Complications of Stroke

1
Complications of Stroke

• Gabriel A. Vidal, MD
• Vascular Neurology
• Ochsner Medical Center
• October 14th, 2009

2
Complications

• Volume expansion (? ICP)
• Blood (ICH)
• Vasogenic edema (Breakdown of BBB eg, tumors)
• Cytotoxic edema (strokes)
• Seizures
• Infection
• DVT

3
Intracranial Pressure

• Skull doesnt allow for expansion (normal ICP 0
  20 mm Hg)
• Brain parenchyma (80)
• CSF (10)
• Blood (10)
• Monroe-Kellie doctrine
• If the volume of one of these compartments
  increases, the volume of another must decrease to
  maintain normal ICP
• What happens when the pressure begins to
  increase?
• Brain parenchyma doesnt shrink
• CSF is shifted to the spinal subarachnoid space
• Arterial and venous structures collapse
• If initial measures dont work
• Brain herniation
• Only one way out
• Decrease blood flow

4
(No Transcript)
5
Cerebral Perfusion Pressure and Auto-regulation

• Cerebral perfusion pressure
• CPP MAP - ICP (70 100 mm Hg)
• Auto-regulation
• Mechanism that when intact, maintains a constant
  cerebral blood flow if the MAP is between 60 and
  160

6
Management of Elevated ICP

• Basic
• Head of bed elevated 30
• Normothermia
• Pain control
• CSF drainage (? CSF compartment volume)
• External ventricular drain
• Hyperventilation (causes vasoconstriction ?
  vascular compartment volume)
• Goal PCO2 30 to 32
• Osmosis (cell shrinkage from diuresis ? brain
  volume)
• Mannitol
• Hypertonic saline
• Sedation (? metabolic activity of the brain, thus
  blood flow)
• Barbiturates
• Propofol
• Hypothermia (? metabolic activity of the brain,
  thus blood flow)
• Cooling blankets
• Surgery
• Lesion excision

7
(No Transcript)
8
Seizures

• Stroke-related seizure was first
• described in 1931 by
• Hughlings Jackson
• Described a partial seizure in the setting of an
  embolic stroke
• In elderly population stroke is among the most
  common causes of seizure and epilepsy
• Epilepsy following a clinically or pathologically
  recognized stroke has been reported with
  frequency estimated between 6 and 21

9
Seizures

• In a population-based study from Rochester in
  cerebral infarction
• 6 developed seizures within 1 week of stroke
  (78 of those within 24 hours of onset)
• 27 developed seizure after the first week
• 18 developed recurrent late seizures (epilepsy)
• Cumulative probability of late seizure was 3 by
  1 year, 4.7 by 2 years, 7.4 by 5 years, and
  8.9 by 10 years

10
Incidence of Seizures by Stroke Type

• In a prospective cohort of 1000 consecutive
  strokes from Australia (99 with CT scan) seizure
  rates within 2 weeks of stroke were
• 4.4 had a seizure
• 15.4 of ICH
• 8.5 of SAH
• 6.5 with cortical infarction
• 3.7 with hemispheric TIA
• Lacunar infarcts and deep ICH were not associated
  with seizures

11
Morbidity and Mortality

• In a hospital-based prospective stroke registry
  2.9 had seizures within 48 hours
• Factors associated with seizure VS non-seizure in
  the stroke cohort
• Advanced age
• Confusional syndrome
• Hemorrhagic stroke
• Large lesion
• Parietal and temporal lobe involvement
• Medical complications present
• In-hospital mortality 33.3 in seizure group VS
  14.2 in non-seizure
• Early seizures was a significant predictive
  clinical variable for mortality

12
Seizures and ICH

• Intracerebral hemorrhage with seizures was
  studied in a retrospective analysis of 1402
  hospital ICH cases from China Chung-Yang, JNNP
  1989521273-76
• Seizures occurred in 4.6
• Recurrent seizures in 2.5.
• Seizures were the presenting symptom in 30.
• Status epilepticus occurred in 17 overall
• 29 with early seizures developed recurrent late
  seizures and 93 with late seizures developed
  recurrent late seizures

13
(No Transcript)
14
Infections - Pneumonia

• Pneumonia is an important cause of death after
  stroke
• More likely to occur in immobile patients and
  those who are unable to cough
• It is associated with increased risk of death and
  unfavorable outcome after stroke
• Fever after a stroke should prompt a search for
  pneumonia
• Protection of airway and measures to treat nausea
  and vomiting lower the risk of aspiration
• Prophylactic antibiotics have not been proven to
  lessen the risk of stroke

15
Infections - UTI

• Relatively common in patients with stroke
• Bacteremia or sepsis is a potential complication
• Screening of urine should be prompted if patient
  develops fever after a stroke
• Prolonged use of indwelling catheter should be
  avoided
• Acidification of the urine may lower the risk of
  infection

16
(No Transcript)
17
Deep Vein Thrombosis and Pulmonary Embolism

• Common causes of morbidity and mortality in
  patients with ICH
• Accounts for 10 of deaths after stroke
• Slows recovery and rehabilitation after stroke
• Early mobilization is key
• No difference between heparin and LMW heparin
• In a retrospective study of 1926 patients with
  ICH 1.6 had diagnosis of DVT
• Studies using fibrinogen scanning or MRI to
  detect occult venous thrombosis report high
  frequencies (10 to 50) of DVT in acute stroke
  paitents with hemiplegia

18
Prevention of DVT

• Recent study randomized patients with ICH to
  compression stockings vs compression stockings
  PLUS intermittent pneumatic compression
• Asymptomatic DVT by ultrasound at day 10
• 15.9 in patients with elastic stockings alone
• 4.7 in the combination group

19
Prevention of DVT

• Boeer and colleagues reported a small trial of 68
  patients with ICH
• Randomized to low-dose heparin TID
• Group 1 10th day
• Group 2 4th day
• Group 3 2nd day
• Group 3 had statistically significant reduction
  in number of PE when compared to other 2 groups
• No overall increase in incidence of rebleeding

20
Treatment of DVT

• Risk of recurrent ICH during the initial 3 months
  after acute ICH is 1
• When anti-coagulation is added, the risk
  increases by 2-fold
• Balance between risk of life-threatening
  thromboembolism vs risk of rebleeding
• The risk of recurrent ICH varies by location
• Higher in lobar ICH due to amyloid angiopathy

21
Treatment of DVT

• Vena cava filter
• May reduce incidence of PE in patients with DVT
• Long-term risk of increased venous
  thromboembolism
• Good BP control during anticoagulation
  subsantially reduces the risk of recurrent ICH
• PROGRESS trial (Perindopril pROtection aGainst
  REcurrent Stroke Study) documented a 50
  reduction of the risk of recurrance among ICH
  survivors by lowering systolic blood pressure by
  11 mmHg

22
Recommendations for DVT

• Intermittent pneumatic compression
• Hypertension treatment
• Low-dose heparin may be considered for DVT
  prophylaxis
• After 3 to 4 days and once stable hemorrhage on
  ICH patients
• IVC filter for patients with ICH and DVT
• Long-term anti-coagulation therapy may be
  considered in high risk patients
• Atrial fibrillation
• But with special consideration to likely cause of
  hemorrhage
• Amyloid angiopathy

23
(No Transcript)