Rehabilitation After Stroke

Prevention of Secondary Stroke and Medical Complications

One of the first issues which must be immediately addressed in the stroke patient is early recurrence of stroke which occurs in up to 8% of stroke patients. Early recurrence of stroke together with progression of medical instability of a severe stroke account for 90% of deaths in the first week following stroke. Approximately 25% of deaths that occur in the first several years after stroke are due to recurrent stroke.

Recurrent Stroke

Every stroke survivor admitted for rehabilitation must be considered for secondary prophylaxis of stroke. Secondary prophylaxis of hemorrhagic stroke includes control of etiologic factors, such as hypertension. Nimodipine 60 mg every 4 hours for 21 days helps to reduce vasospasm and prevent secondary infarction after hemorrhage.

For secondary prevention of non-hemorrhagic stroke, recommendations from the American College of Chest Physicians are as follows:

• Non-Cardioembolic Ischemic Stroke
  • Recommended therapy: aspirin 50-325 mg per day within 48 hours poststroke
  • Alternatives: extended-release-dipyridamole 200 mg + aspirin 25 mg twice per day; clopidogrel 75 mg per day; aspirin 50-1300 mg per day
• Cardioembolic Stroke
  • Recommended therapy with atrial fibrillation: warfarin (INR 2.5, range 2.0-3.0)
  • Alternative option with minor-risk cardiac conditions: aspirin 50-325 mg per day
  • Alternative option with high-risk cardiac conditions (e.g., prosthetic heart valves, valvular heart disease, CAD): warfarin (INR 2.0-3.0)
  • Alternative option after carotid endarterectomy: aspirin 81-325 mg per day

Venous Thromboembolism

Deep venous thrombosis (DVT) may occur in up to 20-75% of stroke survivors and typically occurs in the leg affected by the stroke. The incidence of DVT is thought to be greatest between days 2 and 7 following a stroke. Clinical signs and symptoms, such as pain, swelling, and warmth of the extremity, are at best marginally diagnostic. Clinical suspicion should also be raised in the hemiplegic patient who is not ambulatory and is within 3 months of stroke onset. The risk of DVT increases with increased overall weakness of the patient, presence of atrial fibrillation, and reduced ambulation. Non-invasive testing, such as doppler and impedance plethysmography (measurement and recording of changes in the sizes and volumes of the leg by measuring changes in blood volume) is a routine part of diagnosis.

Prophylactic treatment for DVT includes:

• Aspirin (this is more effective for prevention of pulmonary emboli)
• Low-molecular weight heparins (Enoxaparin) may significantly decrease the incidence of DVT
• Thigh-high compression stockings
• Graded elastic stockings for thromboembolic disease (their efficacy has not been proven in clinical trials)

Some physicians may discontinue prophylactic measures once the patient is ambulating consistently with or without the use of parallel bars.

Pulmonary Embolism

Pulmonary embolism is thought to be the most common cause of death 2-4 weeks after a stroke. Pulmonary embolism is the lodging of a blood clot in the lumen (open cavity) of a pulmonary artery, causing a severe dysfunction in respiratory function. Pulmonary emboli often originate in the deep leg veins and travel to the lungs through blood circulation. Symptoms include sudden shortness of breath, chest pain (worse with breathing), and rapid heart and respiratory rates. Aggressive attention and treatment of DVT is, therefore, very important as it impacts directly on the risk factors for PE. There is a high risk of pulmonary embolism for up to 3 months after stroke.