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All Points on Alert

Macready, Norra

doi: 10.1097/01.NNN.0000267369.58688.2d
Department: EYE ON THERAPY

Be on the Lookout for Post-Stroke Complications.

Post-stroke complications: what to look for, how to treat them

Norra MacReady is a book author whose health and medical articles have appeared in The Economist, Glamour, and WebMD.

Toronto resident Joan Abbott has had a tough few years. Diagnosed with lung cancer in November 2004, Abbott underwent surgery and began chemotherapy in January 2005, only to suffer a heart attack that April. Then, last June, she had a stroke. Today, with plenty of support from family, friends, and an expert team at the Toronto Rehabilitation Institute, she can walk and live independently. “Thank God for therapy,” she says.

Abbott is a survivor—one of more than 3 million stroke survivors in the U.S. and Canada alone. That number reflects the remarkable progress doctors have made in stroke care and rehabilitation in recent years. However, it also underscores another reality: many of those people live with conditions that they and even their doctors often don't realize may be complications of their stroke. Left untreated, these complications can have a major affect on prognosis and quality of life.

Pain, depression, and even urinary tract infections often arise following a stroke, but doctors focus so much on the neurological effects like speech and movement disorders that they may not spot less obvious developments, says Mark Bayley, M.D., Abbott's doctor and medical director of the neurorehabilitation program at the Toronto Research Institute.

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Depression is one of the most common unrecognized side effects of a stroke. “Stroke changes the activity of the brain,” Dr. Bayley points out. Because so many people struggle with speech difficulties in the aftermath of a stroke, even family and friends may not realize that the patient may also be depressed.



Along with depression, you might observe impulsiveness, anger, or irritability in someone whose disposition used to be sunny, says Kiwan Lee, M.D., medical director of the neuro-intensive care unit at Jefferson Medical College in Philadelphia. “Often I hear family members say, ‘Dad used to be a sweetheart, but not any more,’” he explains. “This may be part of the initial brain injury from the stroke. Mood disorders are quite common and often not addressed, because doctors don't look for them.”

Fleeting periods of confusion, disorientation, or muscle weakness may be signs of a seizure, Dr. Lee adds. Lingering brain damage after a stroke can make a person more vulnerable to these events. Yet they often go undiagnosed because they may occur between doctor visits, and patients and caregivers may forget to mention them when they do see the doctor because so many other issues may take priority.

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Urinary tract infections are another frequently unrecognized stroke complication. People recovering from a stroke frequently spend many hours lying immobilized in bed, allowing urine to accumulate in the bladder. This creates a perfect breeding medium for bacteria, Dr. Bayley says. What's more, the stroke may damage the part of the brain that coordinates bladder function, which exacerbates the problem. The risk is compounded even further when patients have urinary catheters; bacteria can multiply in the catheter and travel up to the bladder, where they add to the patient's misery.

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People who have suffered a stroke often experience some type of pain. In at least one study, 9 percent of hospitalized stroke patients complained of shoulder pain and 34 percent complained about other types of pain. The pain became even more common after these people left the hospital, with 12 percent reporting shoulder pain and 37 percent citing other types of pain up to 12 months later.

Doctors still don't know exactly why shoulder pain is so common after a stroke, but they suspect multiple causes. Post-stroke arthritis could be one culprit, says Mark Alberts, M.D., professor of neurology and director of the stroke program at Northwestern Memorial Hospital in Chicago. “When movement is limited, the joint can freeze up from lack of use. That's why physical therapists have patients do range-of-motion exercises,” he says.

Other explanations include joint dislocation from muscle weakness, damage to the nerves that serve the shoulder, or an unrecognized muscle or tendon injury. Abbott had an inflamed rotator cuff, which led to “excruciating pain,” she says. Prednisone injections helped for a while, but eventually the pain returned. “My left arm doesn't work so well,” she says. “I can't put on a coat, blow-dry my hair, or fold or hang my clothes. It's very discouraging.”

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More than 12 million people are thought to have sleep apnea, in which they stop breathing while asleep for dozens, sometimes hundreds of brief episodes during the night. This condition is a strong independent risk factor for stroke. It is also associated with many better-known stroke risk factors, such as high blood pressure, obesity, and heart disease. Dr. Bayley estimates that 70 percent of the patients at the Toronto Rehabilitation Institute have sleep apnea.

It is less clear whether sleep apnea is a stroke complication. Still, Dr. Bayley recommends that all new stroke patients be tested for it. One effective treatment for sleep apnea is continuous positive airway pressure (CPAP), which involves wearing a special mask that blows air into the nose to keep the airway open while the patient is asleep.

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What you can do

Without prompt recognition and aggressive management, complications like these diminish a patient's quality of life and have been associated with poor outcomes. The good news is that they respond to treatment. That's why it's crucial for family, caregivers, and patients themselves to tell clinicians when something doesn't seem quite right, be it an unusual feeling of fatigue, unexplained pain, or a fever that just doesn't seem to quit. As Joan Abbott says, “Without the support of family and friends, stroke survivors could have a difficult time.”

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