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 PurposeThis prospective, multicenter study was performed to determine the frequency of symptomatic
complications up to 30 months after stroke using prespecified definitions of complications.
MethodsWe 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.
ResultsComplications during hospital admission were recorded in 265 (85%) of stroke patients. Specific complications
were as follows: neurologicalrecurrent stroke (9% of patients), epileptic seizure (3%); infections urinary tract
infection (24%), chest infection (22%), others (19%); mobility relatedfalls (25%), falls with serious injury (5%),
pressure sores (21%); thromboembolism deep venous thrombosis (2%), pulmonary embolism (1%); painshoulder
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.
ConclusionsOur 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 stroke outcome infection pain

edical complications are believed to be an important

problem after acute stroke and present potential barriers to optimal recovery. Several previous studies have suggested that complications not only are common, with estimates of frequency ranging from 40% to 96% of patients,1 6
but also are related to poor outcome.6 Many of the complications described are potentially preventable or treatable if
recognized.
Although many studies have reported frequencies of poststroke 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 retrospective case-ascertainment design15 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 Infirmary) 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 rehabilitation 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

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TABLE 1.

Definitions of Complications During Hospital and Community Follow-Up

Complication

Follow-Up in Hospital

Follow-Up After Discharge

1.1 Recurrent stroke

Clinical features lasting more than 24 hours consistent with the

World Health Organization definition of stroke.8

Asked about any episodes of new weakness or

numbness in arms or legs or new problems with vision
or speech.

1.2 Epileptic seizure

Clinical diagnosis of focal and/or generalized seizure in a

previously nonepileptic patient.

As before.

1. Neurological

1.3 Unexplained events

Asked about any unexplained blackouts or funny

turns.

2. Infection
2.1 Urinary tract infection

Clinical symptoms of urinary tract infection or positive urine

culture.

Urine infections requiring medical help and/or antibiotic

treatment.

2.2 Chest infection

Auscultatory respiratory crackles and fever or radiographic

evidence, or new purulent sputum.

Chest infection requiring medical help and/or antibiotic

treatment.

2.3 Other infection

Any pyrexial illness lasting more than 24 hours.

Other infections requiring medical help and/or antibiotic

treatment.

3.1 Falls

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 falls (single or more than 1). Recorded those

resulting in a fracture or serious injury.

3.2 Pressure sore/skin

break

Any skin break or necrosis resulting from either pressure or trivial

trauma (skin trauma directly resulting from falls was not included).

As before.

3. Complications of immobility

4. Thromboembolism
4.1 Deep vein thrombosis

Clinical diagnosis of deep vein thrombosis.

Any episodes of blood clot in the leg.

4.2 Pulmonary embolism

Clinical diagnosis of pulmonary embolism.

Any episodes of blood clot in the lung.

Pain in the shoulder area requiring analgesia on 2 or more

consecutive days.

As before.

Any other source of pain requiring regular analgesia.

As before.

Low mood considered to interfere with daily activities or require

pharmacological or psychiatric intervention.

Asked do you often feel sad or depressed?9

Asked if drug treatment had been prescribed.

5. Pain
5.1 Shoulder pain
5.2 Other pain
6. Psychological
6.1 Depression
6.2 Emotionalism

Episodes of crying or laughing that are sudden or unheralded and

not under social control.

6.3 Anxiety

Symptoms of anxiety considered to interfere with daily activities or

requiring pharmacological or psychiatric intervention.

6.4 Confusion

Cognitive disturbance considered to interfere with nursing care or

rehabilitation.

7. Miscellaneous

Any documented complication resulting in a specific medical or

surgical intervention (eg, gastrointestinal hemorrhage, constipation,
episodes of cardiac failure, cardiac arrhythmias, and arthritis).

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 Functional Independence Measure [FIM]8). Weekly assessments of functional 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 convenient 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

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.

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 Infirmary, 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

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Langhorne et al
TABLE 2.

