Neurological, cardiac, and systemic complications during the first days to weeks after ischaemic stroke can cause substantial morbidity and mortality. The reported 30-day case fatality rate for cerebral infarction varies between 10 and 17%. The incidence and effects of the various complications vary with time after stroke: transtentorial herniation and other cerebral complications prevail during the 1st week, whereas medical complications are more prominent in the weeks thereafter. Many complications are treatable, and some are preventable. The goal of this report is to provide information on their incidence, consequences, and management.

1.
Brown RD Jr, Whisnant JP, Sicks JD, O’Fallon WM, Wiebers DO: Stroke incidence, prevalence, and survival: Secular trends in Rochester, Minnesota, through 1989. Stroke 1996;27:373–380.
2.
Silver SL, Norris JW, Lewis AJ, Hachinski VC: Early mortality following stroke: A prospective review. Stroke 1984;15:492–496.
3.
Gladman JRF, Harwood DMJ, Barer DH: Predicting the outcome of acute stroke: Prospective evaluation of five multivariate models and comparison with simple methods. J Neurol Neurosurg Psychiatry 1992;55:347–351.
4.
Chambers BR, Norris JW, Shurvell BL, Hachinski VC: Prognosis of acute stroke. Neurology 1987;37:221–225.
5.
Hénon H, Godefroy O, Leys D, Mounier-Vehier F, Lucas C, Rondepierre P, Duhamel A, Pruvo JP: Early predictors of death and disability after acute cerebral ischemic event. Stroke 1995;26:392–398.
6.
Viitanen M, Winblad B, Asplund K: Autopsy-verified causes of death after stroke. Acta Med Scand 1987;222:401–408.
7.
Biller J, Adams HP Jr, Bruno A, Love BB, Marsh EE: Mortality in acute cerebral infarction in young adults: A ten-year experience. Angiology 1991;42:224–230.
8.
Toni D, Fiorelli M, Gentile M, Bastianello S, Sacchetti ML, Argentino C, Pozzilli C, Fieschi C: Progressing neurological deficit secondary to acute ischemic stroke: A study on predictability, pathogenesis, and prognosis. Arch Neurol 1995;52:670–675.
9.
Britton M, Rödén Å: Progression of stroke after arrival at hospital. Stroke 1985;16:629–632.
10.
Jørgensen HS, Nakayama H, Raaschou HO, Olsen TS: Effect of blood pressure and diabetes on stroke in progression. Lancet 1994;344:156–159.
11.
Dávalos A, Cendra E, Teruel J, Martinez M, Genís D: Deteriorating ischemic stroke: Risk factors and prognosis. Neurology 1990;40:1865–1869.
12.
Jones HR, Millikan CH: Temporal profile (clinical course) of acute carotid system cerebral infarction. Stroke 1976;7:64–71.
13.
Shaw C-M, Alvord EC Jr, Berry RG: Swelling of the brain following ischemic infarction with arterial occlusion. Arch Neurol 1959;1:161–177.
14.
Ropper AH, Shafran B: Brain edema after stroke: Clinical syndrome and intracranial pressure. Arch Neurol 1984;41:26–29.
15.
Wardlaw JM, Dennis MS, Lindley RI, Warlow CP, Sandercock PAG, Sellar R: Does early reperfusion of a cerebral infarct influence cerebral infarct swelling in the acute stage or the final clinical outcome? Cerebrovasc Dis 1993;3:86–93.
16.
Frank JI: Large hemispheric infarction, deterioration, and intracranial pressure. Neurology 1995;45:1286–1290.
17.
Schwab S, Aschoff A, Spranger M, Albert F, Hacke W: The value of intracranial pressure monitoring in acute hemispheric stroke. Neurology 1996;47:393–398.
18.
Limburg M, van Royen EA, Hijdra A, de Bruïne JF, Verbeeten BWJ Jr: Single-photon emission computed tomography and early death in acute ischemic stroke. Stroke 1990;21:1150–1155.
19.
Ropper AH: Neurological intensive care. Ann Neurol 1992;32:564–569.
20.
Van der Worp HB, Kappelle LJ, Van Gijn J: Medical treatment of acute ischemic stroke; in Bär PR, Beal MF (eds): Neuroprotection in CNS Diseases. New York, Dekker, 1997, pp 349–380.
21.
Adams HP Jr, Brott TG, Crowell RM, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Marler JR, Woolson RF, Zivin JA, Feinberg W, Mayberg M: Guidelines for the management of patients with acute ischemic stroke: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1994;25:1901–1914.
22.
Delashaw JB, Broaddus WC, Kassell NF, Haley EC, Pendleton GA, Vollmer DG, Maggio WW, Grady MS: Treatment of right hemispheric cerebral infarction by hemicraniectomy. Stroke 1990;21:874–881.
