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(Stroke. 2000;31:1223.)
© 2000 American Heart Association, Inc.
Original Contributions |
Medical Complications After Stroke
A Multicenter Study
From the Academic Section of Geriatric Medicine, Royal Infirmary (P.L., D.J.S., L.R.), Glasgow, Scotland, UK; Department of Geriatric Medicine, Gartnavel General Hospital (J.M., L.J.), Glasgow, Scotland, UK; Department of Geriatric Medicine, Stirling Royal Infirmary (C.M., F.D.), Scotland, UK; and Department of Community Health Sciences, University of Edinburgh (G.S.T., G.M.), Scotland, UK.
Correspondence to Dr Peter Langhorne, Academic Section of Geriatric Medicine, Level 3, Centre Block, Royal Infirmary, Glasgow G4 OSF, United Kingdom. E-mail P.Langhorne{at}clinmed.gla.ac.uk
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Abstract |
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 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
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Background and Purpose—This prospective, multicenter study was performed to determine the frequency of symptomatic complications up to 30 months after stroke using prespecified definitions of complications.
Methods—We recruited 311 consecutive stroke patients admitted to hospital. Research nurses reviewed their progress on a weekly basis until hospital discharge and again at 6, 18, and 30 months after stroke.
Results—Complications during hospital admission were recorded in 265 (85%) of stroke patients. Specific complications were as follows: neurological—recurrent stroke (9% of patients), epileptic seizure (3%); infections—urinary tract infection (24%), chest infection (22%), others (19%); mobility related—falls (25%), falls with serious injury (5%), pressure sores (21%); thromboembolism—deep venous thrombosis (2%), pulmonary embolism (1%); pain—shoulder pain (9%), other pain (34%); and psychological—depression (16%), anxiety (14%), emotionalism (12%), and confusion (56%). During follow-up, infections, falls, "blackouts," pain, and symptoms of depression and anxiety remained common. Complications were observed across all 3 hospital sites, and their frequency was related to patient dependency and duration after stroke.
Conclusions—Our prospective cohort study has confirmed that poststroke complications, particularly infections and falls, are common. However, we have also identified complications relating to pain and cognitive or affective symptoms that are potentially preventable and may previously have been underestimated.
Key Words: complications • stroke outcome • infection • pain
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Medical complications are believed to be an important problem after acute stroke and present potential barriers to optimal recovery. Several previous studies have suggested that complications not only are common, with estimates of frequency ranging from 40% to 96% of patients,1 2 3 4 5 6 but also are related to poor outcome.6 Many of the complications described are potentially preventable or treatable if recognized.
Although many studies have reported frequencies of poststroke complications, they have all been subject to important methodological limitations. Most have been retrospective series, and to date, none have met the basic criteria for a reliable cohort study.7 In particular, they have not studied a defined representative sample (inception cohort) of patients assembled early in the course of their disease, with regular and complete follow-up using prespecified objective outcome criteria. Previous studies have either incorporated a retrospective case-ascertainment design1 2 3 4 5 or a prospective analysis of patients selected for an acute intervention study.6 We have performed a prospective multicenter study of recovery among hospitalized stroke patients managed in a routine clinical setting. This included the identification of potential barriers to recovery (poststroke complications), which are described here.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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We recruited stroke patients admitted over a 7-month period to 3 hospital sites in the West of Scotland (Glasgow Royal Infirmary, Drumchapel Hospital, and Stirling Royal Infirmary). Two of the hospital sites (Glasgow Royal Infirmary and Stirling Royal Infirmary) provided acute stroke patient care (coordinated by a mobile stroke team) in general medical wards with subsequent rehabilitation in a stroke rehabilitation ward. The third site (Drumchapel Hospital) is a rehabilitation facility accepting patients from an acute stroke unit
1 week after stroke.
We recruited consecutive admissions who fulfilled the World Health
Organization clinical definition of stroke, except in Glasgow Royal
Infirmary, where because of larger patient numbers, acute stroke
admissions were recruited on alternate days of admission. There was a
rehabilitation philosophy of care across all 3 sites, with the aim of
optimizing patient function; care was provided for several weeks if
necessary until discharge home or appropriate placement in
institutional care, and patients were not transferred to other
rehabilitation environments. Average length of stay was 5 weeks.
Patients were recruited within 7 days of stroke onset, and their
progress was reviewed on a weekly basis until discharge from hospital.
The initial assessment included demographic details, stroke
impairments, and functional dependency (Barthel index and Functional
Independence Measure [FIM]8 ). Weekly assessments of
functional status and the occurrence of prespecified complications were
performed by 3 research nurses (1 per site) in conjunction with the
local clinical staff. The research nurses held regular meetings to
ensure comparability of data collection, assessment methods, and
definitions of complications. After discharge from hospital, 1 of the
research nurses followed up all patients at 6, 18, and 30 months
after stroke. These assessments were performed in the most convenient
location (eg, home, nursing home, or day hospital) and included a
questionnaire about stroke complications.
