Medical Complications After Stroke: A Multicenter Study

P. Langhorne, D. J. Stott, L. Robertson, J. MacDonald, L. Jones, C. McAlpine, F. Dick, G. S.

Taylor and G. Murray

Stroke. 2000;31:1223-1229
doi: 10.1161/01.STR.31.6.1223
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2000 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628

The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://stroke.ahajournals.org/content/31/6/1223

Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published
in Stroke can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.
Once the online version of the published article for which permission is being requested is located, click
Request Permissions in the middle column of the Web page under Services. Further information about this
process is available in the Permissions and Rights Question and Answer document.

Reprints: Information about reprints can be found online at:

http://www.lww.com/reprints

Subscriptions: Information about subscribing to Stroke is online at:

http://stroke.ahajournals.org//subscriptions/

Downloaded from http://stroke.ahajournals.org/ by guest on February 26, 2014

 Medical Complications After Stroke
A Multicenter Study
P. Langhorne, PhD, FRCP; D.J. Stott, MD, FRCP; L. Robertson, RGN; J. MacDonald, FRCP;
L. Jones, RGN; C. McAlpine, FRCP; F. Dick, RGN; G.S. Taylor, BSc; G. Murray, PhD

Background and Purpose—This prospective, multicenter study was performed to determine the frequency of symptomatic
complications up to 30 months after stroke using prespecified definitions of complications.
Methods—We recruited 311 consecutive stroke patients admitted to hospital. Research nurses reviewed their progress on
a weekly basis until hospital discharge and again at 6, 18, and 30 months after stroke.
Results—Complications during hospital admission were recorded in 265 (85%) of stroke patients. Specific complications
were as follows: neurological—recurrent stroke (9% of patients), epileptic seizure (3%); infections— urinary tract
infection (24%), chest infection (22%), others (19%); mobility related—falls (25%), falls with serious injury (5%),
pressure sores (21%); thromboembolism— deep venous thrombosis (2%), pulmonary embolism (1%); pain—shoulder
pain (9%), other pain (34%); and psychological— depression (16%), anxiety (14%), emotionalism (12%), and confusion
(56%). During follow-up, infections, falls, “blackouts,” pain, and symptoms of depression and anxiety remained
common. Complications were observed across all 3 hospital sites, and their frequency was related to patient dependency
and duration after stroke.
Conclusions—Our prospective cohort study has confirmed that poststroke complications, particularly infections and falls,
are common. However, we have also identified complications relating to pain and cognitive or affective symptoms that
are potentially preventable and may previously have been underestimated. (Stroke. 2000;31:1223-1229.)
Key Words: complications 䡲 stroke outcome 䡲 infection 䡲 pain

M edical complications are believed to be an important

problem after acute stroke and present potential barri-
ers to optimal recovery. Several previous studies have sug-
gested that complications not only are common, with esti-
mates of frequency ranging from 40% to 96% of patients,1– 6
but also are related to poor outcome.6 Many of the compli-
cations described are potentially preventable or treatable if
recognized.
Although many studies have reported frequencies of post-
stroke complications, they have all been subject to important
methodological limitations. Most have been retrospective
series, and to date, none have met the basic criteria for a
reliable cohort study.7 In particular, they have not studied a
defined representative sample (inception cohort) of patients
assembled early in the course of their disease, with regular
and complete follow-up using prespecified objective outcome
criteria. Previous studies have either incorporated a retrospec-
tive case-ascertainment design1–5 or a prospective analysis of
patients selected for an acute intervention study.6 We have
performed a prospective multicenter study of recovery among
hospitalized stroke patients managed in a routine clinical
setting. This included the identification of potential barriers to
recovery (poststroke complications), which are described
here.
Subjects and Methods
We recruited stroke patients admitted over a 7-month period to 3
hospital sites in the West of Scotland (Glasgow Royal Infirmary,
Drumchapel Hospital, and Stirling Royal Infirmary). Two of the
hospital sites (Glasgow Royal Infirmary and Stirling Royal Infir-
mary) provided acute stroke patient care (coordinated by a mobile
stroke team) in general medical wards with subsequent rehabilitation
in a stroke rehabilitation ward. The third site (Drumchapel Hospital)
is a rehabilitation facility accepting patients from an acute stroke unit
⬇1 week after stroke.
We recruited consecutive admissions who fulfilled the World
Health Organization clinical definition of stroke, except in Glasgow
Royal Infirmary, where because of larger patient numbers, acute
stroke admissions were recruited on alternate days of admission.
There was a rehabilitation philosophy of care across all 3 sites, with
the aim of optimizing patient function; care was provided for several
weeks if necessary until discharge home or appropriate placement in
institutional care, and patients were not transferred to other rehabil-
itation environments. Average length of stay was ⬇5 weeks.

