Stroke natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Maryam Hadipour, M.D.[2]
Overview
Stroke can cause temporary or permanent complications based on the location and time to appropriate treatment. Delayed treatment or severe hemorrhagic or ischemic stroke can lead to death. Others may suffer from Dysphagia, Pneumonia, Myocardial infarction and arrhythmias, need for mechanical ventilation, pulmonary edema, central sleep apnea, urinary incontinence, falls, Musculoskeletal spasticity, Post-stroke seizure, Bowel incontinence, cognitive impairment. Prognosis depends on patient's age and stroke severity based on clinical evaluation and imaging.
Natural History
Given the ability to alter the natural history of stroke with endovascular thrombectomy, early identification of patients with vessel occlusion is critical. Differentiating acute ischemic stroke (AIS) patients with large vessel occlusions from those without based on clinical presentation is nonetheless challenging due to the variable nature of collateral vasculature and the potential for unique “at risk” and symptomatic tissue patterning across patients with the same anatomical site of occlusion. Vessel occlusions can also commonly manifest with minimal symptomology. While not pathognomonic, the clinical presentation of patients with vessel occlusion is nonetheless often stereotyped and anatomically matched to the site of occlusion and downstream affected cerebrum. Specifically, ICA or proximal MCA occlusions often present with contralateral hemi body and face weakness and/or numbness, contralateral homonymous hemianopsia, and ipsilateral gaze deviation, as well as aphasia for dominant hemispheric lesions and neglect for lesions of the nondominant hemisphere. More nuanced presentations of variable clinical severity and importance are observed with more distal occlusions. One notable distal occlusion site is the M3 branch to the angular gyrus of the dominant hemisphere. Due to the involvement of this vascular territory in speech processing and complex cognition, focal occlusions in this location are sometimes more aggressively pursued for thrombectomy in an attempt to preserve speech and cognition as compared to similarly distant blockages in arteries supplying less eloquent cortex.[1][2]
Complications
The early complications of patients, survived from a stroke is as follows:[3][4][5]
- Dysphagia
- Venous thromboembolism
- Pneumonia
- Urinary tract infection
- Myocardial infarction
- Arrhythmias
- Neurogenic cardiac damage
- Need for mechanical ventilation
- Neurogenic pulmonary edema
- Central sleep apnea
- Gastrointestinal bleeding
- Urinary incontinence
- Falls and bone fractures
- Depression
- Post-stroke fatigue
There are also some long-term complications including:
- Musculoskeletal spasticity
- Hemiplegic shoulder pain
- Post-stroke seizure
- Bowel incontinency
- Cognitive impairment
Prognosis
In the acute phase of stroke, the strongest predictors of outcome are stroke severity and patient age. Stroke severity can be judged clinically, based upon the degree of neurologic impairment (e.g., altered mentation, language, behavior, visual field deficit, motor deficit) and the size and location of the infarction on neuroimaging with magnetic resonance imaging (MRI) or computed tomography (CT). In addition, presence of anemia, atrial fibrillation, cancer, coronary artery disease, dementia, diabetes, heart failure, renal dysfunction, and poor nutrition are among other comorbidities, which can make the prognosis poorer.[6][7][8]
References
- ↑ Inoue M, Noda R, Yamaguchi S, Tamai Y, Miyahara M, Yanagisawa S, Okamoto K, Hara T, Takeuchi S, Miki K, Nemoto S (April 2018). "Specific Factors to Predict Large-Vessel Occlusion in Acute Stroke Patients". J Stroke Cerebrovasc Dis. 27 (4): 886–891. doi:10.1016/j.jstrokecerebrovasdis.2017.10.021. PMID 29196201.
- ↑ Seghier ML (February 2013). "The angular gyrus: multiple functions and multiple subdivisions". Neuroscientist. 19 (1): 43–61. doi:10.1177/1073858412440596. PMC 4107834. PMID 22547530.
- ↑ Chohan SA, Venkatesh PK, How CH (December 2019). "Long-term complications of stroke and secondary prevention: an overview for primary care physicians". Singapore Med J. 60 (12): 616–620. doi:10.11622/smedj.2019158. PMC 7911065 Check
|pmc=value (help). PMID 31889205. - ↑ Barlas RS, Honney K, Loke YK, McCall SJ, Bettencourt-Silva JH, Clark AB, Bowles KM, Metcalf AK, Mamas MA, Potter JF, Myint PK (August 2016). "Impact of Hemoglobin Levels and Anemia on Mortality in Acute Stroke: Analysis of UK Regional Registry Data, Systematic Review, and Meta-Analysis". J Am Heart Assoc. 5 (8). doi:10.1161/JAHA.115.003019. PMC 5015269. PMID 27534421.
- ↑ Coutts SB, Modi J, Patel SK, Aram H, Demchuk AM, Goyal M, Hill MD (November 2012). "What causes disability after transient ischemic attack and minor stroke?: Results from the CT and MRI in the Triage of TIA and minor Cerebrovascular Events to Identify High Risk Patients (CATCH) Study". Stroke. 43 (11): 3018–22. doi:10.1161/STROKEAHA.112.665141. PMID 22984013.
- ↑ Stöllberger C, Exner I, Finsterer J, Slany J, Steger C (2005). "Stroke in diabetic and non-diabetic patients: course and prognostic value of admission serum glucose". Ann Med. 37 (5): 357–64. doi:10.1080/07853890510037356. PMID 16179271.
- ↑ Saposnik G, Kapral MK, Liu Y, Hall R, O'Donnell M, Raptis S, Tu JV, Mamdani M, Austin PC (February 2011). "IScore: a risk score to predict death early after hospitalization for an acute ischemic stroke". Circulation. 123 (7): 739–49. doi:10.1161/CIRCULATIONAHA.110.983353. PMID 21300951.
- ↑ "Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial". Stroke. 34 (6): 1450–6. June 2003. doi:10.1161/01.STR.0000074037.49197.8C. PMID 12750536.