Stroke and Neurodegenerative Disorders

Stroke and Neurodegenerative Disorders:

2. Poststroke Medical Complications
Lisa A. Lombard, MD, Cara Camiolo Reddy, MD, Alex Moroz, MD,
Henry L. Lew, MD, PhD, John Chae, MD, Steven R. Edgley, MD

Objective: This self-directed learning module highlights common poststroke medical

complaints encountered on an inpatient rehabilitation unit. It is part of the study guide on
stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program
for practitioners and trainees in physical medicine and rehabilitation. Using a case vignette
format, this article specifically focuses on the differential diagnosis, evaluation and manage-
ment of chest pain, mental status changes, weight loss and poor motivation in stroke
patients. The goal of this article is to expand the learner’s knowledge of how to diagnose and
manage common medical complications of stroke patients in rehabilitation.

2.1 Clinical Activity: A nurse requests your evaluation of a 74-year-old woman with
type 2 diabetes mellitus; 10 days after a right basal ganglia hemorrhage, the
woman is complaining of chest pain and shortness of breath. Discuss the
differential diagnosis and assessment of chest pain and dyspnea in this patient
population.
Chest pain is 1 of the more concerning complaints after a stroke, since the differential
diagnosis includes several life-threatening conditions that require immediate attention.
Causes of chest pain in the poststroke population include pulmonary embolism, cardiac
disease, pneumonia, gastroesophageal reflux (GERD), and musculoskeletal issues.
Most stroke rehabilitation inpatients have 2 or more components of Virchow’s triad,
which put them at high risk for venous thrombosis. These components include immobility
and weakness resulting in venous stasis, dehydration or exacerbation of premorbid condi-
tions that can cause a hypercoagulable state, and procedures such as angiograms that,
L.A.L. Department of Physical Medicine and
because they penetrate the venous system, may cause endothelial injury. While deep venous
Rehabilitation, Santa Clara Valley Medical
thrombosis (DVT) may result in pain, low-grade fever and swelling, the most concerning Center, 751 South Bascom Ave, San Jose, CA
complication of DVT is pulmonary embolism (PE), because persons with PE may present 95128. Address correspondence to: L.A.L.;
e-mail: Lisa.Lombard@hhs.sccgov.org
with sudden death in 50% of occurrences in a stroke population, according to 1 study [1].
Disclosure: nothing to disclose
In a study examining the National Hospital Discharge Survey [2], of 14,109,000 patients
C.C.R. Department of Physical Medicine and
admitted to acute care hospitals with ischemic stroke, DVT occurred in 0.74%, PE in 0.51%, Rehabilitation, University of Pittsburgh Medical
and the combination of both in 1.17 %. The rates were higher in the 1,606,000 persons Center, Pittsburgh, PA
admitted with hemorrhagic stroke, with 1.37% for DVT occurrence, 0.68% for PE, and Disclosure: nothing to disclose

1.93% for both [2]. Frequencies for DVT for those in rehabilitation settings screened with A.M. NYU School of Medicine, Rusk Institute
of Rehabilitation Medicine, New York, NY
impedance plethysmography have been reported as higher in a study by Oczkowski et al [3]
Disclosure: 2, IPRO
venous thromboembolism occurred in 11% in their population and 2% died of PE.
