170 is optimal

• More aggressive Tx with malignant HTN Myocardial Ischemia, Aortic Dissection, post TPA

• LBP – often Hypovolemia & Tx with Fluids, pressors PRN

Management of Med. & Neurol. Complications

Prevention (pathways, standard orders, etc.)

Diagnosis (index of suspicion, diagnostic, modalities)

Treatment (general and complication specific)

Care and outcomes are best with specialized multi-disciplinary stroke unit.

Hyperglycemia and Stroke

• Blood glucose elevated in 40-50% of patients in the first 24 hours. Over half are not D.M.

• Insulin Tx reduces infarct size and improves prognosis (benefits focal & global brain ischemia)

• Aim to maintain normal glucose and avoid poor outcome.

Infections and Fever in Stroke

• In acute stage of stroke are associated with increased fatalities and poor functional outcomes.

• Each degree of Celsius doubles risk of poor outcome.

• Pneumonia – in 20-30% of patients. 25% of deaths in first month

• UTI’s common, moderate Hypothermia may be helpful

Cardiac Abnormalities in Stroke

• One-third of patients – ST Segment Depression or Ventricular Arrhythmias – first 5 days

• Previously undiagnosed Arrhythmias including A-Fib – seen in 50%

• Insular Cortex Lesions predispose to EKG changes Arrhythmias and sudden death. Rec-24-48 hour monitor and treatment.

Emotional Disturbances after Stroke

• Anosognosia – neglect of perceptual loss

• 33% of patients have poor or no memory of acute event

• Can occur without specific damage to “Learning Structures”

• Partly explains delay in seeking medical care, compared to heart patients.

Emotional Disturbances after Stroke

• Acute Phase includes: overt sadness 72%, disinhibition 56%, lack of adaption 44%, environmental withdrawal 40%, crying 27%, anosognosia & passivity 24%, aggressiveness 11%

• Left and Right brain affected

Emotional Disturbances after Stroke

Catastrophic reaction – occurs in 3%.

Strong correlation with aphasia and with left insular location. 66% of these patients develop depression later in chronic stage.

Acute psychosis seen in L. PCA Infarct

Chronic Phase Emotional Disturbances

Post-Stroke depression – 40% major or minor

Associated with left frontal and B.G. lesions.

Resistance to SSRI’s? Positive thinking affected.

Small vessel disease on MRI – high correlation with PSD-A

Absence of guilt, suicidal ideation, But treat!

Chronic Phase Emotional Disturbances

• Anxiety disorders – 25% or more

• PTSD – like syndrome – independent of neurological impairment. More frequent in patients with concern of death in acute phase.

• Increased with B.G. stroke. Role in re-experience?

Chronic Phase-Mania, Bipolar Dx; Psychosis

• Mania related to right hemisphere lesions• Psychosis – rare. May appear as DMS

including reduplicative paramnesia, Capgras’ syndrome, etc.

• Delusional mis-ID syndrome – functional disconnect between past amnesic information and integration with present information

Chronic Phase – Emotional Hyperactivity & Flattening

• Seen in bilateral Vascular Lesions and Vascular Dementia

• Some have emotional disinhibition, outbursts and loss of emotional control.

• Emotional Flattening – impaired automatic response to emotional valence of stimuli

Post-Stroke Fatigue

• Multifactorial and common (68%)• Heightened sensation of physical or mental

strain• Contributing factors – T.I.M.E., sleep

disorders, immobility-deconditioning, psychologic.

• Treatments – Pharmacologic and Non-Pharmacologic

Cognitive Syndrome of Post-Stroke Dementia

• 30% of patients slow progression

• Predominant executive dysfunction

• Affects subcortical and frontal lobes

• Memory and language deficits less obvious

• Late stages - memory deficits and dementia

Major Risk Factors for Cognitive Impairment

Age – Diabetes Mellitus – Atrial FIB – Ethnicity vs. Educational attainment –

Aphasia – Depression – Previous Stroke – Genetic?

Stroke location and severity

Treat = Cholinergic replacement

Central Post-Stroke Pain

• Can occur after lesions of spinothalamic pathway and corticopetal projections

• Constant or Intermittent pain post-stroke. Associated with sensory abnormality in the painful area.

