Determinants of complications in ﬁrst ever acute stroke patients: a prospective observational study from India
1Bangur Institute of Neurosciences (BIN), Kolkata, West Bengal, India
2Burdwan Medical College and Hospital, Burdwan, West Bengal, India
Online publish date: 12 January 2021
Background and Aims: Post-stroke complications can lead to frequent and major causes of death in the early phases after an acute stroke. Aims of the present study were to determine the association of several risk factors with the occurrence of poststroke complications, the predictors for the development of complications, and to evaluate how these complications affected the overall prognosis among subjects with the first ever acute stroke. This study is the pioneer study of this kind from Eastern India. Previous national and international studies on this lack uniformity in their results probably because of the following reasons: no standard definitions for complications following the stroke, varied follow-up periods ranging from 1 week to 30 months, type and severity of stroke affecting the incidence, and finally, the demographic variables.
Methods: This was an observational, prospective study, in which a total of 521 adult male and female patients who had a first-ever acute stroke, aged between 12 years to 75 years were enrolled over a period of 2 years (September 2016 to September 2018), admitted in Department of Neuromedicine, Bangur Institute of Neurosciences (BIN), Kolkata, India. Patients with first ever acute stroke were studied for post-stroke complications (predefined with standard criteria) during the hospital stay at Bangur Institute of Neurosciences (BIN), Kolkata, India, and their association with risk factors, severity of stroke (National Institutes of Health Stroke Scale Score, NIHSS), length of hospital stay (in days) and outcome (Modified Rankin Scale, MRS) were assessed. Results: A total of screened 498 patients who were admitted at Bangur Institute of Neurosciences (BIN), Kolkata, India, with first ever acute stroke were recruited. The mean age was 61.02 years (range 23-75 years), the majority being male (n = 307; 61.6%). Post-stroke complication during hospital stay was documented in 270 patients (54.2%)(males and females combined). In logistic regression analysis, multiple risk factors (OR, 1.571; 95% CI, 1.084-2.278; P-0.017), severity of stroke (National Institutes of Health Stroke Scale Score, NIHSS) (OR, 1.425; 95% CI, 1.027-1.976; P-0.034) and length of hospital stay (in days) (OR, 3.565; 95% CI, 2.029-6.264; P < 0.0001) were the most robust predictors of occurrence of complications. The independent predictors of poor outcome in subjects with complications were: chest infection (OR, 2.07; 95% CI, 1.006-4.26; P = 0.048), bedsores (OR, 2.26; 95% CI, 1.03-4.94; P-0.042), and seizures (OR, 5.072; 95% CI, 1.08-23.79; P-0.039).
Conclusion: In our study, the most independent predictors of complications were severity of stroke and length of hospital stay. This observation might help clinicians in taking appropriate measures towards preventing post-stroke complications and thereby improving outcome following a stroke.
Post-stroke complications; Length-of-hospital-stay; Post-stroke-outcome; Stroke-severity; Chest-infection
Vishal Madhukar Sawale,Durjoy Lahiri,Ritwik Ghosh,Souvik Dubey,Gautam Das,Goutam Gangopadhyay,Biman Kanti Ray. Determinants of complications in ﬁrst ever acute stroke patients: a prospective observational study from India. Signa Vitae. 2021.doi:10.22514/sv.2021.002.
 Charfi N, Trabelsi S, Turki M, Mâalej Bouali M, Zouari L, Dammak M, et al. Impact du handicap physique et des troubles émotionnels concomitants sur la qualité de vie en post-AVC. L’EncéPhale. 2017; 43: 429-434. (In French)
 Mijajlović MD, Pavlović A, Brainin M, Heiss W, Quinn TJ, Ihle-Hansen HB, et al. Post-stroke dementia-a comprehensive review. BMC Medicine. 2017; 15: 11.
 Brainin M, Tuomilehto J, Heiss W, Bornstein NM, Bath PMW, Teuschl Y, et al. Post-stroke cognitive decline: an update and perspectives for clinical research. European Journal of Neurology. 2015; 22: 229-238, e13-6.
 Doruk D, Simis M, Imamura M, Brunoni AR, Morales-Quezada L, Anghinah R, et al. Neurophysiologic correlates of post-stroke mood and emotional control. Frontiers in Human Neuroscience. 2016; 10: 428.
 McAleese N, Guzman A, O’Rourke SJ, Gillespie DC. Post-stroke emotionalism: a qualitative investigation. Disability and Rehabilitation. 2019; 65: 1-9.
 Lehnerer S, Hotter B, Padberg I, Knispel P, Remstedt D, Liebenau A, et al. Social work support and unmet social needs in life after stroke: a cross-sectional exploratory study. BMC Neurology. 2019; 19: 220.
