Neurological complications of acute ischaemic stroke

This paper reviews the most frequent neurological complications that occur early after a stroke (acute complications) and their management.

Ischemic stroke is a leading cause of death. Acute neurological complications (occurring early after stroke) are responsible for much of this increased mortality. Recognizing acute stroke complications early on and starting adequate treatment may improve patient survival.

This article highlights the major acute stroke complications and their management, as currently found in medical literature:

1. Brain edema. Brain edema represents a collection of fluid in the brain tissue (in between brain cells), that occurs as a result of blood vessels becoming more "leaky". The brain cells themselves may also swell up with fluid. Brain edema (in stroke) generally occurs in the same area of the stroke and pushes on the remaining healthy brain tissue. This complication is the leading cause of death after stroke. Management includes simple measures, such as elevating the head of the bed to 20-30 degrees to improve blood drainage from the brain, drugs that reduce swelling, and even invasive procedures such as surgery to temporarily remove part of the skull to relieve the pressure (also called a hemicraniectomy).
2. Hemorrhagic transformation. This acute complication of ischemic stroke referrers to bleeding in the area of the stroke. Ischemic stroke is caused by blockage of an artery supplying blood to the brain and is different than hemorrhagic stroke, which is caused by bleeding into the brain. However, in up to 30-40% of cases, the blocked artery may rupture and bleeding may also occur. Risk factors for hemorrhagic transformation include: thrombolytic therapy (giving clot-dissolving drugs), treatment with anticoagulants (drugs that prevent blood clotting) and older age. Bleeding may not be significant in all cases, but it may worsen brain edema. Management is not standard, and importance is given mainly to prevention, for example carefully selecting patients that receive thrombolytic therapy.
3. Seizures and epilepsy. Seizures (uncontrolled activation of parts of the brain which may or may not cause convulsions) may develop (usually within 1-2 weeks of the stroke), and are very difficult to predict. There are no guidelines in place for treating seizures occurring after a stroke. Treatment is usually managed by anti-epilepsy medications (carbamazepine, gabapentin, lamotrigine etc.). Medication is not usually started before multiple seizures are verified (not given as prevention), due to the potential side-effects.
5. Recurrent stroke. The risk for additional strokes is highest during the first week after the initial event (occurring in up to 10% of patients), and declines over time. Management involves eliminating risk factors (managing diabetes, high blood pressure and high cholesterol levels). Sometimes invasive procedures are used to open occluded arteries and improve blood flow to the brain.
6. Headache. Headaches, especially if sudden and associated with neurological problems (such as weakness on one side of the body, slurred speech), may be the sign of a new stroke. Some patients may also experience long-term headaches following a stroke. Treatment is managed according to the cause (stroke treatment is needed if the headache is a sign of a new stroke), and treatment of chronic headaches generally includes pain medication.
7. Sleep disorders. Many stroke patients complain of increased sleepiness, insomnia or other sleep disturbances. Some patients may also develop a sleep breathing disorder, such as obstructive sleep apnea (a condition in which breathing repeatedly stops during sleep, causing repeated arousal which disrupts deep sleep needed to restore the brain function). Management may involve sleep medications, and sometimes treatment with CPAP (continuous positive airway pressure) devices; a mask that patients sleep with, which help keep the airways open.

Discuss the possible stroke complications with your physician to decide whether preventive strategies could be implemented.