What are the clinical complications related to stroke after 90 days, such as urinary tract infections (UTIs), aspiration pneumonia, community-acquired pneumonia, pressure ulcers, and other secondary conditions?

From the Guidelines

Stroke survivors are at high risk of developing various clinical complications beyond the 90-day mark, including urinary tract infections, aspiration pneumonia, pressure ulcers, deep vein thrombosis, depression, and seizures, which can significantly impact their morbidity, mortality, and quality of life. These complications often result from immobility, impaired bladder control, swallowing difficulties, and reduced mobility. According to the most recent and highest quality study 1, approximately 10% of younger adults and 30% of adults over 65 years of age develop new stroke-related disability of at least moderate severity by 90 days after a stroke.

Common Complications

• Urinary tract infections: often result from catheterization or impaired bladder control, and can lead to bacteremia or sepsis as a potential complication 1
• Aspiration pneumonia: develops when swallowing difficulties lead to food or liquid entering the lungs, and is a serious complication that can increase length of stay, mortality, and hospital costs 1
• Pressure ulcers: form due to immobility and poor positioning, particularly over bony prominences, and can be prevented with early mobilization and regular skin inspections 1
• Deep vein thrombosis: results from reduced mobility, with potential for life-threatening pulmonary embolism, and can be prevented with early mobilization and anticoagulation therapy
• Depression: affects approximately one-third of stroke survivors, requiring screening and treatment with SSRIs like sertraline (50-200 mg daily) or escitalopram (10-20 mg daily) [@Example@]
• Seizures: may develop from brain tissue scarring, necessitating anticonvulsant therapy such as levetiracetam (500-1500 mg twice daily) or lamotrigine (25-200 mg twice daily) [@Example@]

Prevention Strategies

• Early mobilization: can help prevent pressure ulcers, deep vein thrombosis, and pneumonia 1
• Proper positioning: can help prevent pressure ulcers and improve respiratory function
• Swallowing assessments: can help identify patients at risk of aspiration pneumonia and guide appropriate interventions
• Bladder management protocols: can help prevent urinary tract infections and improve bladder function
• Regular skin inspections: can help identify pressure ulcers early and guide appropriate interventions

Rehabilitation

• Should continue beyond the acute phase to address complications and improve functional outcomes 1
• Can include physical, occupational, and speech therapy to improve mobility, cognition, and communication
• Can help patients achieve maximum restoration of function and independence, and improve their quality of life.

From the Research

Clinical Complications Related to Stroke After 90 Days

• Urinary tract infections (UTIs) are a common complication after stroke, with studies suggesting that patients with stroke have a high risk of infection 2, 3, 4, 5.
• Aspiration pneumonia is another major complication that stroke patients experience, and managing risk for aspiration can help decrease post-stroke pneumonia 2, 6.
• Other complications include pressure ulcers, with studies highlighting the importance of early identification and treatment of patients at high risk for these complications 4.
• Factors associated with an increased risk of developing pneumonia and UTI during ischemic stroke hospitalization include older age, atrial fibrillation, congestive heart failure, and history of cerebrovascular events 4.
• Elevated interleukin-6, higher National Institute of Health Stroke Scale (NIHSS) scores, and decreased hemoglobin may also be used to predict UTI 3.

Predictors and Risk Factors

• Age, procalcitonin, interleukin-6, C-reactive protein, NIHSS score, and diabetes are predictors of infection in stroke patients 3.
• Female gender and higher baseline NIHSS and age are associated with an increased risk of UTI 2.
• Male gender, history of diabetes, and stroke subtype are associated with an increased risk of pneumonia 2.

Management and Prevention

• Using an evidence-based dysphagia protocol can reduce mortality, morbidity, and length of stay caused by post-stroke pneumonia 6.
• Education and measurement of comprehension of the care team, patient, and family concerning dysphagia management and prevention of aspiration pneumonia can help achieve better outcomes 6.
• Intervention strategies such as prophylactic antibiotics, antiseptic-impregnated catheters, and quality improvement interventions to reduce inappropriate catheterization may help reduce the incidence of UTI 5.