Stroke (Apoplexy): Complications

The following are the most important diseases or complications that may be contributed to by an apoplexy (stroke):

Respiratory system (J00-J99)

  • Aspiration pneumonia – pneumonia (pneumonia) resulting from aspiration (inhalation) of saliva, vomit, or food due to dysphagia (difficulty swallowing).

Endocrine, nutritional and metabolic diseases (E00-E90).

  • Malnutrition (Malnutrition)
  • Volume deficiency

Factors influencing health status and leading to health care utilization (Z00-Z99).

  • Suicide (suicide) – approximately double the risk in apoplexy patients; 5-fold higher incidence (frequency of new cases) in younger patients (20 to 54 years); no increased risk for patients >80 years of age.

Skin and subcutaneous (L00-L99).

  • Decubital ulcer – formation of an ulcer due to high pressure load and consequent deficiency of blood supply.

Cardiovascular system (I00-I99)

  • Arrhythmias (cardiac arrhythmias, HRS) – in the acute phase of stroke, significant cardiac arrhythmias occur in approximately 25% of patients
    • Bradycardic arrhythmias are significantly less frequent than tachycardias (supraventricular tachycardias many times more frequent than ventricular tachycardias)
    • Prolongation of QTc time (about 35%).
    • Atrial fibrillation (VHF)
  • Atherosclerosis (arteriosclerosis, arteriosclerosis) – increase of the same due to multiphasic immune cascade of the systemic immune compartment; dying brain cells secrete alarmins into the blood circulation, which via certain receptors (so-called pattern recognition receptors) activate a wide variety of (immune) cells, resulting in a new wave of immune cells that migrate into the sites of inflammation of existing plaques.
  • Leg vein thrombosis – two out of three patients with ischemic stroke and hemiplegia (hemiplegia) suffer deep vein thrombosis (TBVT) and 20 percent suffer pulmonary embolism without thromboprophylaxis.
  • Heart failure (cardiac insufficiency), chronic – due to increased sympathetic activity (post apoplexy).
  • Intracerebral hemorrhage (ICB; brain hemorrhage) – in patients with very high cerebral microbleeds after intravenous thrombolysis/dissolution of a thrombus (blood clot) with the help of drugs (risk ratio [RR]: 2.36; 95% confidence interval between 1.21 and 4.61; p = 0.01)
  • Intracerebral hemorrhage (ICB) with increase in extent (approximately 30% of hemorrhages within the first few hours).
  • Pulmonary embolism – blockage of a pulmonary vessel.
  • Myocardial infarction (heart attack) – increased during the acute phase of a stroke
  • Sudden cardiac death (PHT) due toventricular tachycardia (life-threatening tachycardic arrhythmia (pulse to over 100 beats per minute) originating in the ventricles of the heart).
  • Secondary cerebral hemorrhage after primary ischemic infarction.
  • Space-occupying infarction – swelling of brain tissue and increase in intracranial pressure.

Psyche – nervous system (F00-F99; G00-G99).

  • Anxiety disorders
  • Central post-stroke pain (CPSP) – approximately 6% to 8% of patients develop central neuropathic pain after apoplexy; allodynia is present, i.e., normal touch sensations and low temperatures trigger severe pain in CPSP patients; furthermore, hyperalgesia (increased pain sensitivity) is present; at-risk groups are patients with sensory infarcts
  • Attention-deficit/hyperactivity disorder (ADHD)-46% of children with pre-, peri-, or postnatal cerebral infarcts develop ADHD secondarily
  • Dementia (from approximately 10% before apoplexy to 20% after apoplexy)
    • Patients who had experienced an apoplexy before the start of the study were consequently more likely to have dementia in 69% of cases (hazard ratio, 1.69; 95% confidence interval, 1.49 to 1.92).
    • Patients who had not had an apoplexy at baseline and who subsequently had an apoplexy were twice as likely to develop dementia thereafter than patients without apoplexy (risk ratio 2.18; 1.90-2.50).
  • Epilepsy (seizures).
    • During hospitalization, 17.9% had interictal or ictal activity detected on EEG; 25% had an epileptic seizure in the year after apoplexy)
    • new-onset epilepsy in adulthood is due to apoplexy in 1 in 10 cases; in those over 65, it is found in 1 in 4 patients
  • Fatigue (tiredness) – is one of the most common symptoms after a stroke.
  • Cerebral edema (swelling of the brain) (10-15% of all ischemic strokes).
  • Insomnia (sleep disturbances; 20-60% of patients after stroke).
  • Alzheimer’s disease
  • Paresis (paralysis) – e.g., facial paralysis and arm or leg motor dysfunction/restricted mobility; may recur years later without reinfarction (post-stroke recrudescence, PSR); triggers for PSR may include infection, hypotension, or hyponatremia
  • Post-stroke depression (25-33% of patients after stroke)-depression after stroke; in the first 3 months after apoplexy, the risk was almost 9-fold higher than in the comparison group (hazard ratio [HR] 8.99; adjusted); in the second year, the risk was only just twice as high (HR 1.93; adjusted: 1.82); adjusted for age, sex, marital status, comorbidity, and previous depression diagnosis
  • Post-stroke hypersomnia (excessive daytime sleepiness and/or prolonged sleep time) (20-30% of patients after stroke)
  • Psychosis
  • Sleep-related breathing disorders (SBAS) (up to 70%).
  • Sleep-associated movement disorders such as restless legs syndrome (RLS; restless legs syndrome) or parasomnias (behavioral abnormalities that occur predominantly from sleep)