 Rajsic S, Gothe H, Borba HH, Sroczynski G, Vujicic J, Toell T, et al. Economic burden of stroke: a systematic review on post-stroke care. The European Journal of Health Economics. 2019; 20: 107-134.
 Bovim MR, Askim T, Lydersen S, Fjærtoft H, Indredavik B. Com-plications in the first week after stroke: a 10-year comparison. BMC Neurology. 2016; 16: 133.
 Chohan S, Venkatesh P, How C. Long-term complications of stroke and secondary prevention: an overview for primary care physicians. Singapore Medical Journal. 2019; 60: 616-620.
 Khalid W, Rozi S, Ali TS, Azam I, Mullen MT, Illyas S, et al. Quality of life after stroke in Pakistan. BMC Neurology. 2016; 16: 250.
 Lui SK, Nguyen MH. Elderly stroke rehabilitation: overcoming the complications and its associated challenges. Current Gerontology and Geriatrics Research. 2018; 2018: 9853837.
 GBD 2016 Stroke Collaborators. Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2019; 18: 439-458.
 Krishnamurthi RV, Feigin VL, Forouzanfar MH, Mensah GA, Connor M, Bennett DA, et al. Global and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. The Lancet Global Health. 2013; 1: e259-e281.
 Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation. 2020; 141: e139-e596.
 Wasay M, Khatri IA, Kaul S. Stroke in South Asian countries. Nature Reviews Neurology. 2014; 10: 135-143.
 Lau L, Lew J, Borschmann K, Thijs V, Ekinci EI. Prevalence of diabetes and its effects on stroke outcomes: a meta‐analysis and literature review. Journal of Diabetes Investigation. 2019; 10: 780-792.
 Huynh W, Kwai N, Arnold R, Krishnan AV, Lin CS, Vucic S, et al. The effect of diabetes on cortical function in stroke: implications for poststroke plasticity. Diabetes. 2017; 66: 1661-1670.
 Sweetnam D, Holmes A, Tennant KA, Zamani A, Walle M, Jones P, et al. Diabetes impairs cortical plasticity and functional recovery following ischemic stroke. Journal of Neuroscience. 2012; 32: 5132-5143.
 Maïer B, Kubis N. Hypertension and its impact on stroke recovery: from a vascular to a parenchymal overview. Neural Plasticity. 2019; 2019: 1-14.
 Bager J, Hjalmarsson C, Manhem K, Andersson B. Acute blood pressure levels and long-term outcome in ischemic stroke. Brain and Behavior. 2018; 8: e00992.
 Matsuo R, Ago T, Kiyuna F, Sato N, Nakamura K, Kuroda J, et al. Smoking status and functional outcomes after acute ischemic stroke. Stroke. 2020; 51: 846-852.
 Kumagai N, Okuhara Y, Iiyama T, Fujimoto Y, Takekawa H, Origasa H, et al. Effects of smoking on outcomes after acute atherothrombotic stroke in Japanese men. Journal of the Neurological Sciences. 2013; 335: 164-168.
 Cuadrado-Godia E, Ois A, Roquer J. Heart failure in acute ischemic stroke. Current Cardiology Reviews. 2010; 6: 202-213.
 Battaglini D, Robba C, Lopes da Silva A, dos Santos Samary C, Leme Silva P, Dal Pizzol F, et al. Brain-heart interaction after acute ischemic stroke. Critical Care. 2020; 24: 163.
 Roth EJ. Heart disease in patients with stroke. Part II: impact and implications for rehabilitation. Archives of Physical Medicine and Rehabilitation. 1994; 75: 94-101.
 Alawieh A, Zhao J, Feng W. Factors affecting post-stroke motor recovery: implications on neurotherapy after brain injury. Behavioural Brain Research. 2018; 340: 94-101.
 Johnston KC, Li JY, Lyden PD, Hanson SK, Feasby TE, Adams RJ, et al. Medical and neurological complications of ischemic stroke. Stroke. 1998; 29: 447-453.
 Shah SV, Corado C, Bergman D, Curran Y, Bernstein RA, Naidech AM, et al. Impact of poststroke medical complications on 30-day readmission rate. Journal of Stroke and Cerebrovascular Diseases. 2015; 24: 1969-1977.
 Bae H, Yoon D, Lee J, Kim B, Koo J, Kwon O, et al. In-hospital medical complications and long-term mortality after ischemic stroke. Stroke. 2005; 36: 2441-2445.