H.L.L. Harvard Medical School, VA Boston
Prevention is obviously the best management for DVT and PE. In cases of ischemic Healthcare System, Physical Medicine and
stroke, chemical prophylaxis with heparinoids is commonly used, although there is some Rehabilitation Service, Boston, MA
concern with causing a hemorrhagic conversion of the stroke or gastrointestinal bleeding. Disclosure: nothing to disclose

There is significant controversy in the literature regarding the superiority of either low- J.C. Case Western Reserve University, Metro-
molecular-weight heparin (LMWH) or unfractionated heparin (UFH). In two meta-analyses Health Medical Center, Department of Physical
Medicine and Rehabilitation, Cleveland, OH
of the literature [4,5], LMWH was found to have greater efficacy in the prevention of DVT Disclosure: nothing to disclose
in patients with ischemic stroke. In the review by Andre et al [4], no evidence could be S.R.E. University of Utah, Salt Lake City, UT
found to support the use of mechanical agents, such as sequential compression devices Disclosure: 2, Northstar Neuroscience
(SCD). In a recent multicenter, randomized, open-label trial in 1762 persons with severe Disclosure Key can be found on the Table of
ischemic stroke, enoxaparin at 40 mg given subcutaneously daily was found to be superior Contents and at www.pmrjournal.org

PM&R © 2009 by the American Academy of Physical Medicine and Rehabilitation

1934-1482/09/$36.00 Suppl. 1, S13-S18, March 2009 S13
Printed in U.S.A. DOI: 10.1016/j.pmrj.2009.01.016
S14 Lombard et al
to UFH, dispensed at 5000 units subcutaneously every 12
hours, in the prevention of DVT. Both agents carried a similar
rate of intracranial bleeding, but there was a slightly higher
incidence in major extracranial bleeding with enoxaparin [6].
The prevention of DVT and PE in persons with hemor-
rhagic strokes is more complicated. The concern of initiating
further intracranial bleeding with heparinoids is significant
and, unfortunately, there is a dearth of literature on the safety
and efficacy of chemical prophylaxis in this population. One
study examined mechanical interventions of elastic stockings
and SCD in 151 persons admitted to an acute hospital with
intracerebral hemorrhage. SCD, used with elastic stockings
reduced the risk of asymptomatic DVT by 71% in compari-
son with using stockings alone [7]. There was no mention of
how many hours a day the SCD were applied; it is unclear
how these results translate to an inpatient rehabilitation
setting where patients are out of bed and thus out of the SCD
for a significant number of hours daily.
In persons with ischemic strokes who have sustained a
proximal DVT or PE, adjusted heparin or full-weight-based
enoxaparin followed by warfarin is indicated. In the setting of
hemorrhagic strokes, the risk of bleeding from anticoagula-
tion seems to be associated with location of the original
hemorrhage. A 2-fold increased risk of re-bleeding exists in
lobar bleeds in comparison with deep hemispheric bleeds
[8]. Unfortunately, no studies discuss the use of inferior vena
cava filters as an alternative to chemical anticoagulation in
this population.
Further controversy exists in the timing of mobilizing
patients with DVT or PE. Many patients are kept on bedrest
for some time after diagnosis to prevent embolization of an
“unstable” clot. In 1 older retrospective study of rehabilita-
tion inpatients, persons who were returned to physical ther-
apy fewer than 48 hours after discovery of DVT were at
higher risk for a PE than those kept immobilized between 48
and 72 hours [9]. In a review of a community population,
bed rest had no effect on development of PE after DVT [10];
however, those who were previously immobilized before the
DVT developed were excluded from this study.
For the patient in the case under discussion, if the exam-
ination shows findings consistent with a PE (tachycardia
and/or oxygen desaturation) evaluation with spiral computed
tomography (CT) or ventilation/perfusion scanning is indi-
cated [11].
Because many of the risk factors for stroke (hypertension,
diabetes mellitus, smoking, hypercholesterolemia, etc) are
similar to those of coronary artery disease (CAD), it should
come as no surprise that the potential for cardiac events is
significant in this population. Any person with a history of
stroke who complains of chest pain must be closely evaluated
for a cardiac event, even without a specific history of CAD.