Medical Complications After Stroke

1225

Frequency of Symptomatic Complications in Hospitalized Stroke Patients

Range of Frequencies (%)
From Previous
Retrospective Studies*

Range of Frequencies (%)

From Previous
Prospective Studies of
Acute Patients

Current Study
Frequency, %
(95% CI)

Range Across
Study Sites, %

Recurrent stroke

9 (612)

115

18

Epileptic seizure

3 (15)

16

25

Urinary tract infection

23 (1828)

1625

725

1128

Chest infection

22 (1827)

1828

721

1020

Other infection

19 (1524)

1027

431

21 (1625)

1227

318

5 (27)

18

13

2*

Fall, no injury

21 (1625)

933

25 (2130)

933

2225

Fall, total
Deep vein thrombosis

2 (03)

14

13

12 (1175)

Pulmonary embolus

1 (02)

11

218

01 (339)

9 (612)

611

27

34 (2839)

2938

630

Complication
Neurological

Infections

Mobility
Pressure sore/skin break
Fall, serious injury

Thromboembolism

Pain
Shoulder pain
Other pain
Psychological
Depression

16 (1221)

1617

533

150

Emotionalism

12 (815)

716

Anxiety

14 (1018)

538

8#

36 (3041)

2942

340

Miscellaneous (eg, chest

pain, hemorrhage)

Confusion

61 (5566)

4472

32

Total

85 (8289)

7691

4096

6395

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 15 and 10.
Data from previous prospective studies are taken from references 6 and 1126.
Defined as fracture.
Defined as all falls.
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.

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 exclusion of those who made a rapid recovery in the first few days.

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

Complications in Hospital
A total of 265 patients (85%) experienced at least 1 prespecified 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 readmission 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

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June 2000

previous reports. In particular, recurrent stroke, epileptic

seizure, infections, pressure sores, falls, thromboembolism,
and total complication rates are all comparable with previous
studies. However, in the present study, we appear to have
recorded higher levels of pain and psychological symptoms
than previously reported. Table 2 illustrates that the range of
frequencies across individual sites was very similar, with the
possible exception of recurrent stroke, falls, anxiety, and
miscellaneous complications. It is not clear whether these
minor variations are due to differences in patient case mix or
subtle differences in the definition of complications.
The data outlined in Table 2 are expressed in terms of
hospital incidence rates, ie, the number of patients who
experienced a complication in hospital. In these estimates, a
particular complication could only be recorded once per
patient. This analysis may misrepresent the burden of a
complication, because it may not take into account the
duration of observation (time in hospital) and may underestimate the burden of chronic complications that persist over a
long period. We therefore recalculated complications in terms
of the total number of weekly observations in which a
complication was recorded (weekly point prevalence). As
expected, these point-prevalence estimates (Table 3) were
generally smaller than the hospital incidence results, but the
relative frequency of complications remained very similar.

TABLE 3. Frequency of Symptomatic Complications in

Hospitalized Stroke Patients

Complications After Hospital Discharge

Psychological

The complications reported by patients and/or caregivers at

various census times during follow-up are outlined in Table 4.
Complication rates in hospital are shown for comparison,
although slightly different methods were used. Patients reported a high frequency of infections, falls, pain, and symptoms of depression and anxiety (although smaller numbers of
patients were taking antidepressant medication). Miscellaneous illness, unexplained blackouts and funny turns,
and hospital readmission were also common.

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 proportion 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) mildinitial FIM 100
points (n14); (2) moderateinitial FIM 50 to 100 (n42);
and (3) severeinitial FIM 50 (n74). There were trends
for more dependent patients to have a higher risk of infections, falls, pressure sores, pain, anxiety, and depression.
However, on a 2 test for trend, statistically significant results
were seen only for infections (P0.05), pressure sores
(P0.01), and anxiety (P0.05).

Timing of Complications After Stroke

We wished to ascertain the delay between the index stroke
and onset of individual complications. This was analyzed as

Incidence (Percent
Events per Patient
per Hospital
Admission)

Weekly Point
Prevalence (Percent
Events per Week of
Observation)

Recurrent stroke

9 (612)

2 (13)

Epileptic seizure

3 (15)

Complications
Neurological

0.5 (01)

Infection
Urinary tract infection

23 (1828)

8 (79)

Chest infection

22 (1827)

7 (58)

Other infection

19 (1524)

7 (68)

21 (1625)

19 (1721)

5 (27)

1 (02)

21 (1625)

7 (58)

Mobility
Pressure sore/skin break
Fall, serious injury
Fall, no injury
Thromboembolism
Deep vein thrombosis

2 (03)

0.5 (01)

Pulmonary embolism

1 (02)

0.2 (00.5)

Pain
Shoulder pain

9 (612)

6 (57)

34 (2839)

14 (1216)

Depression

16 (1221)

19 (1523)

Emotionalism

12 (815)

6 (57)

Anxiety

14 (1018)

9 (710)

Confusion

36 (3041)

24 (2226)

61 (5566)

35 (3338)

Other pain

Miscellaneous (eg, chest pain)

Incidence results are expressed as the proportion (95% CI) of patients in

whom a complication was noted during hospital admission. Weekly point
prevalence results are expressed as the proportion (95% CI) of weekly
observations in which a complication was noted.

the cumulative number of patients experiencing a complication 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 particularly 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, prespecified 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

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Langhorne et al
TABLE 4.