Definition of Complications
Because our primary interest was the frequency of all
complications in a cohort of stroke patients, we did not distinguish
between those associated with survival or death. For hospital
follow-up, we used simple clinical definitions of complications (Table 1
) that were modified from those
of Davenport et al.1 Community follow-up required further
modification of questions that could be asked of patients and/or
caregivers (Table 1).
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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A total of 311 consecutive stroke patients were admitted to the 3 hospital sites: Glasgow Royal Infirmary, 129 patients; Drumchapel Hospital, 111 patients; and Stirling Royal Infirmary, 71 patients. The median delay between symptom onset and recruitment into the study was 4 days (interquartile range 2 to 7 days), with a median follow-up of 7 weeks. Of a total possible 2383 weekly assessments in hospital, 2280 (96%) were completed, which represents
15 960 hospital
days of observation. Of a possible 554 community follow-up visits of
survivors, a total of 546 (99%) were completed, of which 478 (88%)
were by interview and 68 (12%) by telephone.
Patient Cohort
The 311 patients had an average age of 76 years (interquartile
range 70 to 82 years); 161 (52%) were male, 229 (74%) were
independent (modified Rankin score 0 to 2) before the stroke, and 248
(80%) underwent early CT scanning; of these, 220 (89%) showed
infarction or no visible lesion, and 28 (11%) showed a primary
intracerebral hemorrhage. The clinical stroke
subtypes were as follows: total anterior circulation stroke, 108
(35%); partial anterior circulation stroke, 105 (34%); lacunar
stroke, 56 (18%); posterior circulation stroke, 9 (3%); and
hemorrhage or unclassifiable, 32 (10%). A total of 60 patients
(19%) died in hospital, 91 (29%) by the 6-month follow-up, 130 (42%)
by 18 months, and 156 (50%) by 30 months. Therefore, we appear to have
recruited a relatively elderly, disabled cohort of patients, with the
exclusion of those who made a rapid recovery in the first few days.
Complications in Hospital
A total of 265 patients (85%) experienced at least 1 prespecified
complication during their stay in hospital. The results for individual
sites ranged from 76% to 91%. Seven (2%) of the patients had an
early hospital readmission, and their readmission complications are
included within the hospital data. The main complications are outlined
in Table 2 (along with summary results
from previous retrospective studies and selective prospective studies
of acute stroke patients). It is clear that the frequencies of many of
the complications identified in the present study are comparable to
those of previous reports. In particular, recurrent stroke, epileptic
seizure, infections, pressure sores, falls, thromboembolism, and total
complication rates are all comparable with previous studies. However,
in the present study, we appear to have recorded higher levels
of pain and psychological symptoms than previously reported. Table 2 illustrates that the range of frequencies across individual
sites was very similar, with the possible exception of recurrent
stroke, falls, anxiety, and miscellaneous complications. It is not
clear whether these minor variations are due to differences in patient
case mix or subtle differences in the definition of complications.
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The data outlined in Table 2
are expressed in terms of hospital
incidence rates, ie, the number of patients who experienced a
complication in hospital. In these estimates, a particular complication
could only be recorded once per patient. This analysis may
misrepresent the burden of a complication, because it may not
take into account the duration of observation (time in hospital) and
may underestimate the burden of chronic complications that persist over
a long period. We therefore recalculated complications in terms of the
total number of weekly observations in which a complication was
recorded (weekly point prevalence). As expected, these
point-prevalence estimates (Table 3) were
generally smaller than the hospital incidence results, but the relative
frequency of complications remained very similar.
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Complications After Hospital Discharge
The complications reported by patients and/or caregivers at
various census times during follow-up are outlined in Table 4. Complication rates in hospital are
shown for comparison, although slightly different methods were used.
Patients reported a high frequency of infections, falls, pain, and
symptoms of depression and anxiety (although smaller numbers of
patients were taking antidepressant medication). Miscellaneous illness,
unexplained "blackouts" and "funny turns," and hospital
readmission were also common.
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Relationship With Stroke Severity
In examining the relationship between stroke severity and
complications, we focused our analysis on the Glasgow Royal
Infirmary data, which incorporated an unselected series of stroke
patients followed up by a single observer during both the acute and
rehabilitation phases of their illness. These results are summarized in
Table 5, which shows the proportion of
patients experiencing complications subdivided by their initial level
of dependency; dependency was classified by the FIM score at first
assessment (median 3 days, interquartile range 1 to 4 days after
stroke). These results were divided into 3 categories: (1)
mild—initial FIM >100 points (n=14); (2) moderate—initial FIM 50 to
100 (n=42); and (3) severe—initial FIM <50 (n=74). There were trends
for more dependent patients to have a higher risk of infections, falls,
pressure sores, pain, anxiety, and depression. However, on a
2 test for trend, statistically significant
results were seen only for infections (P<0.05), pressure
sores (P<0.01), and anxiety (P<0.05).
