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(Stroke. 1996;27:415-420.)
© 1996 American Heart Association, Inc.

Articles

Complications After Acute Stroke

R.J. Davenport, MRCP(UK); M.S. Dennis, FRCPE; I. Wellwood, BA C.P. Warlow, FRCPE

From the Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Edinburgh, Scotland.

Correspondence to R.J. Davenport, Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh, Scotland EH4 2XU. E-mail rjd@skull.dcn.edinburgh.ec.uk.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion Appendix References

 
Background and Purpose We sought to observe the type, timing, and frequency of complications occurring in hospitalized patients after an acute stroke.

Methods In a single hospital, we prospectively identified a consecutive cohort of patients who were either admitted after an acute stroke or who suffered a stroke while already an inpatient (n=613). We retrieved the case notes for 607 (99%) of these strokes, and a single observer, using predefined diagnostic criteria, reviewed the notes and recorded the type, timing, and frequency of complications that occurred during the inpatient period. We also measured the reliability of complication identification from case note review by comparing two observers on a sample of records.

Results Complications were recorded after 360 strokes (59%); the most common individual complications were falls (complicating 22% of all strokes), skin breaks (18%), and urinary tract (16%) or chest (12%) infections. Miscellaneous "other" complications complicated 32% of strokes. Seizures and chest infections occurred early, whereas depression and painful shoulder were later problems. Complications were more common in older patients, who were more disabled before their stroke and had suffered more severe strokes. We demonstrated moderate to good agreement between the two observers for most complications.

Conclusions Complications after acute stroke are common, confirming that stroke rehabilitation requires active and knowledgeable medical input. Knowing the nature and timing of complications, together with the identification of high-risk patients, may be useful to those planning stroke services. The differences in our results and those previously reported, most notably for skin breaks, are probably due to the different methods used, in particular patient selection and diagnostic criteria for complications. Although complications may be useful as a measure of outcome in comparative studies (eg, therapeutic trials and audit), the methodological difficulties in accurately and reliably measuring them must be addressed.

Key Words: complications • stroke, acute • stroke rehabilitation

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion Appendix References

 
Patients who have had an acute stroke are at risk of developing a wide range of complications secondary to their stroke; these complications are important because they may cause death or delay successful rehabilitation.^{1 2 3} Several studies have shown that although deaths within a few days of stroke are usually the direct consequence of brain damage, those occurring over the following weeks are mainly due to potentially preventable problems such as infection, venous thromboembolism, or cardiac disease.^{4 5 6 7 8} It has even been suggested that the effectiveness of organized stroke care in reducing mortality⁹ may be due to improvements in the prevention, identification, and treatment of secondary complications.¹⁰ Complication rates may also be a useful measure of outcome in comparative studies, and they have been used in both nonrandomized^{11 12 13} and randomized controlled trials¹⁴ of stroke units.

Most of the published studies on poststroke complications have focused on individual problems in isolation, such as seizures, venous thromboembolism, or depression. These studies have used a range of different designs; furthermore, methods of patient selection, diagnostic criteria, timing, and duration of follow-up vary considerably between studies, and therefore it is hardly surprising that the reported frequencies of specific complications in these studies also varied (Table 1).

View this table: [in this window] [in a new window]   Table 1. Comparison of Present Study With Published Data

We have been able to identify only five English language studies in which the frequency of several different complications was the main subject of interest (Table 1).^{1 2 3 15 16} We are aware of at least one non-English language report, but this included patients with transient ischemic attacks.³³ There was disagreement between these studies as to the overall definition of a complication; some included vascular risk factors such as hypertension or diabetes mellitus as complications,^{1 2 3} while others concentrated on problems that were clearly secondary to the incident stroke,¹⁶ such as chest infections or venous thromboembolism, and only one of the studies provided specific diagnostic criteria for individual complications.¹⁶ We therefore undertook a retrospective study to estimate the frequency and timing of defined complications in a large cohort of consecutive hospitalized patients after an acute stroke.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion Appendix References

 
Using a method similar to that described previously,³⁴ we prospectively identified consecutive patients who were either admitted to the Department of Internal Medicine at the Western General Hospital with a stroke (first ever or recurrent) or had suffered a stroke during an inpatient stay during the periods October 1990 to May 1991 and May 1992 to September 1994 (the gap occurred because of a lack of funding). We used the World Health Organization definition of stroke³⁵ but excluded subarachnoid hemorrhage; all patients were assessed by a stroke physician. We included all patients managed within the hospital except those admitted to the neuroscience unit in the hospital.