23.
Kalia KK, Yonas H: An aggressive approach to massive middle cerebral artery infarction. Arch Neurol 1993;50:1293–1297.
24.
Hart RG, Easton JD: Hemorrhagic infarcts. Stroke 1986;17:586–589.
25.
Hornig CR, Dorndorf W, Agnoli AL: Hemorrhagic infarction: A prospective study. Stroke 1986;17:179–185.
26.
Hornig CR, Bauer T, Simon C, Trittmacher S, Dorndorf W: Hemorrhagic transformation in cardioembolic cerebral infarction. Stroke 1993;24:465–468.
27.
Toni D, Fiorelli M, Bastianello S, Sacchetti ML, Sette G, Argentino C, Montinaro E, Bozzao L: Hemorrhagic transformation of brain infarct: Predictability in the first 5 hours from stroke onset and influence on clinical outcome. Neurology 1996;46:341–345.
28.
Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, Boysen G, Bluhmki E, Höxter G, Mahagne M-H, Hennerici M, for the ECASS Study Group: Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke: The European Cooperative Acute Stroke Study (ECASS). JAMA 1995;274:1017–1025.
29.
The Multicenter Acute Stroke Trial - Europe Study Group: Thrombolytic therapy with streptokinase in acute ischemic stroke. N Engl J Med 1996;335:145–150.
30.
Multicentre Acute Stroke Trial-Italy (MAST-I) Group: Randomised controlled trial of streptokinase, aspirin, and combination of both in treatment of acute ischaemic stroke. Lancet 1995;346:1509–1514.
31.
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group: Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581–1587.
32.
International Stroke Trial Collaborative Group: The International Stroke Trial (IST): A randomised trial of aspirin, subcutaneous heparin, or both, or neither among 19,435 patients with acute ischaemic stroke. Lancet 1997;349:1569–1581.
33.
Pessin MS, Estol CJ, Lafranchise F, Caplan LR: Safety of anticoagulation after hemorrhagic infarction. Neurology 1993;43:1298–1303.
34.
Adams HP Jr, Brott TG, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Kwiatkowski T, Lyden PD, Marler JR, Torner J, Feinberg W, Mayberg M, Thies W: Guidelines for thrombolytic therapy for acute stroke: A supplement to the guidelines for the mamagement of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1996;27:1711–1718.
35.
Sacco RL, Foulkes MA, Mohr JP, Wolf PA, Hier DB, Price TR: Determinants of early recurrence of cerebral infarction: The Stroke Data Bank. Stroke 1989;20:983–989.
36.
CAST (Chinese Acute Stroke Trial) Collaborative Group: CAST: Randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. Lancet 1997;349:1641–1649.
37.
Lancman ME, Golimstok A, Norscini J, Granillo R: Risk factors for developing seizures after a stroke. Epilepsia 1993;34:141–143.
38.
Giroud M, Gras P, Fayolle H, André N, Soichot P, Dumas R: Early seizures after acute stroke: A study of 1,640 cases. Epilepsia 1994;35:959–964.
39.
Kilpatrick CJ, Davis SM, Tress BM, Rossiter SC, Hopper JL, Vandendriesen ML: Epileptic seizures in acute stroke. Arch Neurol 1990;47:157–160.
40.
So EL, Annegers JF, Hauser WA, O’Brien PC, Whisnant JP: Population-based study of seizure disorders after cerebral infarction. Neurology 1996;46:350–355.
41.
Gupta SR, Naheedy MH, Elias D, Rubino FA: Postinfarction seizures: A clinical study. Stroke 1988;19:1477–1481.
42.
Robinson RG, Starr LB, Kubos KL, Price TR: A two-year longitudinal study of post-stroke mood disorders: Findings during the initial evaluation. Stroke 1983;14:736–741.
43.
Starkstein SE, Robinson RG: Affective disorders and cerebral vascular disease. Br J Psychiatry 1989;154:170–182.
44.
Robinson RG, Bolduc PL, Price TR: Two-year longitudinal study of post-stroke mood disorders: Diagnosis and outcome at one and two years. Stroke 1987;18:837–843.
45.
Fassbender K, Schmidt R, Mössner R, Daffertshofer M, Hennerici M: Pattern of activation of the hypothalamic-pituitary-adrenal axis in acute stroke: Relation to acute confusional state, extent of brain damage, and clinical outcome. Stroke 1994;25:1105–1108.
46.
Gustafson Y, Olsson T, Eriksson S, Asplund K, Bucht G: Acute confusional states (delirium) in stroke patients. Cerebrovasc Dis 1991;1:257–264.
47.