Received November 15, 1999; final revision received February 23, 2000; accepted February 24, 2000.
From the Academic Section of Geriatric Medicine, Royal Infirmary (P.L., D.J.S., L.R.), Glasgow, Scotland, UK; Department of Geriatric Medicine,
Gartnavel General Hospital (J.M., L.J.), Glasgow, Scotland, UK; Department of Geriatric Medicine, Stirling Royal Infirmary (C.M., F.D.), Scotland, UK;
and Department of Community Health Sciences, University of Edinburgh (G.S.T., G.M.), Scotland, UK.
Correspondence to Dr Peter Langhorne, Academic Section of Geriatric Medicine, Level 3, Centre Block, Royal Infirmary, Glasgow G4 OSF, United
Kingdom. E-mail P.Langhorne@clinmed.gla.ac.uk
© 2000 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org

1223
Downloaded from http://stroke.ahajournals.org/ by guest on February 26, 2014
1224 Stroke June 2000

TABLE 1. Definitions of Complications During Hospital and Community Follow-Up

Complication
1. Neurological
1.1 Recurrent stroke
1.2 Epileptic seizure
1.3 Unexplained events
2. Infection
2.1 Urinary tract infection
2.2 Chest infection
2.3 Other infection
3. Complications of immobility
3.1 Falls
3.2 Pressure sore/skin
break
4. Thromboembolism
4.1 Deep vein thrombosis
4.2 Pulmonary embolism
5. Pain
5.1 Shoulder pain
5.2 Other pain
6. Psychological
6.1 Depression
6.2 Emotionalism
6.3 Anxiety
6.4 Confusion
7. Miscellaneous
Follow-Up in Hospital
Clinical features lasting more than 24 hours consistent with the
World Health Organization definition of stroke.8
Clinical diagnosis of focal and/or generalized seizure in a
previously nonepileptic patient.
Clinical symptoms of urinary tract infection or positive urine
culture.
Auscultatory respiratory crackles and fever or radiographic
evidence, or new purulent sputum.
Any pyrexial illness lasting more than 24 hours.
Any documented falls regardless of cause (fall with serious injury
was defined as one that resulted in fracture, radiological
investigation, neurological investigation, or suturing of wound).
Any skin break or necrosis resulting from either pressure or trivial
trauma (skin trauma directly resulting from falls was not included).
Clinical diagnosis of deep vein thrombosis.
Clinical diagnosis of pulmonary embolism.
Pain in the shoulder area requiring analgesia on 2 or more
consecutive days.
Any other source of pain requiring regular analgesia.
Low mood considered to interfere with daily activities or require
pharmacological or psychiatric intervention.
Episodes of crying or laughing that are sudden or unheralded and
not under social control.
Symptoms of anxiety considered to interfere with daily activities or
requiring pharmacological or psychiatric intervention.
Cognitive disturbance considered to interfere with nursing care or
rehabilitation.
Any documented complication resulting in a specific medical or
surgical intervention (eg, gastrointestinal hemorrhage, constipation,
episodes of cardiac failure, cardiac arrhythmias, and arthritis).
Follow-Up After Discharge
Asked about any episodes of new weakness or
numbness in arms or legs or new problems with vision
or speech.
As before.
Asked about any unexplained “blackouts” or “funny
turns.”
Urine infections requiring medical help and/or antibiotic
treatment.
Chest infection requiring medical help and/or antibiotic
treatment.
Other infections requiring medical help and/or antibiotic
treatment.
Any falls (single or more than 1). Recorded those
resulting in a fracture or “serious injury.”
As before.
Any episodes of “blood clot in the leg.”
Any episodes of “blood clot in the lung.”
As before.
As before.
Asked “do you often feel sad or depressed?”9
Asked if drug treatment had been prescribed.
Asked “do you often feel anxious or agitated?”9
Asked if drug treatment had been prescribed.
Asked about any other major illness.
Asked if illness had resulted in readmission to hospital.