Symptoms and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

  • Aphasia (speech and language disorders).
    • 6% of children; 27% of adults
    • May recur even years later without reinfarction (poststroke recrudescence, PSR); triggers for PSR may include infection, hypotension, or hyponatremia
  • Chronic pain secondary to stroke (“post-stroke pain”, PSP); risk factors include increasing age, increased muscle tone or spasticity (increased inherent tension in skeletal muscles), limitation of upper extremity mobility, and sensory deficits (deficits in sensory reception).
  • Dysphagia (dysphagia) (approximately 50%) [→ aspiration pneumonia (see above)].
  • Incontinence (urine and stool).
    • Urinary incontinence: affects approximately 40-60% of hospitalized apoplexy patients; approximately 25% continue to suffer after hospital discharge, and 15% remain incontinent for as much as another year.
  • Propensity to fall, especially post-hospital [prevention of falls is an important component of post-stroke care].
  • Suicidality (suicide risk).

Genitourinary system (kidneys, urinary tract – reproductive organs) (N00-N99).

  • Urinary tract infection (UTI) [cystitis, pyelonephritis]

Further

  • Disability and invalidity (major cause in adulthood).
  • Signs of rapid brain aging (number of lacunae and the extent of leukoaraiosis (nonspecific changes in the white matter of the brain) corresponds to 10-20 years older brains after 10 years) in ischemic apoplexy <50 years of age.

Prognostic factors

  • People living alone: Survival after apoplexy is worse than for married people. Apoplexy patients who had never been married had a 71% increased risk of death compared with married people (follow-up: mean 5.3 years). Even patients who had remarried after divorce had a 23% increased mortality (death rate).
  • One study demonstrated that in overweight and obese stroke patients, the risk of all-cause mortality (total mortality rate) increased with increasing BMI (body mass index; body mass index (BMI)), while the risk of mortality from apoplexy (stroke) decreased.
  • Patients with ischemic stroke have the best prognosis with a systolic blood pressure of about 150 mmHg, as well as a diastolic pressure of 70 mmHg. The lethality rate (mortality rate) was 16% higher at a systolic pressure of 120 mmHg than at 150 mmHg and 24% higher at a systolic pressure of 200 mmHg
  • Ischemic stroke treated with acetylsalicylic acid (ASA) was associated with an increased risk of bleeding (7.4% versus 4.3% without ASA) in one study.Nevertheless, the chance of a good functional outcome seems to be better than without ASA pretherapy (NIHSS score 6.91 versus 7.88). The outcome was beneficial in patients with atherosclerosis (arteriosclerosis, hardening of the arteries) of the large arteries; no effect was seen in small vessel occlusion or if cardioembolism (washout of a thrombus (blood clot) via the heart into arterial circulation) had caused the cerebral infarction.
  • In patients who received adequate anticoagulation (anticoagulation) for known atrial fibrillation (AF), the apoplexy was less severe and mortality (death rate) was also lower. The median NIHSS score (NIHSS is used to estimate the severity, i.e., extent, of an ischemic insult) was 4 (mild stroke) with proper anticoagulation; platelet inhibition alone or subtherapeutic doses of VKA showed a score of 6; and without antithrombotics (anticoagulants), a score of 7. Furthermore, there was a 25% lower mortality under properly dosed vitamin K antagonists (VKA) and a 21% lower in-hospital mortality under the new oral anticoagulants (NOAK).

Recurrence Risk Estimator(RRE) score to determine reinfarction risk.

Criteria Score
TIA (sudden onset of circulatory disturbance in the brain resulting in neurological dysfunction that resolves within 24 hours) or apoplexy in the month prior to the current event 1
Apoplexy due to atherosclerosis of a large artery or unusual causes such as vasculitis, arterial dissection 1
Multiple acute infarcts 1
Acute infarcts in different current areas 1
Multiple infarcts of different ages 1
Isolated cortical infarcts. 1

Interpretation

  • 0 points (risk < 1%)
  • ≥ 3 points (> 10 %)

The specificity (probability that actually healthy individuals who do not have the disease in question are also identified as healthy by the score) and sensitivity (percentage of diseased patients in whom the disease is detected by use of the score, ie, a positive finding occurs) for identifying low-risk patients were 38% and 93%; for high-risk patients, the corresponding ratios were 41% and 90%, The authors see the value of the RRE score primarily in identifying patients at low risk for early reinfarction.