We attempted to retrieve the case notes (medical and nursing) for all patients after death or discharge. A medically qualified observer (R.J.D.) reviewed all the available records and identified complications (see "Appendix" for definitions) that arose during the period spent in our hospital after each admission; complications that arose after discharge were not recorded. Although we used a single observer, we were interested in measuring the degree of interobserver reliability of identifying complications from case notes; we did this by comparing R.J.D. with a blinded paramedical observer (I.W.) on the first 173 strokes. After this reliability study, we recognized that our original list of complication types was incomplete and added depression, confusion, and a miscellaneous "other" category.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion Appendix References

 
We identified 751 strokes during the 36-month study period; 138 of these were admitted to the neuroscience unit and excluded, leaving 613 strokes occurring in 597 patients for analysis. Forty-seven (8%) of these occurred in patients already in the hospital for other reasons. We retrieved the case notes for 607 (99%) of these strokes. The overall mean length of stay was 37 days; thus, the total period of observation for complications was 22 459 hospital days. There was considerable variation of mean length of stay within different categories of patients: for the 136 patients who died in the hospital, it was 17 days; for the 383 discharged home, it was 32 days; and for the 61 discharged to continuing care facilities, it was 109 days.

The patients' median age was 73 years (interquartile range, 65 to 81 years); 54% were female. The median delay between stroke onset and hospital admission, excluding the 47 patients who suffered a stroke while in the hospital and an additional 30 for whom accurate timing data were unavailable, was 6 hours (interquartile range, 3 to 24 hours). In all 30 cases without accurate data, admission was within 24 hours of stroke onset. There were 57 (9%) hemorrhagic strokes (diagnosed on CT or at autopsy). Of the remaining 550 strokes, 71% were proven (CT or autopsy) and 20% were presumed ischemic strokes; 123 (22%) of these 550 strokes were total anterior circulation syndromes according to the Oxfordshire Community Stroke Project classification.³⁶ Table 3 shows the results of the interobserver study; values ranged from an acceptable 0.77 for falls to a disappointing 0.35 for pyrexial illness.

View this table: [in this window] [in a new window]   Table 3. Interobserver Agreement for Identification of Complications in 173 Patients

During 607 hospital admissions for acute stroke, at least one complication occurred in 360 (59%); the frequencies of individual complications are shown in Table 1. The most common individual complication was falls; a total of 299 falls occurred in 134 strokes (22%). No intervention other than simple analgesia was required after 248 (83%) of these falls, but 21 (7%) led to a radiograph, 20 (7%) required a dressing or suturing, and 10 (3%) resulted in a fracture (one patient required an operation). In addition to the specific complications identified in Table 1, 193 (32%) of our patients experienced a wide range of miscellaneous problems, the more common and serious of which are summarized in Table 2.

View this table: [in this window] [in a new window]   Table 2. Other Complications Occurring in 193 Strokes

Of the 360 complicated strokes, 223 (62%) experienced more than one type of complication. We also recorded the frequency of recurrent individual complications except for seizures, depression, confusion, and painful shoulder, when it was not possible to reliably identify recurrent events from the case notes. Falls were recurrent in 64 patients (48%), urinary tract infections in 26 (27%), skin breaks in 23 (21%), and chest infections in 8 (11%). There was one recurrent deep venous thrombosis and no recurrent pulmonary emboli.