Patients were recruited within 7 days of stroke onset, and their
progress was reviewed on a weekly basis until discharge from
hospital. The initial assessment included demographic details, stroke
impairments, and functional dependency (Barthel index and Func-
tional Independence Measure [FIM]8). Weekly assessments of func-
tional status and the occurrence of prespecified complications were
performed by 3 research nurses (1 per site) in conjunction with the
local clinical staff. The research nurses held regular meetings to
ensure comparability of data collection, assessment methods, and
definitions of complications. After discharge from hospital, 1 of the
research nurses followed up all patients at ⬇6, 18, and 30 months
after stroke. These assessments were performed in the most conve-
nient location (eg, home, nursing home, or day hospital) and
included a questionnaire about stroke complications.
Definition of Complications
Because our primary interest was the frequency of all complications
in a cohort of stroke patients, we did not distinguish between those
associated with survival or death. For hospital follow-up, we used
simple clinical definitions of complications (Table 1) that were
modified from those of Davenport et al.1 Community follow-up
required further modification of questions that could be asked of
patients and/or caregivers (Table 1).
Results
A total of 311 consecutive stroke patients were admitted to
the 3 hospital sites: Glasgow Royal Infirmary, 129 patients;
Drumchapel Hospital, 111 patients; and Stirling Royal Infir-
mary, 71 patients. The median delay between symptom onset
and recruitment into the study was 4 days (interquartile range
2 to 7 days), with a median follow-up of 7 weeks. Of a total
possible 2383 weekly assessments in hospital, 2280 (96%)
were completed, which represents ⬇15 960 hospital days of

Downloaded from http://stroke.ahajournals.org/ by guest on February 26, 2014

 Langhorne et al Medical Complications After Stroke 1225

TABLE 2. Frequency of Symptomatic Complications in Hospitalized Stroke Patients

Current Study Range of Frequencies (%)
Range of Frequencies (%) From Previous
Frequency, % Range Across From Previous Prospective Studies of
Complication (95% CI) Study Sites, % Retrospective Studies* Acute Patients†
Neurological
Recurrent stroke 9 (6–12) 1–15 5 18
Epileptic seizure 3 (1–5) 1–6 2–5 3
Infections
Urinary tract infection 23 (18–28) 16–25 7–25 11–28
Chest infection 22 (18–27) 18–28 7–21 10–20
Other infection 19 (15–24) 10–27 4 4–31
Mobility
Pressure sore/skin break 21 (16–25) 12–27 3–18 䡠䡠䡠
Fall, serious injury 5 (2–7) 1–8 1–3‡ 2*
Fall, no injury 21 (16–25) 9–33 䡠䡠䡠 䡠䡠䡠
Fall, total 25 (21–30) 9–33 22–25§ 䡠䡠䡠
Thromboembolism
Deep vein thrombosis 2 (0–3) 1–4 㛳1–3㛳 1–2㛳 (11–75)¶
Pulmonary embolus 1 (0–2) 1–1 2–18 0–1㛳 (3–39)¶
Pain
Shoulder pain 9 (6–12) 6–11 4 27
Other pain 34 (28–39) 29–38 6–30 䡠䡠䡠
Psychological
Depression 16 (12–21) 16–17 5–33 1–50
Emotionalism 12 (8–15) 7–16 䡠䡠䡠 䡠䡠䡠
Anxiety 14 (10–18) 5–38 7 8#
Confusion 36 (30–41) 29–42 5 3–40
Miscellaneous (eg, chest 61 (55–66) 44–72 32 䡠䡠䡠
pain, hemorrhage)
Total 85 (82–89) 76–91 40–96 63–95
Results are expressed as the proportion (%) of patients noted to have a complication on at least 1 occasion.
*Data from previous retrospective studies are taken from references 1–5 and 10.
†Data from previous prospective studies are taken from references 6 and 11–26.
‡Defined as fracture.
§Defined as all falls.
㛳Clinical detection.
¶Radiological detection.
#Includes both agitation and anxiety.