Chimowitz et al [12] gave stress tests to 69 patients with
different types of brain ischemia. Of the patients with large
artery cerebrovascular disease, 50% had abnormal stress tests
in comparison with 23% in persons with other causes of
brain ischemia. They also found that 60% of the abnormal
stress tests in the large artery cerebrovascular group were
POSTSTROKE MEDICAL COMPLICATIONS
suggestive of severe CAD [12]. Patients with a history of CAD
prior to their stroke should be closely monitored. In 1 retro-
spective review of stroke rehabilitation inpatients, the pa-
tients with CAD alone and CAD with congestive heart failure
(CHF) had 3 times more cardiac complications than those
without CAD or CHF [13]. Workup for the patient in this
case should include an electrocardiogram (ECG), laboratory
tests with troponin and with creatine phosphokinase (CPK)
and, if indicated, brain natriuretic protein (BNP) to evaluate
for CHF.
As with any other patient population, other issues (esoph-
ageal spasm; back, shoulder, rib pain; pneumonia; GERD)
may present as chest pain. These possibilities can be exam-
ined after life-threatening causes of chest pain are ruled out.
2.2 Clinical Activity: The patient in Case 1 has been
stable for the last 4 days. However, this morning
she is more somnolent and difficult to arouse. Out-
line the possible etiology of acute mental status
changes following stroke and formulate assessment
and treatment strategies.
The appropriate evaluation of acute mental status changes
after stroke requires a very broad list of differential diagnoses.
Infection, seizures, stroke progression, hydrocephalus, and
electrolyte abnormalities can commonly be seen after stroke.
The stroke population is a medically complex group. The
rate of medical complications seems to be associated with the
severity of the stroke, with 97% of severe stroke patients
having at least 1 complication during their rehabilitation stay
[14]. In a study of 1029 consecutive patients admitted to a
freestanding rehabilitation hospital, several factors were as-
sociated with a higher rate of complications, including sever-
ity of neurologic deficit, hypoalbuminemia, and hyperten-
sion [15]. The most common complications are reported to
be depression, shoulder pain, falls, urinary tract infections
(UTIs), and dehydration [15-17].
It is important to evaluate for infections. One large study
found that UTIs are common after stroke and are associated
with female sex, higher scores on the National Institutes of
Health Stroke Scale (NIHSS) and advanced age [18]. Voiding
dysfunction may include incontinence, retention frequency
and urgency. Other medical comorbidities, such as DM,
prostate disease and neuropathies may also contribute to the
dysfunction. Urinary retention may occur immediately after
stroke as a symptom of “cerebral shock,” but incontinence
may also appear later—not only because of the development
of uninhibited bladder but also because of communication,
mobility, or cognitive issues [19]. Urinary incontinence is
associated with a worse medical status and a poorer outcome
from stroke; in a review of 2-year poststroke outcomes,
patients with urinary incontinence were more likely to have
motor weakness, visual field deficits, higher fatality rates,
greater disability, and higher rates of institutionalization.
Urinary tract infection and pneumonia are independently
associated with worse scores on the Barthel index and higher
mortality rates at 3 months after stroke [18].
PM&R
While rare in ischemic strokes, communicating hydro-
cephalus may be a complication after intracranial hemor-
rhage. Blood products, dead cells and other debris block
uptake of cerebral spinal fluid (CSF), and cause dilatation of
all portions of the ventricular system. Presentation of hydro-
cephalus can range from a plateau of function to a severe
depression in mental status. In a study of persons with
intracranial hemorrhage in an acute care setting, hydroceph-
alus was associated with a younger population (age 57 y vs.
age 67 y), ganglionic or thalamic bleeds, and lower Glasgow
Coma Scale (GCS) scores. The patients with hydrocephalus
were less likely to be discharged home and had a higher
mortality rate [20]. A CT scan is the most common starting
point for evaluation of hydrocephalus; dilatation of the lateral
ventricles and periventricular lucency (indicating transependy-
mal CSF shifts) are commonly seen with hydrocephalus.
Patients with a generalized seizure or those in a post-ictal
state may present with severe depression of consciousness.