Medical Complications After Stroke

1227

Frequency of Complications up to 30 Months After Stroke

Observation Period (*Census Time)
Hospital
Admission
(Weekly*)

Discharge
to 6*
Months

6 18*
Months

18 30*
Months

2 mo*

4 mo*

12 mo

12 mo

311

220

181

155

311

220

180

148

Recurrent stroke

9 (612)

6 (29)

9 (418)

12 (718)

Epileptic seizure

3 (15)

1 (02)

5 (18)

5 (19)

9 (418)

19 (1325)

13 (719)

Urinary tract infection

23 (1828)

16 (1022)

23 (1630)

22 (1529)

Chest infection

22 (1827)

13 (819)

23 (1630)

29 (2137)

Other infection

19 (1524)

8 (413)

25 (1832)

21 (1428)

Duration of observation period

Number of patients alive at census
Number lost to follow-up
Number observed
Complications
Neurological

Unexplained blackout
Infection

Mobility
Pressure sore/skin break

21 (1625)

8 (312)

8 (312)

11 (617)

5 (27)

8 (312)

15 (920)

12 (617)

Fall, no injury

21 (1625)

29 (2236)

34 (2742)

33 (2739)

Falls, multiple

25 (2130)

22 (1529)

34 (2742)

29 (2434)

36 (2844)

49 (4157)

45 (3753)

Deep vein thrombosis

2 (03)

1 (01)

Pulmonary embolism

1 (02)

Fall, serious injury

Falls, total
Thromboembolism

Pain
Shoulder pain
Other pain

9 (612)

15 (921)

11 (616)

12 (617)

34 (2839)

41 (3350)

35 (2742)

37 (2945)

16 (1221)

17 (1123)

12 (717)

15 (821)

50 (4258)

43 (3551)

54 (4562)

4 (07)

5 (18)

8 (313)

61 (5566)

34 (2642)

44 (3652)

49 (4158)

24 (1731)

41 (3349)

49 (4158)

2 (04)#

15 (921)

31 (2438)

35 (2743)

Psychological
Depression, clinical
Depression, drug therapy
Depression, symptoms
Anxiety, clinical
Anxiety, drug therapy
Anxiety, symptoms
Miscellaneous (eg, chest pain)
Hospital readmission

14 (1018)

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.
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

judged to be unable to benefit from further rehabilitation,
we believe we have achieved good ascertainment of
complications during the main recovery period after
stroke. Any bias in our hospital complication estimates

will be toward underestimating the frequency of complications. Estimates of complications at later follow-up
depended on information from patients and caregivers,
which may have underestimated or overestimated complication rates.

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TABLE 5. Frequency of Symptomatic Complications in

Relation to Initial Level of Dependency
Initial Level of Dependency (FIM Score)
Complication

FIM 100

FIM 50 100

FIM 50

Significance
(2 Test)

Recurrent stroke

NS

21 (142)

12 (122)

14 (620)

Seizure

2 (04)

4 (08)

NS

Infection

14 (032)

35 (1951)

54 (4365)

P0.05

Falls

21 (042)

31 (2340)

39 (2850)

NS

7 (020)

12 (222)

36 (2547)

P0.01

Pressure sore
Thromboembolism

5 (011)

5 (010)

NS

Pain

14 (035)

43 (2858)

38 (2749)

NS

Depression

14 (032)

17 (628)

30 (1941)

NS

12 (222)

42 (3153)

P0.01

Anxiety

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 symptomatic 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 complications. 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 pulmonary 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 complications 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 discrepancy 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 depression 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 between poststroke complications and poor outcome and have
suggested that complications may act as barriers to recovery.

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 during 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 randomized 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 prolonged 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 complications 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.

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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
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