 Vernino S, Brown RD, Sejvar JJ, Sicks JD, Petty GW, O’Fallon WM. Cause-specific mortality after first cerebral infarction. Stroke. 2003; 34: 1828-1832.
 Grube MM, Koennecke H, Walter G, Meisel A, Sobesky J, Nolte CH, et al. Influence of acute complications on outcome 3 months after ischemic stroke. PLoS ONE. 2013; 8: e75719.
 Langhorne P, Stott DJ, Robertson L, MacDonald J, Jones L, McAlpine C, et al. Medical complications after stroke. Stroke. 2000; 31: 1223-1229.
 Wang P, Zhao X, Yang Z, Wang A, Wang C, Liu L, et al. Effect of in-hospital medical complications on case fatality post-acute ischemic stroke: data from the China National Stroke Registry. Chinese Medical Journal. 2013; 125: 2449-2454.
 Kumar S, Selim MH, Caplan LR. Medical complications after stroke. The Lancet Neurology. 2010; 9: 105-118.
 Wang P, Wang Y, Zhao X, Du W, Wang A, Liu G, et al. In-hospital medical complications associated with stroke recurrence after initial ischemic stroke. Medicine. 2016; 95: e4929.
 Kim B, Lee J, Sohn MK, Kim DY, Lee S, Shin Y, et al. Risk factors and functional impact of medical complications in stroke. Annals of Rehabilitation Medicine. 2017; 41: 753-760.
 Warlow C. Epidemiology of stroke. The Lancet. 1998; 352: S1-S4.
 Kwah LK, Diong J. National Institutes of Health Stroke Scale (NIHSS). Journal of Physiotherapy. 2014; 60: 61.
 Ingeman A, Andersen G, Hundborg HH, Svendsen ML, Johnsen SP. In-hospital medical complications, length of stay, and mortality among stroke unit patients. Stroke. 2011; 42: 3214-3218.
 Roth EJ, Lovell L, Harvey RL, Heinemann AW, Semik P, Diaz S. Incidence of and risk factors for medical complications during stroke rehabilitation. Stroke. 2001; 32: 523-529.
 Kitisomprayoonkul W, Sungkapo P, Taveemanoon S, Chaiwanichsiri D. Medical complications during inpatient stroke rehabilitation in Thailand: a prospective study. Journal of the Medical Association of Thailand. 2010; 93: 594-600.
 Hung J, Tsay T, Chang H, Leong C, Lau Y. Incidence and risk factors of medical complications during inpatient stroke rehabilitation. Chang Gung Medical Journal. 2005; 28: 31-38.
 Kalra L, Yu G, Wilson K, Roots P. Medical complications during stroke rehabilitation. Stroke. 1995; 26: 990-994.
 Doshi VS, Say JH, Young SH, Doraisamy P. Complications in stroke patients: a study carried out at the rehabilitation medicine service, changi general hospital. Singapore Medical Journal. 2004; 44: 643-652.
 Knoflach M, Matosevic B, Rucker M, Furtner M, Mair A, Wille G, et al. Functional recovery after ischemic stroke-a matter of age: data from the Austrian Stroke Unit Registry. Neurology. 2012; 78: 279-285.
 Colbert JF, Traystman RJ, Poisson SN, Herson PS, Ginde AA. Sex-related differences in the risk of hospital-acquired sepsis and pneumonia post acute ischemic stroke. Journal of Stroke and Cerebrovascular Diseases. 2016; 25: 2399-2404.
 Reeves MJ, Bushnell CD, Howard G, Gargano JW, Duncan PW, Lynch G, et al. Sex differences in stroke: epidemiology, clinical presentation, medical care, and outcomes. The Lancet Neurology. 2008; 7: 915-926.
 Sen A. Missing women. British Medical Journal. 1992; 304: 587-588.
 Kapoor M, Agrawal D, Ravi S, Roy A, Subramanian SV, Guleria R. Missing female patients: an observational analysis of sex ratio among outpatients in a referral tertiary care public hospital in India. BMJ Open. 2019; 9: e026850.
 Balan S, Mahalingam R. Are we losing the war on missing girls? The Lancet Global Health. 2014; 2: e22.
 Gupta D. Disparities in development, status of women and social opportunities: Indian experience. Journal of Alternative Perspectives in the Social Sciences. 2009; 1: 687-719.
 Grau AJ, Urbanek C, Palm F. Common infections and the risk of stroke. Nature Reviews Neurology. 2010; 6: 681-694.
 Davenport RJ, Dennis MS, Wellwood I, Warlow CP. Complications after acute stroke. Stroke. 1996; 27: 415-420.
