Should stroke be considered in a patient with a history of septic shock and aortic repair (aortic vascular repair) within the past 18 months presenting with fatigue?

Should Stroke Be Considered in This Patient?

Yes, stroke must be actively considered and ruled out in a patient with prior septic shock and aortic repair presenting with fatigue within 18 months, as both conditions independently confer substantial stroke risk, and fatigue is a common but often subtle manifestation of stroke. 1

Why This Patient Has Elevated Stroke Risk

Septic Shock as a Stroke Risk Factor

• Patients hospitalized with sepsis have a 0.5% risk of stroke within one year, with risk factors including valvular heart disease, congestive heart failure, renal failure, peripheral vascular disease, pulmonary circulation disorders, and coagulopathy 2
• Septic cardiomyopathy causes biventricular impairment of intrinsic myocardial contractility with reduced left ventricular ejection fraction, creating a substrate for thromboembolic stroke 3
• The stroke risk increases 43% per additional risk factor point in sepsis survivors 2

Aortic Repair as a Stroke Risk Factor

• Aortic arch atheroma ≥4 mm proximal to the left subclavian artery carries an 11% risk of recurrent ischemic stroke at 1 year, even on antiplatelet therapy 1
• The risk of new vascular events (stroke, MI, peripheral event, vascular death) is 20%, 36%, and 50% at 1,2, and 3 years respectively after aortic procedures 1
• Postoperative stroke after aortic dissection repair occurs in 15.5% of patients, with both ischemic (12.7%) and hemorrhagic (2.9%) subtypes 4
• Procedure-related covert brain lesions confer approximately 4-fold increased risk of subsequent symptomatic stroke during long-term follow-up 1

Fatigue as a Stroke Presentation

Why Fatigue Should Trigger Stroke Evaluation

• Poststroke fatigue occurs in at least 50% of stroke survivors and is a common, debilitating sequela that may be the predominant presenting symptom 1
• Fatigue can be the primary manifestation of stroke, particularly when focal neurological deficits are subtle or masked 1
• The relationship between stroke and fatigue is bidirectional: stroke causes fatigue, but fatigue as a presenting complaint may indicate an unrecognized stroke 1

Distinguishing Neurological from Physiological Fatigue

• Neurological fatigue from stroke may never resolve completely and requires long-term adaptation 1
• Assessment should evaluate temporality (sudden versus persistent onset) and intensity to differentiate stroke-related fatigue from other causes 1
• Patients with stroke-related fatigue often have decreased participation in physical activities and rehabilitation, poor neurological recovery, decreased quality of life, and increased mortality 1

Diagnostic Approach

Immediate Neurological Assessment

• Perform focused neurological examination documenting any focal weakness, numbness, aphasia, visual field disturbance, diplopia, hemispatial neglect, dysarthria, vertigo, or ataxia—even if subtle 1
• Recognize that focal neurological signs can be masked or subtle, particularly aprosodic speech (lack of inflection), abulia (decreased motivation), or flat affect 1
• Use the NIHSS score to quantify any neurological deficit, with mild dysfunction defined as NIHSS 0-5 1

Neuroimaging Strategy

• Obtain urgent non-contrast CT brain as first-line imaging to exclude hemorrhagic stroke, which occurs in 2.9% of post-aortic repair patients 4
• Proceed with MRI with diffusion-weighted imaging if CT is negative but clinical suspicion remains, as this detects covert CNS infarction that may present only with fatigue 1
• Consider CT angiography to evaluate for large vessel occlusion if acute ischemic stroke is identified 5

Additional Evaluations

• Screen for depression using validated scales (Beck Depression Inventory, CES-D, GDS, or Hamilton Depression Scale), as poststroke depression occurs in 18-68% of patients and commonly coexists with fatigue 1
• Assess for sleep disorders, particularly obstructive sleep apnea, which occurs in approximately 40% of stroke patients and contributes to fatigue 6
• Evaluate for atrial fibrillation, as this is a well-documented modifiable risk factor for recurrent stroke in patients with prior cardiovascular procedures 1

Critical Pitfalls to Avoid

Do Not Dismiss Fatigue as Nonspecific

• Fatigue in this high-risk patient should not be attributed to deconditioning, depression, or sleep disturbance without first excluding stroke 1
• The absence of obvious focal neurological deficits does not exclude stroke, as covert CNS injury can present with only non-focal symptoms 1

Do Not Delay Imaging

• Early postoperative stroke (within 7 days to 1 month after aortic procedures) is commonly associated with the patient's overall atherothromboembolic risk factors 1
• Late postoperative stroke can occur beyond 1 year, particularly in patients with aortic arch atheroma 1

Consider Both Ischemic and Hemorrhagic Stroke

• Hemorrhagic stroke after aortic repair has higher in-hospital mortality (42.1% versus 20.5% for ischemic) and worse neurological outcomes 4
• Patients with complex arch replacement and long cardiopulmonary bypass times are at particular risk for hemorrhagic stroke 4