"Stress ulcers in the intensive care unit: Diagnosis, management, and prevention", section on 'High-risk patients'.) Management Withholding of antiplatelet or anticoagulant therapy in the setting of clinically overt GI bleeding should be individualized. The management of GI bleeding is discussed in detail elsewhere. (See "Approach to acute upper gastrointestinal bleeding in adults" and "Approach to acute lower gastrointestinal bleeding in adults" and "Evaluation of occult gastrointestinal bleeding".) Urinary incontinence Urinary incontinence is a common problem after stroke and is associated with poor functional outcome and mortality, perhaps because it is a marker of stroke severity [79-83]. Urinary incontinence is present in 32 to 79 percent of patients on admission, and 25 to 28 percent at discharge [84]. Data from prospective population-based studies suggest that in previously continent patients, new urinary incontinence is found in 35 to 40 percent of patients at 7 to 10 days after acute stroke [83]. The prevalence of poststroke incontinence decreases with time. Of a group of 95 patients with incontinence 7 to 10 days after stroke, incontinence persisted at three months, one year, and two years in 36, 24, and 13 percent, respectively [85]. The most frequent urodynamic finding is detrusor hyperreflexia [86]. The loss of inhibitory input from higher neurologic centers is thought to cause this hyperreflexia leading to urinary urgency, frequency, and urge incontinence. In addition to detrusor hyperreflexia, detrusor hyporeflexia or areflexia may also occur following stroke, leading to overflow incontinence. Detrusor-sphincter dyssynergia is an uncommon phenomenon in patients with recent stroke, unlike other neurologic disorders associated with incontinence. Risk factors Risk factors for the development of urinary incontinence in patients with stroke include hemiparesis, depression, cognitive impairment, age >75 years, dysphagia, https://www.uptodate.com/contents/complications-of-stroke-an-overview/print 12/34 7/5/23, 12:05 PM Complications of stroke: An overview - UpToDate visual field defect, and large infarcts (cortical plus subcortical area involvement) [87,88]. Other factors contributing to urinary retention include the use of anticholinergic drugs, diabetic cystopathy, and bladder outlet obstruction. Prevention Indwelling bladder catheter placement should be avoided when possible to decrease the risks of nosocomial infection, which is a potential contributing factor for urinary incontinence. Evaluation and management Practitioners can easily overlook urinary incontinence if patients or nursing staff are not directly queried. Diagnosis of the type of incontinence and appropriate treatment can be coordinated with a urologist. Detrusor hyperreflexia can be treated with scheduled voiding, tailored fluid restriction, and anticholinergic drugs. There is little evidence to support specific interventions for urinary incontinence after stroke [89]. The evaluation and treatment of urinary incontinence is discussed in detail separately. (See "Urinary incontinence in men" and "Female urinary incontinence: Evaluation" and "Female urinary incontinence: Treatment".) Falls and bone fractures Falls have been cited as the one of the most common complications of acute stroke [1,90]. In a prospective multicenter study of 311 patients followed up to 30 months after stroke, falls occurred in 25 percent and were associated with serious injury in 5 percent [1]. Hip fractures represent 45 percent of poststroke fractures and are two to four times more common in the population with stroke compared with an age-matched reference population [91]. A retrospective case-control study found that the rate of falls among hospitalized patients with acute ischemic stroke was only 2.3 percent [92]. Hospitalized patients with stroke not only have skeletal "unloading" secondary to bed rest, but they also have disuse of the paretic limbs. These factors predispose patients to bone resorption. Patients who are able to ambulate early after stroke appear to lose bone density only on the paretic side (hemiosteoporosis), while those who are not ambulatory lose bone mineral density on both sides. Relearning to walk by two months has been associated with diminished bone density loss compared with remaining nonambulatory [93]. Risk factors Patients with cognitive impairment, neglect, anosognosia, and/or polypharmacy may be at especially high risk for falls [23]. Most fractures after stroke occur on the paretic side and are secondary to accidental falls [91,94]. Poststroke patients tend to fall toward the paretic side and lack