Rokey R, Rolak LA, Harati Y, Kutka N, Verani MS: Coronary artery disease in patients with cerebrovascular disease: A prospective study. Ann Neurol 1984;16:50–53.
48.
Broderick JP, Phillips SJ, O’Fallon M, Frye RL, Whisnant JP: Relationship of cardiac disease to stroke occurrence, recurrence and mortality. Stroke 1992;23:1250–1256.
49.
McDermott MM, Lefevre F, Arron M, Martin GJ, Biller J: ST segment depression detected by continuous electrocardiography in patients with acute ischemic stroke or transient ischemic attack. Stroke 1994;25:1820–1824.
50.
Mikolich JR, Jacobs WC, Fletcher GF: Cardiac arrhythmias in patients with acute cerebrovascular accidents. JAMA 1981;246:1314–1317.
51.
Oppenheimer SM, Hachinski VC: The cardiac consequences of stroke. Neurol Clin 1992;10:167–176.
52.
Norris JW, Hachinski VC, Myers MG, Callow J, Wong T, Moore RW: Serum cardiac enzymes in stroke. Stroke 1979;10:548–553.
53.
Britton M, Carlsson A, De Faire U: Blood pressure course in patients with acute stroke and matched controls. Stroke 1986;17:861–864.
54.
Harper G, Castleden CM, Potter JF: Factors affecting changes in blood pressure after acute stroke. Stroke 1994;25:1726–1729.
55.
Lisk DR, Grotta JC, Lamki LM, Tran HD, Taylor JW, Molony DA, Barron BJ: Should hypertension be treated after acute stroke? A randomized controlled trial using single photon emission computed tomography. Arch Neurol 1993;50:855–862.
56.
Carlberg B, Asplund K, Hägg E: Factors influencing admission blood pressure in patients with acute stroke. Stroke 1991;22:527–530.
57.
Waltz AG: Effect of blood pressure on blood flow in ischemic and in nonischemic cerebral cortex: The phenomena of autoregulation and luxury perfusion. Neurology 1968;18:613–621.
58.
Fieschi C, Angoli A, Battistini N, Bozzao L, Prencipe M: Derangement of regional blood flow and of its regulatory mechanisms in acute cerebrovascular lesions. Neurology 1968;18:1166–1179.
59.
Dirnagl U, Pulsinelli W: Autoregulation of cerebral blood flow in experimental focal brain ischemia. J Cereb Blood Flow Metab 1990;10:327–336.
60.
Wahlgren NG, MacMahon DG, De Keyser J, Indredavik B, Ryman T, for the INWEST Study Group: Intravenous Nimodipine West European Stroke Trial (INWEST) of nimodipine in the treatment of acute ischaemic stroke. Cerebrovasc Dis 1994;4:204–210.
61.
Toni D, Sacchetti ML, Argentino C, Gentile M, Cavaletti C, Frontoni M, Fieschi C: Does hyperglycaemia play a role on the outcome of acute ischaemic stroke patients? J Neurol 1992;239:382–286.
62.
van Kooten F, Hoogerbrugge N, Naarding P, Koudstaal PJ: Hyperglycemia in the acute phase of stroke is not caused by stress. Stroke 1993;24:1129–1132.
63.
O’Neill PA, Davies I, Fullerton KJ, Bennett D: Stress hormone and blood glucose response following acute stroke in the elderly. Stroke 1991;22:842–847.
64.
Tracey F, Stout RW: Hyperglycemia in the acute phase of stroke and stress response (letter). Stroke 1994;25:524–525.
65.
Adams HP Jr, Olinger CP, Marler JR, Biller J, Brott TG, Barsan WG, Banwart K: Comparison of admission serum glucose concentration with neurologic outcome in acute cerebral infarction: A study in patients given naloxone. Stroke 1988;19:455–458.
66.
Berger L, Hakim AM: The association of hyperglycemia with cerebral edema in stroke. Stroke 1986;17:865–871.
67.
Candelise L, Landi G, Nobile Orazio E, Boccardi E: Prognostic sginficance of hyperglycemia in acute stroke. Arch Neurol 1985;42:661–663.
68.
Sandercock PAG, van den Belt AGM, Lindley RI, Slattery J: Antithrombotic therapy in acute ischaemic stroke: An overview of the completed randomised trials. J Neurol Neurosurg Psychiatry 1993;56:17–25.
69.
Warlow C, Ogston D, Douglas AS: Deep venous thrombosis of the legs after strokes. BMJ 1976;1:1178–1183.
70.
Landi G, D’Angelo A, Boccardi E, Candelise L, Mannuccio PM, Morabito A, Nobile Orazio E: Venous thromboembolism in acute stroke: Prognostic importance of hypercoagulability. Arch Neurol 1992;49:279–283.
71.