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Timing of Complications After Stroke
We wished to ascertain the delay between the index stroke and
onset of individual complications. This was analyzed as the
cumulative number of patients experiencing a complication at successive
periods after the index stroke (Figure). It was clear that most
complications developed within the first 6 weeks after stroke, with an
early onset being seen particularly for pressure sores, pain, and
infections. Falls and depression appeared to develop more gradually,
which could reflect progress in rehabilitation (falls) or a reluctance
to make an early diagnosis of depression.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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To the best of our knowledge, this is the first study of poststroke complications that has used a prospective design to observe a relatively unselected group of patients over a prolonged period of time with prespecified clinical criteria for complications. We sought to maximize the reliability of the study by having a clearly defined inception cohort, prespecified definitions of complications, and a standardized regular follow-up of all patients.7 Although our initial follow-up was performed by 3 observers, we sought to ensure comparability of data recording by having standardized definitions of complications and regular meetings to ensure comparability of data recording. Because most patients remained in hospital until they were independent enough to return home or judged to be unable to benefit from further rehabilitation, we believe we have achieved good ascertainment of complications during the main recovery period after stroke. Any bias in our hospital complication estimates will be toward underestimating the frequency of complications. Estimates of complications at later follow-up depended on information from patients and caregivers, which may have underestimated or overestimated complication rates.
The limitations of our study include the focus on symptomatic complications; the rather simple, pragmatic nature of some definitions of complications; and the differing case mix in the 3 hospital sites. We used simple clinical definitions because we believed this would be the most practical and accurate representation of the clinical symptoms experienced by stroke patients. Although the patient case mix may have varied between hospitals, we were keen to include this combination because it is representative of the range of acute and rehabilitation services available in the United Kingdom. Our definitions of complications were rather inclusive (eg, pressure sore defined as any suspicious skin lesion), which may have resulted in our high prevalence of some complications. However, we feel these data are useful as an indicator of all potential symptomatic complications.
Our findings appear to confirm previous studies1 2 3 4 5 6 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 that showed that there are relatively low frequencies of the symptomatic complications of recurrent stroke, poststroke seizures, clinical deep vein thrombosis, and clinical pulmonary embolism. We have also confirmed the relatively high frequencies of urinary tract infection, chest infection, and other types of pyrexial illness. However, many of the complications that are more difficult to specify, such as pain, depression, anxiety, and confusion, appear to have been relatively frequent in our study and more common than in previous series. This could reflect the prospective nature of our data collection, in which the research nurses sought to identify all potential barriers to patient recovery. The discrepancy could also be due to the different (and rather subjective) definitions used compared with previous studies. This is particularly the case with symptoms of depression or anxiety, which were common (34% to 54% prevalence) when based on a screening question but much less common if based on drug prescriptions. An alternative explanation is that depression and anxiety have previously been underrecognized, and it is interesting to note a recent study using psychiatrist follow-up27 reported a prevalence of depression of 53% at 3 months and 42% at 12 months.
Previous authors6 have noted the strong association between poststroke complications and poor outcome and have suggested that complications may act as barriers to recovery. This raises the possibility that rigorous attention to detail in the prevention and early treatment of complications could improve stroke outcome. Indeed, the data from the randomized trials of stroke unit care28 indicate that the causes of death that are most likely to be prevented by stroke unit care are those classified29 as complications of immobility (in particular, thromboembolism and infection). In more prolonged follow-up, it is clear that this group of patients has significant morbidity and risk of readmission to hospital. Interventions to detect and treat the more common complications appear worthy of further study.
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Acknowledgments |
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This project was funded by the Chief Scientists Office, Scottish Office. We are grateful to our medical and nursing colleagues in Glasgow Royal Infirmary, Stirling Royal Infirmary, and Drumchapel Hospital whose cooperation made this study possible.
Received November 15, 1999; revision received February 23, 2000; accepted February 24, 2000.
