9. Prise en charge et prévention des complications après un AVC chez les patients hospitalisés

Les complications médicales sont fréquentes à la suite d’un AVC en phase aiguë et sont associées à un séjour hospitalier prolongé ainsi qu’à des coûts accrus par rapport aux autres causes d’hospitalisation au pays. Les patients ayant subi un AVC en phase aiguë présentent un risque de complications telles que la thromboembolie veineuse, la fièvre et les crises convulsives, entre autres, au cours de la première phase de leur rétablissement. Les priorités des soins offerts aux patients hospitalisés comprennent la prise en charge des séquelles de l’AVC pour optimiser le rétablissement, la prévention des complications post-AVC qui pourraient nuire au processus de rétablissement, et la prévention des récidives d’AVC. 

Les personnes ayant une expérience vécue ont aimé l’approche de soins centrés sur le patient; elles ont trouvé utile de connaître la raison d’être des interventions. Elles ont expliqué que parfois, elles avaient l’impression de subir les interventions; recevoir une explication leur permettait donc de se sentir engagées, d’avoir l’impression de faire partie de l’équipe. Ces personnes ont également souligné l’importance, pour les dispensateurs de soins, de répéter l’information au besoin pour assurer la compréhension du patient, de sa famille ou de ses aidants. La peur et le stress causé par le choc d’avoir subi un AVC rendent l’assimilation de l’information plus difficile; le fait de répéter peut donc contribuer à favoriser le traitement et la compréhension des renseignements. Les personnes ayant une expérience vécue ont affirmé qu’il pourrait être utile de créer un document d’une page indiquant les éléments importants à prendre en considération au cours des premiers jours suivant l’AVC à l’intention des patients en soins de courte durée et de leur famille. Ce document pourrait donner des renseignements importants sur le déroulement des soins les premiers jours et sur leur raison d’être. Cela aiderait également les patients et leur famille à assimiler l’information et à s’en souvenir, en plus d’assurer l’uniformité des renseignements transmis par les dispensateurs de soins aux patients.

Pour s’assurer que les personnes qui subissent un AVC sont évaluées, prises en charge et traitées rapidement, les équipes interdisciplinaires doivent avoir accès à l’infrastructure et aux ressources nécessaires. Les exigences peuvent comprendre les éléments ci-dessous, qui sont établis à l’échelle des systèmes.

1. Des protocoles normalisés fondés sur des données probantes doivent être établis pour la prestation de soins optimaux à l’hôpital pour tous les patients ayant subi un AVC en phase aiguë, peu importe où ils sont traités dans l’établissement de santé (unité de prise en charge de l’AVC ou autre service) à l’échelle du système de soins de l’AVC régional.
2. Une formation professionnelle continue et des possibilités de formation doivent être offertes à tous les professionnels de la santé qui prodiguent des soins aux patients ayant subi un AVC en phase aiguë.
3. Des systèmes d’orientation doivent assurer l’accès rapide à des soins spécialisés, par exemple en dentisterie et en hématologie.

Indicateurs du système :

1. Durée médiane du séjour en soins de courte durée, classée par type d’AVC, pour tous les patients ayant subi un AVC admis à l’hôpital (prioritaire).
2. Proportion de patients ayant subi un AVC dont le séjour a été prolongé au-delà de la durée attendue en raison d’une ou de plusieurs complications.

Indicateurs de processus :

3. Durée médiane du séjour en soins de courte durée, classée par type d’AVC et de complications, pour tous les patients ayant subi un AVC admis à l’hôpital et ayant connu au moins une complication pendant leur hospitalisation (prioritaire). 

Indicateurs de résultats et d’expérience axés sur le patient :

4. Proportion de patients admis à l’hôpital en raison d’un diagnostic d’AVC en phase aiguë qui ont connu au moins une complication pendant leur hospitalisation (p. ex., TVP, embolie pulmonaire, hémorragie cérébrale secondaire, saignement gastro-intestinal, plaies de pression, infection des voies urinaires, pneumonie, crises convulsives).
5. À l’aide d’un outil validé, évaluation de la qualité de vie à 30 et 90 jours chez les patients ayant connu des complications à l’admission aux soins de courte durée à la suite d’un AVC en phase aiguë.

