From the Guidelines
Clinical complications in post-stroke patients after 90 days commonly include motor deficits, spasticity, post-stroke depression, cognitive impairment, and recurrent stroke risk. These complications can significantly impact the patient's quality of life, morbidity, and mortality. Motor deficits may persist with approximately 50-70% of patients experiencing some degree of hemiparesis, requiring ongoing physical therapy 2-3 times weekly and possibly antispasticity medications like baclofen (10-25mg three times daily) or tizanidine (2-8mg three times daily) for spasticity management, as suggested by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1. Post-stroke depression affects about 30% of survivors and should be treated with SSRIs such as sertraline (50-100mg daily) or escitalopram (10-20mg daily). Cognitive impairments persist in 20-30% of patients, necessitating cognitive rehabilitation. Secondary stroke prevention is crucial through antiplatelet therapy, such as aspirin 81-325mg daily or clopidogrel 75mg daily, but Dual Antiplatelet Therapy (DAPT) is associated with increased risk of bleeding and no benefit in long-term reduction of recurrent stroke risk beyond 90 days after stroke 1. Patients should also be monitored for dysphagia, seizures (occurring in 2-4% of patients), and central post-stroke pain (treated with gabapentin 300-1200mg three times daily or pregabalin 50-300mg twice daily). Aggressive management of hypertension (target <130/80 mmHg), diabetes (HbA1c <7%), and hyperlipidemia (LDL <70 mg/dL) is also essential for secondary stroke prevention. All patients who have had a stroke should have an assessment of their capacity to perform activities of daily living, as recommended by the primary care of adult patients after stroke guideline 1. Regular follow-up and monitoring for these complications can help improve the patient's quality of life, reduce morbidity, and prevent mortality. Key considerations include:
- Ongoing physical therapy and antispasticity medications for motor deficits
- SSRI treatment for post-stroke depression
- Cognitive rehabilitation for cognitive impairments
- Antiplatelet therapy for secondary stroke prevention
- Monitoring for dysphagia, seizures, and central post-stroke pain
- Aggressive management of hypertension, diabetes, and hyperlipidemia.
From the Research
Clinical Complications in Post-Stroke Patients After 90 Days
- Post-stroke patients may experience various clinical complications, including fatigue, depression, contracture and spasticity, hemiplegic shoulder pain, and central poststroke pain 2.
- The risk of recurrent stroke is significant, affecting 9% to 15% of people within 1 year 3.
- Long-term secondary prevention strategies are crucial to reduce the burden of recurrent stroke, including blood pressure management, diabetes control, lipid lowering, and antiplatelet therapy 3, 4.
Management of Post-Stroke Patients
- Blood pressure lowering treatment to a target of <130/80 mmHg is recommended, except in subgroups at increased risk of harm 3.
- HMGCoA-reductase inhibitors (statins) and targeting a low-density lipoprotein level of <1.8 mmol/l (70 mg/dl) are recommended for lipid management 3.
- Antiplatelet therapy with aspirin and clopidogrel is recommended for 21 to 90 days after stroke, but not longer 2, 3.
- Diabetes management should include a glucagon-like peptide 1 receptor agonist or sodium-dependent glucose cotransporter 2 inhibitor, and aiming for an HbA1c level of <7% is reasonable 2, 3.
Combination Therapy
- Combination therapy with antiplatelets, angiotensin-converting enzyme (ACE) inhibitors, and statins may have additive protective effects in reducing ischemic stroke severity and tissue at risk 5.
- ACE inhibitors and angiotensin II receptor antagonists have demonstrated their efficacy in preventing target organ damage and reducing cardiovascular morbidity and mortality in ischemic heart disease 6.