• Aberrant neural activity – DEAFF- Facil./Inhib. Imbalance

Central Post-Stroke Pain

• Begins within first month (63%) – up to 3 years

• Incidence 8% or more. Tx - Resistant

• Tx: Modalities – Antidepressants, anticonvulsants, glutamergic, gabaergic, opiates

CPSP Treatment – Evidence Based

• Short term pain control – Lidocaine, Propofol, I.V.’s

• 1st line Drugs – Amitriptylline 75mg+, LTG 200mg+

• 2nd line Drugs – Mexilitine up to 10mg/kg/day, Fluvoxamine up to 125mg/day, Gabapentin 1200mg/day or more.

Sleep and Stroke

• 50% or more have SDB, mostly OSA.

• SDB – poorer long-term outcome, increased mortality.

• SDB – may improve spontaneously. More often requiring CPAP or O₂. Hypnotics, DA agents and stimulants for patients with Thalamic Brainstem Lesions

Other Complications of Stroke

• Falls, Fractures, Osteoporosis

Prophylactic I.V. Bisphosphonates??

• Voiding and Sexual Dysfunction

Medical – Urological – Rehabilitation – Nursing Team Approach

Secondary Stroke Prevention

• 200,000 of Total Strokes• Profound effect on Morbidity-Mortality• ABCDE Treatment options

– A – Anti-platelet, Anticoag., Art. Revascularization

– B – Blood pressure control

– C - Cholesterol, Cig. Cessation

– D – Diet

– E – Exercise

Summary

• Prevention, Diagnosis, and Treatment of Stroke complications can decrease both Morbidity and Mortality.

• Monitor closely for early detection.

• Better outcomes with specialized stroke units.

Selected References:

1. Annoni, Jean-Marie et al. Emotional Disturbances after Stroke, Clinical and Experimental Hypertension 28:243-249, 2006.

2. Appelros P. et al. Lacunar Infarcts, Functional and Cognitive Outcomes……Cerebrovascular Disease 2005 July: 20:34-40.

3. Bassetti, Clandio L. Sleep and Stroke. Seminars in Neurology, Volume 25, Number 2 2005:19-32

4. Bowler, John V., Hachinski, Vlandimir. Vascular Dementia Clinical Summary. Medlinks Neurology. 6/1/06: 1-35.

5. Chen, Yan, Guo, Jeff J. Meta-Analysis of Antidepressant Treatment for Patients with Post-Stroke Depression (Letter to Editor) (Stroke 2006; 37:1365-1366).

6. De Groot, Marleen H. et al. Fatigue Associated with Stroke and Other Neurologic Conditions: Implication for Stroke Rehabilitation. Arch Physical Medical Rehabilitation 2003; 84:1714-1720.

7. Dumoulin, Chantale et al. Urinary Incontinence After Stroke: Does Rehabilitation Make A Difference?…….Top Stroke Rehabilitation 2002; 12(3):66-76.

8. Feleppa, Michele et al. Early Post-Stroke Seizures Clinical and Experimental Hypertension, 28: 265-270, 2006.

Selected References (cont.)

9. Ferro, Jose M. and Pinto, Francisco Post Stroke Epilepsy……Drugs Aging 2004; 21(10):639-653.

10. Frese, A et al. Pharmacologic Treatment of Central Post-Stroke Pain Clinical Joint Pain. Volume 22, Number 3, March/April 2006.

11. Kappelle, L,J and Van Derworp, H.B. Treatment or Prevention of Complications of Acute Ischemic Stroke Current Neurology and Science Reports 2004, 4:36-41.

12. Kelly, James et al. Pulmonary Embolism and Pneumonia May Be Cofounded after Acute Stroke and May Co-Exist Age and Ageing 2002; 31:235-239.

13. Leys, Didier et al. Post-Stroke Dementia Lancet Neurology 2005; 4:752-759.

14. Moroz, Alex et al. Stroke and Neurodegenerative Disorders .2. Stroke: Comorbidities and Complications Arch Physical Medical Rehabilitation 2004;85(3 Supply 1):511-4.

15. Poole, Kenneth E.S. et al. Falls Fractures and Osteoporosis After Stroke…. (Stroke, 2002; 33:1432-1436).

16. Williams, Linda S. Depression and Stroke: Cause or Consequences? Seminars in Neurology, Volume 25, Number 4, 2005:396-409.