observation. Of a possible 554 community follow-up visits of
survivors, a total of 546 (99%) were completed, of which 478
(88%) were by interview and 68 (12%) by telephone.
Patient Cohort
The 311 patients had an average age of 76 years (interquartile
range 70 to 82 years); 161 (52%) were male, 229 (74%) were
independent (modified Rankin score 0 to 2) before the stroke,
and 248 (80%) underwent early CT scanning; of these, 220
(89%) showed infarction or no visible lesion, and 28 (11%)
showed a primary intracerebral hemorrhage. The clinical
stroke subtypes were as follows: total anterior circulation
stroke, 108 (35%); partial anterior circulation stroke, 105
(34%); lacunar stroke, 56 (18%); posterior circulation stroke,
9 (3%); and hemorrhage or unclassifiable, 32 (10%). A total
of 60 patients (19%) died in hospital, 91 (29%) by the
6-month follow-up, 130 (42%) by 18 months, and 156 (50%)
by 30 months. Therefore, we appear to have recruited a
relatively elderly, disabled cohort of patients, with the exclu-
sion of those who made a rapid recovery in the first few days.
Complications in Hospital
A total of 265 patients (85%) experienced at least 1 prespeci-
fied complication during their stay in hospital. The results for
individual sites ranged from 76% to 91%. Seven (2%) of the
patients had an early hospital readmission, and their readmis-
sion complications are included within the hospital data. The
main complications are outlined in Table 2 (along with
summary results from previous retrospective studies and
selective prospective studies of acute stroke patients). It is
clear that the frequencies of many of the complications
identified in the present study are comparable to those of

Downloaded from http://stroke.ahajournals.org/ by guest on February 26, 2014

1226 Stroke June 2000

previous reports. In particular, recurrent stroke, epileptic TABLE 3. Frequency of Symptomatic Complications in
seizure, infections, pressure sores, falls, thromboembolism, Hospitalized Stroke Patients
and total complication rates are all comparable with previous Incidence (Percent Weekly Point
studies. However, in the present study, we appear to have Events per Patient Prevalence (Percent
recorded higher levels of pain and psychological symptoms per Hospital Events per Week of
than previously reported. Table 2 illustrates that the range of Complications Admission) Observation)
frequencies across individual sites was very similar, with the Neurological
possible exception of recurrent stroke, falls, anxiety, and Recurrent stroke 9 (6–12) 2 (1–3)
miscellaneous complications. It is not clear whether these
Epileptic seizure 3 (1–5) 0.5 (0–1)
minor variations are due to differences in patient case mix or
Infection
subtle differences in the definition of complications.
The data outlined in Table 2 are expressed in terms of Urinary tract infection 23 (18–28) 8 (7–9)
hospital incidence rates, ie, the number of patients who Chest infection 22 (18–27) 7 (5–8)
experienced a complication in hospital. In these estimates, a Other infection 19 (15–24) 7 (6–8)
particular complication could only be recorded once per Mobility
patient. This analysis may misrepresent the burden of a Pressure sore/skin break 21 (16–25) 19 (17–21)
complication, because it may not take into account the
Fall, serious injury 5 (2–7) 1 (0–2)
duration of observation (time in hospital) and may underes-
Fall, no injury 21 (16–25) 7 (5–8)
timate the burden of chronic complications that persist over a
long period. We therefore recalculated complications in terms Thromboembolism
of the total number of weekly observations in which a Deep vein thrombosis 2 (0–3) 0.5 (0–1)
complication was recorded (weekly point prevalence). As Pulmonary embolism 1 (0–2) 0.2 (0–0.5)
expected, these point-prevalence estimates (Table 3) were Pain
generally smaller than the hospital incidence results, but the Shoulder pain 9 (6–12) 6 (5–7)
relative frequency of complications remained very similar. Other pain 34 (28–39) 14 (12–16)
Psychological
Complications After Hospital Discharge
The complications reported by patients and/or caregivers at Depression 16 (12–21) 19 (15–23)
various census times during follow-up are outlined in Table 4. Emotionalism 12 (8–15) 6 (5–7)
Complication rates in hospital are shown for comparison, Anxiety 14 (10–18) 9 (7–10)
although slightly different methods were used. Patients re- Confusion 36 (30–41) 24 (22–26)
ported a high frequency of infections, falls, pain, and symp- Miscellaneous (eg, chest pain) 61 (55–66) 35 (33–38)
toms of depression and anxiety (although smaller numbers of
Incidence results are expressed as the proportion (95% CI) of patients in
patients were taking antidepressant medication). Miscella-
whom a complication was noted during hospital admission. Weekly point
neous illness, unexplained “blackouts” and “funny turns,” prevalence results are expressed as the proportion (95% CI) of weekly
and hospital readmission were also common. observations in which a complication was noted.