ample protective responses, such as outstretching an arm, putting them at higher risk for fractures. (See "Falls in older persons: Risk factors and patient evaluation".) https://www.uptodate.com/contents/complications-of-stroke-an-overview/print 13/34 7/5/23, 12:05 PM Complications of stroke: An overview - UpToDate Prevention Fall precautions should be implemented for all patients with acute stroke; specific elements include measures to reduce the risk of delirium, the use of bed and chair alarms, minimal use of mechanical restraints, and use of ceiling lifts to assist with transfers [23]. However, the evidence supporting these measures for fall prevention in patients with stroke is limited [95]. Depression Poststroke depression is common, although difficult to quantify precisely due to methodologic differences among studies. A 2013 meta-analysis, with pooled data from 43 studies and over 20,000 patients, found that the prevalence of depression observed at any time after stroke was 29 percent (95% CI 25-32 percent) [96]. There was no significant difference in prevalence rates of depression at different time points after stroke. In pooled data from 10 studies with over 16,000 patients, predictors of poststroke depression were disability, prestroke depression, cognitive impairment, stroke severity, and anxiety. In a later case-control study that compared over 135,000 patients with stroke and no diagnosis of depression at baseline with 145,000 matched controls, the incidence of depression during the first two years after hospitalization was significantly higher for the group with stroke (25 versus 8 percent) [97]. Depression after stroke is correlated with poorer functional outcomes [98], although causation cannot be inferred from this. Nonetheless, when patients are matched for initial functional outcome, remission of depression is associated with a better functional outcome at three and six months than continued depression [99]. There appears to be a relationship between depression and 12- and 24-month mortality, but confounders likely exist [100]. The theory that depression is more commonly associated with left than with right hemisphere strokes and with lesions of the left anterior brain than with other regions [101] is not supported by the data. In a systematic review of 48 studies, the relative risk of depression after a left versus right hemisphere stroke was 0.95 (95% CI 0.83-1.10) [102]. Similarly, the risk of depression after a left anterior lesion compared with all other brain lesions was 1.17 (0.87-1.62). Risk factors Possible risk factors for poststroke depression include physical disability, stroke severity, prestroke depression, cognitive impairment, and insufficient family and social support [98]. Prevention It is unclear whether interventions to prevent poststroke depression are effective. A 2020 systematic review identified 49 trials involving 3342 subjects that evaluated prevention of poststroke depression [103]. The review concluded that there was only very low certainty evidence that pharmacologic or psychologic therapies reduced the prevalence of poststroke depression. https://www.uptodate.com/contents/complications-of-stroke-an-overview/print 14/34 7/5/23, 12:05 PM Complications of stroke: An overview - UpToDate Further study in rigorous clinical trials is needed to determine the utility of antidepressant interventions for preventing depression after acute stroke. Assessment There are many depression scales that can be used to assess depression after stroke. The single question "Do you often feel sad or depressed?" was found to have a sensitivity and specificity of 86 and 78 percent, respectively when used against the Montgomery-Asberg depression rating in screening for poststroke depression [104]. (See "Unipolar depression in adults: Assessment and diagnosis".) Treatment Major depression is a treatable illness that responds to a variety of therapeutic interventions, and it is likely that the standard approach to the treatment of depression in adults is generalizable to patients with poststroke depression. The initial treatment of depression is discussed separately. (See "Unipolar major depression in adults: Choosing initial treatment".) There is no definitive evidence to guide the specific choice of therapy for patients with poststroke depression [98]. The effectiveness of pharmacotherapy, psychotherapy, or combined use of these modalities for poststroke depression is not established, but accumulating evidence suggests that these interventions are beneficial. For patients able to engage in physical activity, exercise may be helpful. (See "Unipolar major