Post-Stroke Complications

Post-stroke complications are common and can significantly impact patient outcomes. Advances in acute stroke treatment, including reperfusion therapy, stroke unit care and rigorous rehabilitation regimes, have considerably improved patient outcomes after stroke. To retain the achieved functional outcome, long-term strategies for the management of patients after stroke are needed.

Recent evidence suggests that 90% of stroke patients suffer from stroke-related health problems after hospital discharge, more than 80% of which require medical interventions. Half of all stroke survivors are readmitted to a hospital or die within the first year after the index stroke event.^1,2 Recurrent cardiovascular disease, including recurrent stroke, and other complications, including epilepsy, fractures, fatigue, cognitive impairment, pain and depression contribute to long-term disability, reduced quality of life, and worse functional outcomes. However, intensified post-stroke care, including timely prevention, detection, and treatment of complications as well as recognition of remaining rehabilitation needs, can contribute to improved quality of life and functional outcomes.³

Advances in acute stroke management have shown a remarkable increase in good short-term outcomes for stroke survivors. Recent literature suggests that neurological status at 24 h after thrombectomy for stroke due to anterior circulation large vessel occlusion explains approximately half of the variability in functional outcome at 3 months after stroke⁴. This suggests that the other half is explained by other factors such as delayed neurological improvement or worsening, rehabilitation, and occurrence of complications. Preventing secondary functional deterioration may be even more important when baseline functional status is better, as in minor stroke and in the absence of thrombectomy. One study of >1,700 stroke/TIA patients showed that 16% of patients suffered in-hospital complications during care for the index event and nearly 90% suffered one or more complications post-discharge.⁵

In-hospital and post-discharge complications were responsible for 8% and 32% of non-excellent outcomes 12 months after the index event. In those with moderate and severe stroke (NIHSS > 5), acute therapy was the strongest predictor of excellent outcome. In this cohort, however, most strokes were minor (mean NIHSS 4), which corresponds to a well-described trend of decreasing stroke severity attributed to improved recognition and better risk factor management in primary prevention, including atrial fibrillation detection and treatment.

Among the specific complications, the rates of post-discharge pain, severe fatigue, falls, and depression were high and occurred in 20%–40% of patients, which is similar to that previously reported in meta-analyses of observational and population-based studies.⁵

These complications resulted in the largest impact on functional outcome. By comparison, recurrent stroke, neurological deterioration, and treatment side effects such as major bleeding were more serious at the individual level, but because they were much less common, had smaller impact at the population level. Falls were common and impactful- multiple falls in the same patient showed a strong association with non-excellent functional outcome.⁵

All in all, complications accounted for more than one third of non-excellent 1-year functional outcome after stroke and TIA.⁵ Their impact was greatest after hospital discharge, in TIA and minor stroke, in younger patients, men, and those without pre-existing disability. Pain, severe fatigue, depression, and falls were most common and impactful. Major improvements in functional outcome may therefore be attainable by focused prevention, detection, and treatment of post-stroke and TIA complications.

References

1. Ullberg T, Månsson K, Berhin I, Pessah-Rasmussen H. Comprehensive and Structured 3-month Stroke Follow-up Using the Post-stroke Checklist (The Struct-FU study): A Feasibility and Explorative Study. J Stroke Cerebrovasc Dis. 2021;30(2):105482. doi:10.1016/j.jstrokecerebrovasdis.2020.105482
2. Bravata DM, Ho SY, Meehan TP, Brass LM, Concato J. Readmission and Death After Hospitaliuation for Acute Ischemic Stroke: 5-Year Follow-Up in the Medicare Population. Stroke. 2007 Jun;38(6):1899–904. doi:10.1161/STROKEAHA.106.481465
3. Boehme C, Toell T, Lang W, Knoflach M, Kiechl S. Longer term patient management following stroke: A systematic review. Int J Stroke Off J Int Stroke Soc. 2021 Oct;16(8):917–26. doi:10.1177/17474930211016963
4. Kniep H, Meyer L, Bechstein M, Broocks G, Guerreiro H, Van Horn N, et al. How Much of the Thrombectomy Related Improvement in Functional Outcome Is Already Apparent at 24 Hours and at Hospital Discharge? Stroke. 2022;53(9):2828–37. doi:10.1161/STROKEAHA.121.037888
5. Boehme C, Mayer-Suess L, Toell T, Karisik A, Mölgg K, Felicetti S, et al. Effect of in-hospital and post-discharge complications on 1-year functional outcome after stroke and transient ischemic attack. Eur Stroke J. 2026 Jan 1;11(1):23969873251383315. doi:10.1093/esj/23969873251383315