Relationship With Stroke Severity
In examining the relationship between stroke severity and
complications, we focused our analysis on the Glasgow Royal
Infirmary data, which incorporated an unselected series of
stroke patients followed up by a single observer during both
the acute and rehabilitation phases of their illness. These
results are summarized in Table 5, which shows the propor-
tion of patients experiencing complications subdivided by
their initial level of dependency; dependency was classified
by the FIM score at first assessment (median 3 days,
interquartile range 1 to 4 days after stroke). These results
were divided into 3 categories: (1) mild—initial FIM ⬎100
points (n⫽14); (2) moderate—initial FIM 50 to 100 (n⫽42);
and (3) severe—initial FIM ⬍50 (n⫽74). There were trends
for more dependent patients to have a higher risk of infec-
tions, falls, pressure sores, pain, anxiety, and depression.
However, on a ␹2 test for trend, statistically significant results
were seen only for infections (P⬍0.05), pressure sores
(P⬍0.01), and anxiety (P⬍0.05).
Timing of Complications After Stroke
We wished to ascertain the delay between the index stroke
and onset of individual complications. This was analyzed as
the cumulative number of patients experiencing a complica-
tion at successive periods after the index stroke (Figure). It
was clear that most complications developed within the first
6 weeks after stroke, with an early onset being seen particu-
larly for pressure sores, pain, and infections. Falls and
depression appeared to develop more gradually, which could
reflect progress in rehabilitation (falls) or a reluctance to
make an early diagnosis of depression.
Discussion
To the best of our knowledge, this is the first study of
poststroke complications that has used a prospective design to
observe a relatively unselected group of patients over a
prolonged period of time with prespecified clinical criteria for
complications. We sought to maximize the reliability of the
study by having a clearly defined inception cohort, prespeci-
fied definitions of complications, and a standardized regular
follow-up of all patients.7 Although our initial follow-up was
performed by 3 observers, we sought to ensure comparability
of data recording by having standardized definitions of
complications and regular meetings to ensure comparability
of data recording. Because most patients remained in hospital

Downloaded from http://stroke.ahajournals.org/ by guest on February 26, 2014

 Langhorne et al Medical Complications After Stroke 1227

TABLE 4. Frequency of Complications up to 30 Months After Stroke

Observation Period (*Census Time)