Noel P, Gregoire F, Capon A, Lehert P: Atrial fibrillation as a risk factor for deep venous thrombosis and pulmonary emboli in stroke patients. Stroke 1991;22:760–762.
72.
Leizorovicz A, Simonneau G, Decousus H, Boissel JP: Comparison of efficacy and safety of low molecular weight heparins and unfractioned heparin in initial treatment of deep venous thrombosis: A meta-analysis BMJ 1994;309:299–304.
73.
Meuleman DG, Hobbelen PMJ, Van Dedem G, Moelker HCT: A novel anti-thrombotic heparinoid (ORG 10172) devoid of bleeding inducing capacity: A survey of its pharmacological properties in experimental animal models. Thromb Res 1982;27:353–363.
74.
Hull RD, Raskob GE, Pineo GF, Green D, Trowbridge AA, Elliot CG, Lerner RG, Hall J, Sparling T, Brettell HR, Norton J, Carter CJ, George R, Merli G, Ward J, Mayo W, Rosenbloom D, Brant R: Subcutaneous low-molecular-weight heparin compared with continuous intravenous heparin in the treatment of proximal-vein thrombosis. N Engl J Med 1992;326:975–982.
75.
Davenport RJ, Dennis MS, Wellwood I, Warlow CP: Complications after acute stroke. Stroke 1996;27:415–420.
76.
Bounds JV, Wiebers DO, Whisnant JP, Okazaki H: Mechanisms and timing of deaths from cerebral infarction. Stroke 1981;12:474–477.
77.
Walker AE, Robins M, Weinfeld FD: The National Survey of Stroke. 3. Clinical findings. Stroke 1981;12(suppl 1):I-13–I-31.
78.
Przelomski MM, Roth RM, Gleckman RA, Marcus EM: Fever in the wake of a stroke. Neurology 1986;36:427–429.
79.
Castillo J, Martínez F, Leira R, Prieto JM, Lema M, Noya M: Mortality and morbidity of acute cerebral infarction related to temperature and basal analytic parameters. Cerebrovasc Dis 1994;4:66–71.
80.
Azzimondi G, Bassein L, Nonino F, Fiorani L, Vignatelli L, Re G, D’Alessandro R: Fever in acute stroke worsens prognosis: A prospective study. Stroke 1995;26:2040–2043.
81.
Hindfelt B: The prognostic significance of subfebrility and fever in ischaemic cerebral infarction. Acta Neurol Scand 1976;53:72–79.
82.
Wijdicks EFM, Scott JP: Outcome in patients with acute basilar artery occlusion requiring mechanical ventilation. Stroke 1996;27:1301–1303.
83.
Burtin P, Bollaert PE, Feldmann L, Nace L, Lelarge Ph, Bauer Ph, Larcan A: Prognosis of stroke patients undergoing mechanical ventilation. Intensive Care Med 1994;20:32–36.
84.
El-Ad B, Bornstein NM, Fuchs P, Korczyn AD: Mechanical ventilation in stroke patients – is it worthwhile? Neurology 1996;47:657–659.
85.
Borrie MJ, Campbell AJ, Spears GFS: Urinary incontinence after stroke: A prospective study. Age Ageing 1986;15:177–181.
86.
Gelber DA, Good DC, Laven LJ, Verhulst SJ: Causes of urinary incontinence after acute hemispheric stroke. Stroke 1993;24:378–382.
87.
Hondé C, Derks C, Tudor D: Local treatment of pressure sores in the elderly: Amino acid copolymer membrane versus hydrocolloid dressing. J Am Geriatr Soc 1994;42:1180–1183.
88.
Smithard DG, O’Neill PA, Park C, Morris J, Wyatt R, England R, Martin DF: Complications and outcome after acute stroke: Does dysphagia matter? Stroke 1996;27:1200–1204.
89.
Barer DH: The natural history and functional consequences of dysphagia after hemispheric stroke. J Neurol Neurosurg Psychiatry 1988;52:236–241.
90.
Norton B, Homer-Ward M, Donnelly MT, Long RG, Holmes GKT: A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. BMJ 1996;312:13–16.
91.
Dávalos A, Ricart W, Gonzalez-Huix F, Soler S, Marrugat J, Molins A, Suñer R, Genís D: Effect of malnutrition after acute stroke on clinical outcome. Stroke 1996;27:1028–1032.
92.
Wijdicks EFM, Fulgman JR, Batts KP: Gastrointestinal bleeding in stroke. Stroke 1994;25:2146–2148.
93.
Davenport RJ, Dennis MS, Warlow CP: Gastrointestinal hemorrhage after acute stroke. Stroke 1996;27:421–424.
94.
Langhorne P, Williams BO, Gilchrist W, Howie K: Do stroke units save lives? Lancet 1993;342:395–398.
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