We measured the timing of complications from the day of stroke; Fig 1 shows the cumulative percentage over the first 30 days for all episodes of different complication types recorded (except for depression and seizures, which are time to first recorded episode). Although some occurred early (seizures and chest infections), others were still occurring for the first time quite late after stroke onset.

View larger version (17K): [in this window] [in a new window]   Figure 1. Delay between stroke onset and complications within first 30 days.

We investigated a number of potential risk factors for developing a complication with univariate analyses (Fig 2). Complications were more common with increasing age, prestroke disability, total anterior circulation strokes, and urinary incontinence. Experiencing a complication was associated with an increased risk of death during admission (odds ratio, 1.9; 95% confidence interval, 1.2 to 2.9).

View larger version (21K): [in this window] [in a new window]   Figure 2. Risk factors for poststroke complications. OHS indicates Oxford Handicap Score,37 dichotomized into 0 to 2 (independent) and 3 to 5 (dependent); TACS, total anterior circulation syndrome (hemorrhagic strokes excluded); GCS, Glasgow Coma Scale; CI, confidence interval; and OR, odds ratio. *Previous history of atrial fibrillation and/or atrial fibrillation on admission electrocardiogram; occurring within 7 days of stroke.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion Appendix References

 
Our study design raises a number of important methodological issues, including patient selection, sample size, and the retrospective identification of complications, all of which may exert a powerful influence on the results. These issues may be particularly relevant for comparative studies that use complication rates as an outcome measure, in which sources of bias may be sufficiently large to either obscure a real difference in rates or create an apparent one. Using our results and previous studies as examples, we shall address these issues in turn.

Our design aimed to reduce selection bias, although of course it was a hospital-based study and thus suffered from referral bias. We identified patients prospectively using an internationally recognized definition of stroke³⁵ and used several sources of identification to ensure case ascertainment that was as complete as possible. We excluded patients admitted to our neuroscience unit; these latter patients were a highly selected group, with a high proportion of hemorrhagic and atypical strokes, and were often referred from beyond our own hospital's catchment area. In two of the previous multiple complication studies listed in Table 1 it was unclear how patients were selected for inclusion,^{2 3} and another study relied on hospital discharge records,¹ which may fail to identify all suitable patients. We recorded complications from the time of acute admission; all the multiple complication studies in Table 1 were based in rehabilitation units, with a mean delay from stroke onset to admission varying from 8 to 37 days,^{1 2 3 15 16} and thus included only patients who had survived the acute phase but required rehabilitation. Therefore, they may have underestimated complications that occur early or lead rapidly to death (eg, seizures, chest infections). Case note retrieval bias may further influence results, since notes of patients who die or are transferred to a long-term-care facility may be more difficult to trace,³⁸ yet they may experience disproportionately more complications, leading to an underestimate of complications. Certainly the 6 patients in our study whose notes were untraceable had poor outcomes (2 died within 48 hours of admission, 2 are in continuing-care facilities, and the remaining 2 live at home but are dependent); however, they account for just 1% of our sample and thus are unlikely to significantly bias our results. In addition, our sample size was more than double that of the previous largest study,¹⁶ which allowed more precise estimates of the frequencies of complications.

The next methodological problem concerns the retrospective identification of complications from case notes, which may be influenced by the diagnostic criteria used, interobserver bias, and the standard of note keeping. Differing diagnostic criteria will affect frequency estimates. For example, prospective studies of deep venous thromboses after stroke have produced rates varying from 11%^{29 39} to 75%,³⁰ with many studies around 30%,^{31 40 41 42} compared with our rate of 3%. The studies that recorded the highest frequency^{30 43} based the diagnosis on serial ¹²⁵I-labeled fibrinogen scans performed daily for 10 to 14 days; in contrast, we applied retrospective criteria based on clinical diagnoses, backed up by appropriate tests when performed, which reflects real-life stroke care in the United Kingdom. Table 1 contains several similar examples in which prospective studies of single complications have reported higher rates than the retrospective multiple complication studies. In addition to the effect of diagnostic criteria, it is possible that the multiple complication studies reflect a lower level of awareness among medical staff for certain complications (eg, depression) than the more sensitized investigators who used specific diagnostic methods involved in the prospective studies. Similarly, we suspect that differing criteria are responsible for some of the variations in frequencies between ours and the other multiple complication studies shown in Table 1. For example, our rate of 18% for skin breaks is much higher, but our definition included any breaks in the skin, not simply over pressure areas. Surprisingly, despite the undoubted importance of diagnostic criteria, only one of the previous studies provided specific criteria for individual complications¹⁶ ; Dromerick and Reding¹ defined a complication as "medical or management problems that generated a physician order" but did not qualify individual complications further.