Hospital Discharge
Admission to 6* 6 –18* 18 –30*
(Weekly*) Months Months Months
Duration of observation period 2 mo* 4 mo* 12 mo 12 mo
Number of patients alive at census 311 220 181 155
Number lost to follow-up 0 0 1 7
Number observed 311 220 180 148
Complications
Neurological
Recurrent stroke 9 (6–12) 6 (2–9) 9 (4–18) 12 (7–18)
Epileptic seizure 3 (1–5) 1 (0–2) 5 (1–8) 5 (1–9)
Unexplained blackout† 䡠䡠䡠 9 (4–18) 19 (13–25) 13 (7–19)
Infection
Urinary tract infection 23 (18–28) 16 (10–22) 23 (16–30) 22 (15–29)
Chest infection 22 (18–27) 13 (8–19) 23 (16–30) 29 (21–37)
Other infection 19 (15–24) 8 (4–13) 25 (18–32) 21 (14–28)
Mobility
Pressure sore/skin break 21 (16–25) 8 (3–12) 8 (3–12) 11 (6–17)
Fall, serious injury 5 (2–7) 8 (3–12) 15 (9–20) 12 (6–17)
Fall, no injury 21 (16–25) 29 (22–36) 34 (27–42) 33 (27–39)
Falls, multiple† 䡠䡠䡠 22 (15–29) 34 (27–42) 29 (24–34)
Falls, total 25 (21–30) 36 (28–44) 49 (41–57) 45 (37–53)
Thromboembolism
Deep vein thrombosis‡ 2 (0–3) 0 1 (0–1) 0
Pulmonary embolism‡ 1 (0–2) 0 0 0
Pain
Shoulder pain 9 (6–12) 15 (9–21) 11 (6–16) 12 (6–17)
Other pain 34 (28–39) 41 (33–50) 35 (27–42) 37 (29–45)
Psychological
Depression, clinical§ 16 (12–21) 䡠䡠䡠 䡠䡠䡠 䡠䡠䡠
Depression, drug therapy㛳 䡠䡠䡠 17 (11–23) 12 (7–17) 15 (8–21)
Depression, symptoms¶ 䡠䡠䡠 50 (42–58) 43 (35–51) 54 (45–62)
Anxiety, clinical§ 14 (10–18) 䡠䡠䡠 䡠䡠䡠 䡠䡠䡠
Anxiety, drug therapy㛳 䡠䡠䡠 4 (0–7) 5 (1–8) 8 (3–13)
Anxiety, symptoms¶ 䡠䡠䡠 34 (26–42) 44 (36–52) 49 (41–58)
Miscellaneous (eg, chest pain) 61 (55–66) 24 (17–31) 41 (33–49) 49 (41–58)
Hospital readmission 2 (0–4)# 15 (9–21) 31 (24–38) 35 (27–43)
Results are expressed as the proportion (95% CI) of patients in whom a complication was noted during the period
of observation after stroke.
*Approximate period of observation.
†Recorded only after discharge.
‡Clinical diagnosis.
§Clinical impression of hospital staff.
㛳Prescribed antidepressant drug.
¶Reported symptoms of depression or anxiety in response to the questions “do you often feel sad or depressed?”
and “do you often feel anxious or agitated?”
#Eight patients had early readmission and are included with the hospital data.