Both ischemic and hemorrhagic strokes may result in sei-
zures, according to 1 study by Bladin et al [21]. In their
examination of 1897 persons with acute strokes admitted to
university hospitals, they found that seizures occurred in
10.6% of hemorrhagic patients and 8.6% of ischemic patients
during the acute hospitalization. The major risk factor for
hemorrhagic stroke seizures was cortical location of the
bleeding. In ischemic patients, seizures were associated with
cortical infarction and stroke severity. Recurrent seizures
occurred in 2.5% of the total patient population. Status
epilepticus may also present with acute mental status
changes, and if not promptly recognized and managed, may
result in further disability or death. Toxicity of antiepileptic
medications, such as phenytoin and valproic acid, may
present with a depressed level of consciousness and should
be considered in the differential diagnosis of acute mental
status changes in persons taking these medications.
Hyponatremia and poor glycemic control are both possi-
ble causes of mental status changes. Antidiuretic hormone
levels have been noted to be increased in those with stroke
[22]. The etiology seems to be a lack of suppression of
vasopressin release to hyposmolar serum [23]. As the hypo-
natremia usually occurs slowly, substantial decreases in lab-
oratory values can be seen before clinical presentation. First-
line treatment of syndrome of inappropriate antidiuretic
hormone (SIADH) is free water restriction. Significant in-
creases or decreases in blood sugar can result in a change in
mental status and mimic a new stroke. Fluctuation in oral
intake, changes in activity patterns and other medical issues
can complicate glycemic control in persons with diabetes.
Close monitoring of capillary blood glucose is essential in this
population. Hyperglycemia is associated with poor func-
tional outcomes after stroke [24].
Despite advancements in the secondary prevention of
stroke (see Study Guide Chapter 4), previous stroke remains
a high risk factor for a recurrent stroke. Fourteen percent of
persons with a new stroke will have a second stroke within a
year [25]. Additionally, those with cerebral infarcts are at risk
for hemorrhagic transformation. The frequency of transfor-
Vol. 1, Iss. 3, Supplement 1, 2009 S15
mation has been reported to be 8.5% of all ischemic strokes;
those who are at particular risk have large infarcts, mass
effect, hypodensity observed early after the stroke, exposure
to antithrombotic or thrombolytic drugs, and age greater
than 70 years [26].
In the evaluation of this patient, an organized approach in
the workup will be essential, starting with a comprehensive
history and physical examination, vital signs, capillary blood
glucose and pulse oximetry; infection and dehydration may
be apparent. Laboratory tests, including a complete blood
count, electrolyte panel, and serum levels of any medications
the patient is taking should be assessed. Urinalysis and a
chest x-ray will help evaluate for infection. A CT scan of the
head will help evaluate for hemorrhage, as well as develop-
ment of hydrocephalus. Magnetic resonance imaging (MRI)
or CT perfusion scan will help evaluate for a new infarct. If
concerns for seizure exist, an electroencephalogram (EEG)
should be performed.
The decision of whether to transfer a patient to an acute
level of care depends on multiple factors, including the
rehabilitation setting (freestanding hospital versus in an acute
facility), comfort level of physician and nursing staff, avail-
ability of specialist care in rehabilitation, need for further
workup or procedures, and the patient’s ability to tolerate
therapies. Transfer rates to acute care for persons with stroke
have been reported to be 13% [17] to 19% [15]. In a study by
Roth et al [15] factors associated with transfer to an acute care
facility were elevated white blood cell count at admission,
low admission hemoglobin levels, greater neurologic deficit,
and a history of cardiac arrhythmia.
2.3 Clinical Activity: A 58-year-old man on your
stroke rehabilitation unit has experienced signifi-
cant weight loss since his hospital admission. Dis-
cuss the challenges and management of proper nu-
trition following stroke.