Identification of complications from case notes is also subject to interobserver variation, though not in our study, which used a single observer. Four of the five published studies did not state how many observers were involved or who they were^{1 2 3 15} ; Kalra et al¹⁶ used a trained audit analyst, with peer review by a physician in all positive or doubtful cases. For most complications in our study the value was greater than 0.6, indicating good or very good agreement.⁴⁴

The type and quality of care patients receive may influence complication rates; while patients cared for in a dedicated stroke unit, who are under more scrupulous observation by experienced staff, may experience fewer complications such as pressure sores or deep venous thromboses, other complications, such as aspiration or musculoskeletal problems, may appear to be more frequent simply because of better recognition and documentation in the case notes rather than a real increase.¹⁶ If this were the case, one might expect to identify complications and institute treatment at an earlier stage and thus improve prognosis; therefore, the severity of complications as well as the frequency may be a useful measure in comparative studies. Variation in case note documentation may be particularly relevant, since fewer complications may be identified from poorly documented notes, and it is recognized that the amount of missing case note data may vary markedly between different hospitals.³⁸

Our study recorded only complications that occurred during the inpatient stay; clearly, estimates of the frequency of complications will vary depending on the period of observation. Thus, in our study the increased likelihood of experiencing a complication with an increased length of stay may simply reflect the fact that these patients were under observation longer rather than either the possibility that those with more severe strokes had more complications or that complications prolonged the hospital stay. Unfortunately, we do not know the rate of complications after discharge from the hospital, and therefore we are unable to analyze this aspect further. The ideal study would prospectively observe all patients for a fixed period of time after stroke, which would help eliminate the possible bias of varying periods of observation.

Our study confirms the conclusion of Kalra et al¹⁶ that a stroke service must be medically active and as such must have access to acute-care and diagnostic facilities. In hospitals with acute-care and rehabilitation units on the same site this is usually straightforward, but many rehabilitation units are on separate sites; it is disruptive and potentially dangerous for a patient to transfer for rehabilitation only to have to return to the acute-care hospital after a complication. Knowing which complications occur early and which patients are at high risk of complications may be useful in avoiding such precipitant transfers.

Our study is the largest investigation of poststroke complications to date and, unlike most of the previous studies, recorded multiple complications from the time of acute admission. We suspect that many of the differences in rates between our study and those previously published reflect methodological differences, in particular the issue of diagnostic criteria, which have received scant regard in the past. Knowledge of the frequency, type, and timing of complications after stroke is important in terms of direct patient care and the planning of future services. Although complication rates may be used as an outcome in therapeutic trials and in the auditing and quality monitoring of stroke care both within and between units, the methodological problems associated with their measurement are significant and must be addressed within the study design.

View this table: [in this window] [in a new window]   Table TAPP. Complications and Their Definitions

	Acknowledgments

 
This study was supported by the Medical Research Council (UK) (R.J.D.), the Stroke Association (UK) (M.S.D. and the Stroke Register), and the Scottish Home and Health Department (I.W.).

	Appendix

Top Abstract Introduction Subjects and Methods Results Discussion Appendix References

 

Received September 5, 1995; revision received November 6, 1995; accepted December 5, 1995.

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Top Abstract Introduction Subjects and Methods Results Discussion Appendix References

 
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