until they were independent enough to return home or will be toward underestimating the frequency of compli-
judged to be unable to benefit from further rehabilitation, cations. Estimates of complications at later follow-up
we believe we have achieved good ascertainment of depended on information from patients and caregivers,
complications during the main recovery period after which may have underestimated or overestimated compli-
stroke. Any bias in our hospital complication estimates cation rates.
Downloaded from http://stroke.ahajournals.org/ by guest on February 26, 2014
1228 Stroke June 2000
TABLE 5. Frequency of Symptomatic Complications in
Relation to Initial Level of Dependency
Initial Level of Dependency (FIM Score)
Significance
Complication FIM ⬎100 FIM 50 –100 FIM ⬍50
Recurrent stroke 21 (1–42) 12 (1–22) 14 (6–20)
Seizure 0 2 (0–4) 4 (0–8)
Infection 14 (0–32) 35 (19–51) 54 (43–65)
Falls 21 (0–42) 31 (23–40) 39 (28–50)
Pressure sore 7 (0–20) 12 (2–22) 36 (25–47)
Thromboembolism 0 5 (0–11) 5 (0–10)
Pain 14 (0–35) 43 (28–58) 38 (27–49)
Depression 14 (0–32) 17 (6–28) 30 (19–41)
Anxiety 0 12 (2–22) 42 (31–53)
Results are expressed as the proportion (95% CI) of patients experiencing a
complication subdivided by their initial level of dependency (initial FIM).
The limitations of our study include the focus on symp-
tomatic complications; the rather simple, pragmatic nature of
some definitions of complications; and the differing case mix
in the 3 hospital sites. We used simple clinical definitions
because we believed this would be the most practical and
accurate representation of the clinical symptoms experienced
by stroke patients. Although the patient case mix may have
varied between hospitals, we were keen to include this
combination because it is representative of the range of acute
and rehabilitation services available in the United Kingdom.
Our definitions of complications were rather inclusive (eg,
pressure sore defined as any suspicious skin lesion), which
may have resulted in our high prevalence of some complica-
tions. However, we feel these data are useful as an indicator
of all potential symptomatic complications.
Our findings appear to confirm previous studies1– 6,10 –27
that showed that there are relatively low frequencies of the
symptomatic complications of recurrent stroke, poststroke
seizures, clinical deep vein thrombosis, and clinical pulmo-
nary embolism. We have also confirmed the relatively high
frequencies of urinary tract infection, chest infection, and
other types of pyrexial illness. However, many of the com-
plications that are more difficult to specify, such as pain,
depression, anxiety, and confusion, appear to have been
relatively frequent in our study and more common than in
previous series. This could reflect the prospective nature of
our data collection, in which the research nurses sought to
identify all potential barriers to patient recovery. The discrep-
ancy could also be due to the different (and rather subjective)
definitions used compared with previous studies. This is
particularly the case with symptoms of depression or anxiety,
which were common (34% to 54% prevalence) when based
on a screening question but much less common if based on
drug prescriptions. An alternative explanation is that depres-
sion and anxiety have previously been underrecognized, and
it is interesting to note a recent study using psychiatrist
follow-up27 reported a prevalence of depression of 53% at 3
months and 42% at 12 months.
Previous authors6 have noted the strong association be-
tween poststroke complications and poor outcome and have
suggested that complications may act as barriers to recovery.
Downloaded from http://stroke.ahajournals.org/ by guest on February 26, 2014
(␹2 Test)
NS
NS
P⬍0.05
NS
P⬍0.01
NS
NS
NS
P⬍0.01 Timing of symptomatic complications after stroke. Results are
expressed as the cumulative proportion (%) of patients who
were noted to have a symptomatic complication in hospital dur-
ing the first 12 weeks after stroke. UTI indicates urinary tract
infection; DVT, deep venous thrombosis.
This raises the possibility that rigorous attention to detail in
the prevention and early treatment of complications could
improve stroke outcome. Indeed, the data from the random-
ized trials of stroke unit care28 indicate that the causes of
death that are most likely to be prevented by stroke unit care
are those classified29 as complications of immobility (in
particular, thromboembolism and infection). In more pro-
longed follow-up, it is clear that this group of patients has
significant morbidity and risk of readmission to hospital.
Interventions to detect and treat the more common compli-
cations appear worthy of further study.
Acknowledgments
This project was funded by the Chief Scientists Office, Scottish