As mentioned in activity 2.2, hypoalbuminemia is associated
with an increased rate of medical complications [15], sug-
gesting that good nutrition is an important component in the
recovery process after stroke. The first step is to determine
whether the patient is being provided enough calories to
meet his metabolic demands. Specific patient factors should
be examined. For example, a patient with severe apraxia or
weakness may be unable to feed himself effectively. A thor-
ough history and review of systems should be obtained from
the patient with special attention to a history of gastrointes-
tinal disease, mood disturbance, and current nausea, last
bowel movement, vertigo, heartburn, cough and depression.
Gastric ulcers, GERD and constipation can all lead to reduced
oral intake. Aspirin, often given to prevent stroke, may cause
gastritis. Patients with cerebellar or brainstem strokes may
have severe vertigo or nausea that would result in decreased
oral intake; treatment of the underlying disturbance with
antiemetic or scopolamine may alleviate the problem. De-
pression, fatigue and poor initiation can often follow stroke
and result in anorexia. (See Clinical Activity 2.4.)
S16 Lombard et al
Considering the importance of good nutrition in stroke
recovery, one might be tempted to give dietary supplements
to all stroke survivors. In trial 1 of the FOOD (Feed Or
Ordinary Diet) trial, the benefit of routine dietary supple-
mentation to all persons with stroke was examined [27].
Within 7 days of a new onset stroke, over 4000 patients were
enrolled from 125 acute care hospitals in 15 countries. At
baseline, 8% of patients were found to be undernourished.
All patients were randomized to either a standard hospital
diet or a hospital diet with oral protein energy supplements
until discharge. No significant benefit or harm was seen with
the use of oral supplements.
Dysphagia remains the most significant dietary concern
after stroke. In examinations of consecutive patients admit-
ted to acute care hospitals with stroke, aspiration was found
in 42% to 51% [28,29]. Cortical strokes may cause decreased
oral-motor control and decreased pharyngeal peristalsis,
while brainstem or cerebellar lesions may result in decreased
swallow initiation and coordination.
Untreated, aspiration can result in pneumonia and mal-
nutrition. Sixty-eight percent of stroke patients who were
found in both clinical and videofluoroscopic evaluation to be
aspirating developed lower respiratory tract infections during
their acute hospital stay [28]. It is best to get at least a bedside
swallow evaluation of patients soon after admission to the
acute care hospital to fully evaluate for any aspiration as well
as the appropriate route for feeding; however, this method
lacks significant sensitivity to discover all persons who aspi-
rate [30]. There seems to be a significant benefit from early
feeding; in the FOOD trial part 2, early tube feeding in
comparison with withholding tube feeding was associated
with an absolute reduction in risk of death of 5.8% [31].
If a patient is diagnosed with severe dysphagia, the routes
of feeding are limited primarily to nasogastric tubes (NGT) or
percutaneous endoscopic gastrostomy (PEG) tubes. Often,
NGT are placed in the acute care setting. Problems include
irritation, dislodgement or erroneous placement, which re-
quires x-ray verification, and sinusitis. They are not designed
for long-term nutritional support. The PEG tubes do not
carry many of the risks of NGT, but require an invasive
procedure with sedation for placement, and may result in
localized infection [32]. Patients and family members may
have some reluctance to accepting a PEG tube placement;
reassurance that the feeding tube will not interfere with
swallowing therapies and the potential for it to be a tempo-
rary measure is often necessary. A prospective study compar-
ing PEG tubes versus NGT in persons with stroke found
higher serum albumin levels and no treatment failures after 4
weeks with PEG tube feeding; patients with NGT had reduc-
tions in serum albumin levels during the study interval and a
50% treatment failure rate [33]. The superiority of PEG tubes
was not seen in an earlier Cochrane database review, how-
ever [34].