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A. Chamorro, J.P. Horcajada, V. Obach, M. Vargas, M. Revilla, F. Torres, A. Cervera, A.M. Planas, and J. Mensa The Early Systemic Prophylaxis of Infection After Stroke Study: A Randomized Clinical Trial Stroke, July 1, 2005; 36(7): 1495 - 1500. [Abstract] [Full Text] [PDF]
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M. L. Hackett, C. Yapa, V. Parag, and C. S. Anderson Frequency of Depression After Stroke: A Systematic Review of Observational Studies Stroke, June 1, 2005; 36(6): 1330 - 1340. [Abstract] [Full Text] [PDF]
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S F. Mackintosh, K Hill, K J Dodd, P Goldie, and E Culham Falls and injury prevention should be part of every stroke rehabilitation plan Clinical Rehabilitation, April 1, 2005; 19(4): 441 - 451. [Abstract] [PDF]
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 P. U. Heuschmann, P. L. Kolominsky-Rabas, B. Misselwitz, P. Hermanek, C. Leffmann, R. W. C. Janzen, J. Rother, H.-J. Buecker-Nott, K. Berger, and for The German Stroke Registers Study Group Predictors of In-Hospital Mortality and Attributable Risks of Death After Ischemic Stroke: The German Stroke Registers Study Group Arch Intern Med, September 13, 2004; 164(16): 1761 - 1768. [Abstract] [Full Text] [PDF]
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M. Barber, P. Langhorne, A. Rumley, G. D.O. Lowe, and D. J. Stott Hemostatic Function and Progressing Ischemic Stroke: D-dimer Predicts Early Clinical Progression Stroke, June 1, 2004; 35(6): 1421 - 1425. [Abstract] [Full Text] [PDF]
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C. Meisel, K. Prass, J. Braun, I. Victorov, T. Wolf, D. Megow, E. Halle, H.-D. Volk, U. Dirnagl, and A. Meisel Preventive Antibacterial Treatment Improves the General Medical and Neurological Outcome in a Mouse Model of Stroke Stroke, January 1, 2004; 35(1): 2 - 6. [Abstract] [Full Text] [PDF]
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C. Roffe, S. Sills, M. Halim, K. Wilde, M. B. Allen, P. W. Jones, and P. Crome Unexpected Nocturnal Hypoxia in Patients With Acute Stroke Stroke, November 1, 2003; 34(11): 2641 - 2645. [Abstract] [Full Text] [PDF]
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L.B. Goldstein, D.B. Matchar, J. Hoff-Lindquist, G.P. Samsa, and R.D. Horner VA Stroke Study: Neurologist care is associated with increased testing but improved outcomes Neurology, September 23, 2003; 61(6): 792 - 796. [Abstract] [Full Text] [PDF]
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 K. Prass, C. Meisel, C. Hoflich, J. Braun, E. Halle, T. Wolf, K. Ruscher, I. V. Victorov, J. Priller, U. Dirnagl, et al. Stroke-induced Immunodeficiency Promotes Spontaneous Bacterial Infections and Is Mediated by Sympathetic Activation Reversal by Poststroke T Helper Cell Type 1-like Immunostimulation J. Exp. Med., September 2, 2003; 198(5): 725 - 736. [Abstract] [Full Text] [PDF]
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H. P. Adams Jr, R. J. Adams, T. Brott, G. J. del Zoppo, A. Furlan, L. B. Goldstein, R. L. Grubb, R. Higashida, C. Kidwell, T. G. Kwiatkowski, et al. Guidelines for the Early Management of Patients With Ischemic Stroke: A Scientific Statement From the Stroke Council of the American Stroke Association Stroke, April 1, 2003; 34(4): 1056 - 1083. [Full Text] [PDF]
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I. L. Katzan, R. D. Cebul, S. H. Husak, N. V. Dawson, and D. W. Baker The effect of pneumonia on mortality among patients hospitalized for acute stroke Neurology, February 25, 2003; 60(4): 620 - 625. [Abstract] [Full Text] [PDF]
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S.E. Lamb, L. Ferrucci, S. Volapto, L.P. Fried, J.M. Guralnik, and Y. Gustafson Risk Factors for Falling in Home-Dwelling Older Women With Stroke: The Women's Health and Aging Study * Editorial Comment Stroke, February 1, 2003; 34(2): 494 - 501. [Abstract] [Full Text] [PDF]
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J. P. Broderick and W. Hacke Treatment of Acute Ischemic Stroke: Part II: Neuroprotection and Medical Management Circulation, September 24, 2002; 106(13): 1736 - 1740. [Full Text] [PDF]
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C. Roffe, S. Sills, K. Wilde, and P. Crome Effect of Hemiparetic Stroke on Pulse Oximetry Readings on the Affected Side Stroke, August 1, 2001; 32(8): 1808 - 1810. [Abstract] [Full Text] [PDF]
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E. J. Roth, L. Lovell, R. L. Harvey, A. W. Heinemann, P. Semik, and S. Diaz Incidence of and Risk Factors for Medical Complications During Stroke Rehabilitation Stroke, February 1, 2001; 32(2): 523 - 529. [Abstract] [Full Text] [PDF]
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