neurologic complications
Patients with large cerebral infarctions may be at risk for other complications beyond herniation.
Hemorrhagic conversion after ischemic stroke in patients who do not receive thrombolysis is most strongly associated with a cardioembolic etiology. Hemorrhagic transformation can peak at up to 2 weeks after ischemic stroke. Seizures and status epilepticus in the acute setting are unusual presenting symptoms or complications in ischemic stroke, but any patient with a more severe neurologic exami-nation than the neuroimaging would suggest should be monitored. Antiepileptic medications are not routinely used in ischemic stroke patients, even in those with space-occupying infarcts, particularly due to the concern of the neurotoxic properties of some agents.
Infections
Infectious complications are some of the most likely outcomes in stroke patients and account for a significant proportion of the early morbidity in the care of stroke patients. Pneumonia, usually due to aspiration, is present in as many as 22% of stroke admissions at some point in their hospitalization166 and is more likely in patients with dysarthria/dysphasia, age older than 65 years, cognitive impair-ment, and a failed bedside water swallow evaluation.167 Urinary tract infections (UTIs) are also very common in stroke patients and present in up to 24% of patients during their inpatient admission.166 Bladder dysfunction is very common in the acute period, although in our experience UTIs are more likely to occur as a result of inappropriately prolonged periods of indwelling urinary catheters. Both pneumonia and UTI have been associated with poorer functional outcomes in several studies.168,169 Some clinicians have advocated prophylactic antibiotics early in the clinical course of patients with large ischemic strokes,170,171 although this has not been proven in other clinical trials.172 Admission to an organized inpatient stroke unit is one of the few interventions that reduces in-hospital mortality rate after stroke, and the mechanism appears to be through reduction of infectious complications.173 Although less frequently documented in clinical studies, we have also observed occasionally life-threatening infections from peripheral IV lines. Our practice is to revisit on a daily basis whether patients require indwelling catheters and IV lines.
cardiovascular Events
The incidence of ST-elevation myocardial infarction during the hospital stay is rare, but elevated tro-ponins are observed in up to 18% of stroke patients.174,175 Some myocardial infarctions will manifest
as a non–ST-segment elevation event, and may not have associated chest pain, and as such it is often assumed to be secondary to neurocardiogenic origins. Troponin elevations from cardiac stunning are less likely in ischemic stroke than they are in hemorrhagic strokes, and they are most likely to occur in individuals with large hemispheric infarcts. It is still reasonable to assume based on epidemiologic data that patients with ischemic stroke also have atherosclerotic coronary artery disease. Treatment of myocardial infarction after ischemic stroke remains difficult when there are competing interests between the brain and the heart in relation to blood pressure management and antithrombotics.
Unless there is an ST-elevation myocardial infarction, we avoid cardiac catheterization because of the possible need for multiple antithrombotic agents; for this same reason we also avoid IV heparin unless there is an imminent need for a cardiac catheterization. Decompensated congestive heart failure is an additional cardiac problem we have observed in our stroke patients, and in most cases it appears to be due to withholding diuretics to induce autohypertension. In general, it is reasonable to continue patients’ diuretics and β blockers to prevent pulmonary edema or rebound tachycardia.
Pulmonary complications
Pulmonary embolus (PE) remains one of the most preventable medical complications of any stroke subtype. The incidence of deep vein thrombosis (DVT) and pulmonary embolus is less than 3% in all stroke admissions.166 Treatment with prophylactic heparinoids as early as possible is clearly warranted in all stroke patients unless there is a clear medical contraindication; HI-1 and HI-2 hemorrhagic transformation patients should probably not have their DVT prophylaxis withheld. It appears that the use of compression stockings alone is not sufficient after stroke to prevent DVT.176
Respiratory failure after stroke is not only associated with malignant MCA infarcts, but can also be present in other stroke subtypes and independent of cardiopulmonary injury. Independent risk factors for mortality in respiratory failure after ischemic stroke include age older than 60 years and a Glasgow Coma Scale (GCS) score less than 10, while respiratory failure is associated with a low prob-ability of survival (33%) 2 years after stroke.177 In a sample of patients with stroke and mechanical ventilation in Northern Manhattan Hospital mortality rate, was as high as 50% in ischemic stroke patients and higher in the hemorrhagic stroke subtypes.178 It is unclear to what degree this is influ-enced by the decision to withdraw care in these patients by the family, and a cause and effect pathway is difficult to establish. As such, intubation should not be withheld for procedures, particularly when intubation is not felt to be permanently required.179
Death
In-hospital mortality rate after ischemic stroke is low overall, with one large series from Germany indicating a rate close to 5% and a higher rate being reported in other case series. The causes of death within 30 days after ischemic stroke is heterogeneous, but medical complications remain at the fore-front, with pneumonia being a principal cause of death following stroke.34,168,180 Case series have also described atrial fibrillation as a risk factor for in-hospital mortality, although it is not clear if this is related to the larger infarcts observed in this population or due to underlying cardiac disease.181-183 Out of all the complications after stroke, the most likely one to be associated with mortality is elevated ICP and cerebral perfusion failure.180
• tro e is the most common neurologic emergency in developed countries
• schemic stro e is treatable, but only a small proportion of patients ill receive r t A
! cRItIcAL conSIDERAtIonS
care
• r t A is indicated for eligible acute stro e patients ithin hours from onset, but may be beneficial between 3.0 and 4.5 hours. The 2009 AHA/ASA scientific advisory board has class I (benefit is greater than risk) recommendations for those who meet the eligibility criteria and exclusion criteria set out by ECASS III (ie, excluding age older than 80 years, on anti-coagulants regardless of INR, NIHSS greater than 25, and history of prior stroke and diabetes);
and class IIB (benefit if either greater than or equal to risk) recommendation for those who do not meet the additional exclusion criteria. For class I recommendation, it is advisable that the treating physician gives the IV r-tPA therapy, and for class IIB, it is advisable that the treating physician “may consider” giving the IV r-tPA.
• alignant cerebral edema is an important cause of early neurologic decompensation and mor-tality, and adequately powered and designed clinical trials document the effectiveness of hemi-craniectomy in improving mortality rate and long-term outcome.
• edical complications remain an important cause of morbidity and mortality in ischemic stroke patients and include infection such as hospital-acquired pneumonia, sepsis, DVT/PE, and cardiovascular diseases.
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