 Weimar C, Roth MP, Zillessen G, Glahn J, Wimmer MLJ, Busse O, et al. Complications following acute ischemic stroke. European Neurology. 2002; 48: 133-140.
 Ji R, Wang D, Shen H, Pan Y, Liu G, Wang P, et al. Interrelationship among common medical complications after acute stroke. Stroke. 2013; 44: 3436-3444.
 Pandian JD, Kaur A, Jyotsna R, Sylaja PN, Vijaya P, Padma MV, et al. Complications in acute stroke in India (CAST-I): a multicenter study. Journal of Stroke and Cerebrovascular Diseases. 2012; 21: 695-703.
 Westendorp WF, Nederkoorn PJ, Vermeij J, Dijkgraaf MG, de Beek DV. Post-stroke infection: a systematic review and meta-analysis. BMC Neurology. 2011; 11: 110.
 Adams HP, Davis PH, Leira EC, Chang K-, Bendixen BH, Clarke WR, et al. Baseline NIH stroke scale score strongly predicts outcome after stroke: a report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999; 53: 126-131.
 Frankel MR, Morgenstern LB, Kwiatkowski T, Lu M, Tilley BC, Broderick JP, et al. Predicting prognosis after stroke: a placebo group analysis from the national institute of neurological disorders and stroke rt-PA stroke trial. Neurology. 2000; 55: 952-959.
 Kwakkel G, Kollen BJ. Predicting activities after stroke: what is clinically relevant? International Journal of Stroke. 2013; 8: 25-32.
 Haeusler KG, Schmidt WUH, Föhring F, Meisel C, Helms T, Junge-hulsing GJ, et al. Cellular immunodepression preceding infectious complications after acute ischemic stroke in humans. Cerebrovascular Diseases. 2008; 25: 50-58.
 Sorbello D, Dewey HM, Churilov L, Thrift AG, Collier JM, Donnan G, et al. Very early mobilisation and complications in the first 3 months after stroke: further results from phase II of a very early rehabilitation trial (AVERT). Cerebrovascular Diseases. 2009; 28: 378-383.
 Saxena SK, Ng TP, Yong D, Fong NP, Gerald K. Total direct cost, length of hospital stay, institutional discharges and their determinants from rehabilitation settings in stroke patients. Acta Neurologica Scandinavica. 2006; 114: 307-314.
 Tong X, Kuklina EV, Gillespie C, George MG. Medical complications among hospitalizations for ischemic stroke in the United States from 1998 to 2007. Stroke. 2010; 41: 980-986.
 Kwan J, Hand P. Infection after acute stroke is associated with poor short-term outcome. Acta Neurologica Scandinavica. 2007; 115: 331-338.
 Ovbiagele B, Hills NK, Saver JL, Johnston SC. Frequency and determinants of pneumonia and urinary tract infection during stroke hospitalization. Journal of Stroke and Cerebrovascular Diseases. 2006; 15: 209-213.
 Badve MS, Zhou Z, van de Beek D, Anderson CS, Hackett ML. Frequency of post-stroke pneumonia: systematic review and meta-analysis of observational studies. International Journal of Stroke. 2019; 14: 125-136.
 Tirschwell DL, Kukull WA, Longstreth WT. Medical complications of ischemic stroke and length of hospital stay: experience in Seattle, Washington. Journal of Stroke and Cerebrovascular Diseases. 1999; 8: 336- 343.
 Spratt N, Wang Y, Levi C, Ng K, Evans M, Fisher J. A prospective study of predictors of prolonged hospital stay and disability after stroke. Journal of Clinical Neuroscience. 2003; 10: 665-669.
 Alvarez-Sabín J, Molina CA, Montaner J, Arenillas JF, Huertas R, Ribo M, et al. Effects of admission hyperglycemia on stroke outcome in reperfused tissue plasminogen activator-treated patients. Stroke. 2003; 34: 1235-1240.
 Chambers BR, Norris JW, Shurvell BL, Hachinski VC. Prognosis of acute stroke. Neurology. 1987; 37: 221-225.
 Willmot M, Leonardi-Bee J, Bath PMW. High blood pressure in acute stroke and subsequent outcome. Hypertension. 2004; 43: 18-24.
 Pan B, Jin X, Jun L, Qiu S, Zheng Q, Pan M. The relationship between smoking and stroke. Medicine. 2019; 98: e14872.
 Modrego PJ, Pina MA, Lerín FJ. The impact of ageing on stroke subtypes, length of stay and mortality: study in the province of Teruel, Spain. Acta Neurol Scand. 2003; 108: 435-442.
Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.
Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.
Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.
IndexCopernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.
Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.
Scopus Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.
Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.