depression in adults: Choosing initial treatment", section on 'Exercise'.) Poststroke fatigue Poststroke fatigue lacks a consensus definition, but encompasses a subjective feeling of exhaustion and lack of physical or mental energy and/or an increased need for rest that interferes with usual activities [105,106]. It is generally distinguished from poststroke depression, although the two may exist concurrently. The pathophysiology of poststroke fatigue is unsettled; possible factors include disturbances in cortical excitability, inflammation, and genes that modulate inflammation [105,107,108]. The prevalence of poststroke fatigue ranges from 23 to 75 percent in different studies [109]; the wide range is likely due to variation in definitions, patient populations, assessment scales, and time points (most often six months after stroke onset) among different reports [105]. Some studies distinguish between early poststroke fatigue (up to two to three months after stroke onset) and late poststroke fatigue (more than three months after stroke onset) [107,108,110]. However, it is unclear whether these two phases of fatigue are distinct [107]. There is no consensus about the need to screen for poststroke fatigue, and no proven therapy is available [111]. In a randomized trial of 36 patients with poststroke fatigue more than three months after stroke, modafinil was more effective than placebo for reducing fatigue and improving quality of life [112], but definitive conclusions are precluded by the small size of the https://www.uptodate.com/contents/complications-of-stroke-an-overview/print 15/34 7/5/23, 12:05 PM Complications of stroke: An overview - UpToDate trial, and further study is needed. Other suggested interventions for poststroke fatigue include promoting physical activity and exercise, identifying and treating depression, anxiety, pain, and sleep disturbances, and avoiding sedating drugs and excessive alcohol [105,106]. NEUROLOGIC COMPLICATIONS Intracranial complications Intracranial complications of acute stroke include the development of cerebral edema, symptomatic hemorrhagic transformation of ischemic stroke, elevated intracranial pressure, and hydrocephalus. Cerebral edema with space-occupying mass effect develops in a minority of ischemic stroke but can cause neurologic deterioration and life- threatening herniation. The clinical features and management of intracranial complications of stroke are reviewed separately for each major type of stroke: Ischemic stroke (see "Malignant cerebral hemispheric infarction with swelling and risk of herniation") Intracerebral hemorrhage (see "Spontaneous intracerebral hemorrhage: Acute treatment and prognosis") Subarachnoid hemorrhage (see "Aneurysmal subarachnoid hemorrhage: Treatment and prognosis") The general management of elevated intracranial pressure is discussed elsewhere. (See "Evaluation and management of elevated intracranial pressure in adults".) Early neurologic deterioration Early neurologic deterioration (END) after acute stroke occurs in 2 to 38 percent of patients and is associated with poor outcomes [113-116]. The wide range in the frequency of END probably reflects differences in the patient populations studied and variations in the definitions of END. The mechanisms of END are heterogeneous. Common causes include extension of the infarct into surrounding areas of hypoperfused brain tissue, hematoma expansion of intracerebral hemorrhage, delayed cerebral ischemia associated with subarachnoid hemorrhage, other intracranial complications (eg, progressive cerebral edema, hemorrhagic transformation of ischemic stroke) and toxic-metabolic encephalopathy due to medical complications (eg, concomitant infection; cardiovascular, pulmonary, and/or renal dysfunction) [113,117-119]. Interventions that address the underlying cause may help to improve outcome. However, the cause of END is often unclear [113]. https://www.uptodate.com/contents/complications-of-stroke-an-overview/print 16/34 7/5/23, 12:05 PM Complications of stroke: An overview - UpToDate Seizures Early seizures after stroke are relatively uncommon but are associated with poor outcome. Risk factors include worse stroke severity and cortical involvement. Poststroke seizures are reviewed elsewhere. (See "Overview of the management of epilepsy in adults", section on 'Poststroke seizures'.) SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Stroke in adults".