Office. We are grateful to our medical and nursing colleagues in
Glasgow Royal Infirmary, Stirling Royal Infirmary, and Drumchapel
Hospital whose cooperation made this study possible.
References
1. Davenport RJ, Dennis MS, Wellwood I, Warlow C. Complications after
acute stroke. Stroke. 1996;27:415– 420.
2. McClatchie G. Survey of the rehabilitation outcomes of stroke. Med J
Aust. 1980;1:649 – 651.
3. Dobkin BH. Neuromedical complications in stroke patients transferred
for rehabilitation before and after diagnostic related groups. J Neurol
Rehabil. 1987;1:3–7.
4. Dromerick A, Reding M. Medical and neurological complications during
inpatient stroke rehabilitation. Stroke. 1994;25:358 –361.
5. Kalra L, Yu G, Wilson K, Roots P. Medical complications during stroke
rehabilitation. Stroke. 1995;26:990 –994.
6. Johnston KC, Li JY, Lyden PD, Hanson SK, Feasby TE, Adams R,
Faught E, Haley EC, for the RANTTAS Investigators. Medical and
neurological complications of ischemic stroke: experience from the
RANTTAS trial. Stroke. 1999;29:447– 453.
7. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology:
A Basic Science for Clinical Medicine. 2nd ed. Boston, Mass: Little
Brown & Co; 1991.
8. Wade DT. Measurement in Neurological Rehabilitation. Oxford, UK:
Oxford University Press; 1992.
9. Mahoney J, Drinka TJK, Abler R, Gunter-Hunt G, Matthews C,
Gravelstein S, Carnees M. Screening for depression: single question
versus GDS. J Am Geriatr Soc. 1994;42:1006 –1008.
10. Fan CW, McDonnell R, Johnson Z, Keating D, O’Keeffe S, Crowe M.
Complications in patients admitted to hospital with acute stroke. Age
Ageing. 1999;28(suppl 2):P58. Abstract.
11. Henon H, Labert F, Durieu I, Godefroy O, Lucas C, Pasquier F, Leys D.
Confusional state in stroke: relation to pre-existing dementia, patient
characteristics, and outcome. Stroke. 1999;30:773–779.
 Langhorne et al
12. Mann G, Hankey G, Cameron D. Swallowing function after stroke:
prognosis and prognostic factors at 6 months. Stroke. 1999;30:744 –748.
13. Burn J, Dennis M, Bamford J, Sandercock P, Wade D, Warlow C.
Epileptic seizures after a first stroke: the Oxfordshire community stroke
project. BMJ. 1997;315:1582–1587.
14. Nyberg L, Gustafson Y. Patient falls in stroke rehabilitation: a challenge
to rehabilitation strategies. Stroke. 1995;26:838 – 842.
15. Reding MJ, Winter SW, Hochrein SA, Simon HB, Thompson MM.
Urinary incontinence after hemispheric stroke: a neurologic-
epidemiologic perspective. J Neurol Rehabil. 1987;1:25–30.
16. Feibel JH, Springer CJ. Depression and failure to resume social activities
after stroke. Arch Phys Med Rehabil. 1982;63:276 –277.
17. Eastwood MR, Rifat SL, Nobbs H, Ruderman J. Mood disorder following
cerebrovascular accident. Br J Psychiatry. 1989;154:195–200.
18. Desmond DW, Tatemichi TK, Figueroa M, Gropen TI, Stern Y. Disori-
entation following stroke: frequency, course and clinical correlates.
J Neurol. 1994;241:585–591.
19. Braus DF, Krauss JK, Strobel J. The shoulder-hand syndrome after
stroke: a prospective clinical trial. Ann Neurol. 1994;36:728 –733.
20. Kilpatrick CJ, Davis SM, Tress BM, Rossiter SC, Hopper JL,
Vandendreisen ML. Epileptic seizures in acute stroke. Arch Neurol.
1990;47:157–160.
21. Przelomski MM, Roth RM, Gleckman RA, Marcus EM. Fever in the
wake of a stroke. Neurology. 1986;36:427– 429.
Downloaded from http://stroke.ahajournals.org/ by guest on February 26, 2014
Medical Complications After Stroke 1229
22. Castillo J, Martinez F, Leira R, Prieto JM, Lema M, Noya M. Mortality
and morbidity of acute cerebral infarction related to temperature and basal
analytic parameters. Cerebrovasc Dis. 1994;4:66 –71.
23. Oezkowski WJ, Ginsberg JS, Shin A, Panju A. Venous thromboembolism
in patients undergoing rehabilitation for stroke. Arch Phys Med Rehabil.
1992;73:712–716.
24. McCarthy ST, Turner JJ, Robertson D, Hawkey CJ. Low-dose heparin as
a prophylaxis against deep-vein thrombosis after acute stroke. Lancet.
1977;2:800 – 801.
25. Cope C, Reyes TM, Skversky NJ. Phlebographic analysis of the incidence
of thrombosis in hemiplegia. Radiology. 1973;109:581–584.
26. Dickmann U, Voth E, Schicha H, Henze T, Prange H, Emrich D. Heparin
therapy, deep-vein thrombosis and pulmonary embolism after intracere-
bral haemorrhage. Klin Wochenschr. 1988;66:1182–1183.
27. Kauhanen ML, Korpelainen JT, Hiltunen P, Brusin E, Mononen H,
Maatta R, Nieminen P, Sotaniemi KA, Myllyla VV. Poststroke
depression correlates with cognitive impairment and neurological deficits.
Stroke. 1999;30:1875–1880.
28. Langhorne P, Dennis MS. Stroke Units: An Evidence Based Approach.
London, UK: BMJ Books; 1998.
29. Bamford J, Dennis M, Sandercock P, Burn J, Warlow C. The frequency,
causes and timing of death within 30 days of a first stroke: the
Oxfordshire Community Stroke Project. J Neurol Neurosurg Psychiatry.
1990;53:824 – 829.