Swallowing function remains a dynamic process after
acute stroke. In a study of serial clinical evaluations and video
fluoroscopic examinations of stroke patients, 51% were as-
sessed to have dysphagia on admission, and 27% persisted
POSTSTROKE MEDICAL COMPLICATIONS
after the first 7 days. At 1 month, 15% were found to be
aspirating, but 8 of the 12 patients identified were those who
had not previously been identified as having swallowing
difficulties [29]. Constant vigilance is needed to ensure swal-
lowing safety throughout the recovery process. Those who
still require tube feedings due to poor recovery of swallow at
the end of their rehabilitation stay carry a higher mortality
rate [35].
2.4 Clinical Activity: During team conference, the
therapy staff reports that your 76-year-old stroke
patient whom you are treating for a right MCA
stroke is not actively participating in therapy. De-
scribe the differential diagnosis and treatment for
reduced motivation following stroke.
While depression is quite common after stroke, it is very
important to consider a broad differential diagnosis to make
sure other treatable etiologies of poor motivation are ex-
cluded. Any of the medical conditions discussed in Activity
2.2 (infection, additional stroke, hydrocephalus, recurrent
seizure, fluctuations in blood sugar, and hyponatremia)
could result in decreased participation in therapy. Further,
thyroid dysfunction may also play a role; endocrine abnor-
malities were seen in 79% of acute stroke patients with 36%
displaying thyroid dysfunction [36]. Because pain may also
be contributing to poor therapy performance, a thorough
interview and examination of the patient is necessary.
Fatigue is a common complaint after stroke, with reported
frequencies of 30% to 68% [37] and could result in decreased
therapy participation. If no specific etiology is determined,
treatment is multifactorial, with attention to pacing of thera-
pies, increasing strength and endurance, and ensuring good
sleep cycle regulation. Although there is no FDA-approved
medication for the treatment of fatigue for persons with
stroke, several classes of medications have been suggested:
stimulants (methylphenidate, pemoline, dextroamphet-
amine, modafinil, amantadine), and antidepressants [37]. To
the authors’ knowledge, no trials have been published exam-
ining these medications in this population.
Apathy may present with a flattened affect, hypophonia,
and shortened responses. It has been associated with hypo-
activity in the frontal and anterior temporal regions in SPECT
imaging, and correlated with infarcts in the posterior limb of
the internal capsule [38]. Apathy can be seen independently
or in conjunction with depression.
The frequency of poststroke depression has been reported
in the literature as a rather large range, likely due to many
different rating systems and definitions. This can be a difficult
group to study, since standard tools and diagnostic lists may
not be applicable to an aphasic patient. Depression seems to
have several different peaks of increased frequency; in a
3-year longitudinal study, its prevalence was 25% to 30% in
the first 3 months, decreased to 16% to 19% at 1 to 2 years,
and then increased again to 29% at 3 years [39]. Lesion
location as a predictive factor for development of stroke has
been reported inconsistently in the literature; however, pre-
PM&R
vious history of mood disorder is shown to be an indepen-
dent predictor of poststroke depression [40].
It does seem that depression has an effect on the recovery
from stroke, but the evidence of the specific influence is
mixed. In a study of 117 stroke survivors, depression nega-
tively influenced functional recovery only if it occurred after
hospitalization, but not during it [41]. In another study,
stroke patients who were depressed and not treated had
lower mobility scores than those who were not depressed
[42]. This study also highlighted the importance of treating
depression; patients whose depression was treated had a
similar recovery pattern to those who did not have depres-
sion. In another examination of the effect of medication
treatment of depression, patients treated with selective sero-
tonin reuptake inhibitors (SSRI) had an average improve-
ment during rehabilitation similar to that of the nonde-
pressed patients; however, those without depression were
twice as likely to have an “excellent” recovery in ADLs and
mobility [43]. Apathy is frequently associated with depres-
sion [40], and according to 1 study, may be more frequently
associated with poor functional recovery than depression
alone [44]. For treatment of depression, tricyclic antidepres-
sants were the mainstay before the advent of SSRI; both have
been shown to be efficacious in the treatment of poststroke
depression, with SSRI showing fewer side effects [45].
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