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) Basics topics (see "Patient education: Stroke (The Basics)" and "Patient education: Recovery after stroke (The Basics)") Beyond the Basics topics (see "Patient education: Stroke symptoms and diagnosis (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS Medical complications after ischemic stroke are common ( table 1 and table 2) and influence outcome. Potentially serious complications include pneumonia, urinary tract infection, gastrointestinal bleeding, myocardial infarction, deep vein thrombosis, and pulmonary embolism. (See 'Medical complications' above.) https://www.uptodate.com/contents/complications-of-stroke-an-overview/print 17/34 7/5/23, 12:05 PM Complications of stroke: An overview - UpToDate We evaluate swallowing function using a water swallow test at the time of admission for all patients with acute stroke before administering oral medications or food. Prevention of aspiration in patients with dysphagia includes initial nil per os (NPO; nothing by mouth) status for those who may be at risk for aspiration and subsequent dietary modifications for those who have persistent dysphagia. Patients with acute stroke who cannot take food and fluids orally should receive nutrition and hydration via nasogastric, nasoduodenal, or percutaneous endoscopic gastrostomy tube feedings while undergoing efforts to restore swallowing. (See 'Dysphagia' above.) VTE prophylaxis is indicated for all patients with acute stroke who have restricted mobility, as reviewed separately. (See "Prevention and treatment of venous thromboembolism in patients with acute stroke".) Pneumonia and urinary tract infection are the two most common infectious complications of acute stroke. Screening on admission for swallowing difficulty is an important measure to prevent pneumonia in patients with acute stroke, as discussed above. Measures to prevent aspiration pneumonia in patients with dysphagia include initial NPO status and subsequent dietary modifications for those who have persistent dysphagia. Placement of an indwelling bladder catheter is an important risk factor for urinary tract infection and should be avoided if possible. (See 'Pneumonia' above and 'Urinary tract infection' above.) Myocardial infarction, cardiac arrhythmias, and neurogenic cardiac injury are potential complications of acute stroke. All patients with acute stroke should have ECG and troponin level on admission, and continuous cardiac monitoring at least the first 24 hours of admission. (See 'Cardiac complications' above.) Besides pneumonia, serious pulmonary complications of stroke include neurogenic pulmonary edema and the need for intubation and mechanical ventilation. (See 'Pulmonary complications' above.) Gastrointestinal (GI) bleeding is one of the more common complications of acute stroke. Risk factors include older age, severe stroke, and a history of peptic ulcer disease or cancer predating the incident stroke. GI stress ulcer prophylaxis with proton pump inhibitors or histamine-2 antagonists is not used routinely for patients with acute stroke but is reserved for select patients who need intensive care unit management. (See 'Gastrointestinal bleeding' above.) Urinary incontinence after stroke is associated with poor functional outcome and mortality, perhaps because it is a marker of stroke severity. in previously continent patients, new urinary incontinence is found in 35 to 40 percent of patients at 7 to 10 days after acute https://www.uptodate.com/contents/complications-of-stroke-an-overview/print 18/34 7/5/23, 12:05 PM Complications of stroke: An overview - UpToDate stroke. The prevalence of poststroke incontinence decreases with time. (See 'Urinary incontinence' above.) Falls after acute stroke and are associated with serious injury in 5 percent of patients. Fall precautions should be implemented for all patients with stroke, particularly those with hemiparesis, cognitive impairment, neglect, anosognosia, and/or polypharmacy. (See 'Falls and bone fractures' above.) The prevalence of poststroke depression is 18 to 61 percent. Stroke severity, physical disability, and cognitive impairment are likely risk factors. The effectiveness of pharmacotherapy, psychotherapy, or combined use of these modalities for poststroke depression is not established, but accumulating evidence suggests that these interventions are beneficial. Thus, the standard approach to the treatment of depression is likely to be generalizable to patients with poststroke depression. (See 'Depression' above.) Neurologic complications of acute stroke encompass intracranial morbidities (progressive cerebral edema, symptomatic hemorrhagic transformation of ischemic stroke, elevated intracranial pressure, hydrocephalus), neurologic deterioration, and (uncommonly) seizures. 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