Notes relatives à la mesure des indicateurs

Remarque : voir le document sur les indicateurs de qualité clés pour les soins de l’AVC au Canada et les définitions de cas d’AVC (7^e édition) pour obtenir de plus amples renseignements.www.pratiquesoptimalesavc.ca

1. Le risque a été rajusté pour tenir compte d’autres troubles concomitants, de l’âge et du sexe.
2. L’analyse de la durée du séjour doit être classée selon la présence ou l’absence de complications à l’hôpital, afin de déterminer l’incidence d’une complication sur la durée du séjour. 
3. Des sondages auprès des patients et de leur famille doivent être effectués pour surveiller la qualité des soins pendant l’admission des patients à l’hôpital en raison d’un AVC.

Les ressources et les outils ci-dessous qui sont externes à Cœur + AVC et aux Recommandations peuvent être utiles à la mise en œuvre des soins de l’AVC. Cependant, leur présence ne constitue pas une approbation réelle ou implicite par le groupe de rédaction des pratiques optimales en matière de soins de l’AVC. Le lecteur est encouragé à examiner ces ressources et ces outils d’un œil critique et à les mettre en œuvre dans sa pratique à sa discrétion.

Renseignements destinés aux dispensateurs de soins

• Tableau 2A des Recommandations : Analyses de laboratoire recommandées pour les patients ayant subi un AVC en phase aiguë ou un accident ischémique transitoire
• Tableau 4 de l’annexe 3 du module sur la prise en charge de l’AVC en phase aiguë des Recommandations : « Outils de dépistage et d’évaluation de la gravité de l’AVC »
• Pratiques optimales de soins de l’AVC au Canada, « La réadaptation et le rétablissement après un AVC » 
• Cœur + AVC, « Trousse d’outils pour la mise en œuvre des soins virtuels de l’AVC » 
• Cœur + AVC, « Agir en vue de soins optimaux communautaires et de longue durée de l’AVC : Une ressource pour les dispensateurs de soins de santé » 
• Association des infirmières et infirmiers autorisés de l’Ontario (AIIAO), lignes directrices sur la santé buccale (en anglais seulement) 
• AIIAO, ressources en matière de continence (en anglais seulement)
• AIIAO, lignes directrices sur la prévention des chutes chez les personnes âgées (en anglais seulement)
• Fondation d’aide aux personnes incontinentes (Canada), graphiques
• SCC, lignes directrices sur la fibrillation auriculaire
• American College of Chest Physicians (ACCP), lignes directrices et rapports de comités d’experts sur les soins vasculaires pulmonaires (en anglais seulement)
• Association canadienne des radiologistes, lignes directrices
• Info AVC
• Les responsables de la coordination pour les pratiques optimales de soins de l’AVC en phase aiguë (en Ontario) et le Ontario Regional Education Group, en partenariat avec Cœur + AVC : Principaux changements apportés aux recommandations canadiennes pour les pratiques optimales de soins de l’AVC en phase aiguë 2022. (Disponible en anglais seulement)

Renseignements destinés aux personnes ayant une expérience vécue, y compris les membres de la famille, les amis et les aidants

• Cœur + AVC, « Votre cheminement après un AVC »
• Cœur + AVC, « Liste de vérification après un AVC »
• Cœur + AVC, « Infographie sur la prise en charge de l’AVC en phase aiguë »
• Cœur + AVC, « Aide-mémoire pour les soins de santé virtuels »
• Cœur + AVC, infographie sur la prévention secondaire
• Cœur + AVC, infographie sur la réadaptation et le rétablissement
• Cœur + AVC, infographie sur les transitions et la participation communautaire
• Cœur + AVC, « Vivre avec les changements physiques »
• Cœur + AVC, « Agir en vue de soins optimaux communautaires et de longue durée de l’AVC : Une ressource pour les dispensateurs de soins de santé »
• Cœur + AVC, « La magie de la communauté » (soutien en ligne par les pairs)
• Fondation d’aide aux personnes incontinentes (Canada), ressources pour les patients
• Info AVC

Evidence Table and Reference List

Sex and Gender Considerations Reference List

Medical complications are relatively common following stroke and are associated with increased lengths of stay and higher cost. Appropriate investigations and management strategies should be implemented for all hospitalized patients to avoid complications, prevent stroke recurrence, and improve the odds of a good recovery. Estimates of the percentage of patients who experience at least one medical complication during hospitalization vary widely from 25% (Ingeman et al., 2011) to 85% (Langhorne et al., 2000). Some of the most commonly cited complications include UTIs, fever, pneumonia, and DVT (Otite et al., 2017; Indredavik et al., 2008; Roth et al., 2001).

Cardiovascular Investigations

Detecting atrial fibrillation (AF) after a stroke or TIA is important since it is a major risk factor for subsequent stroke and, once identified, can be effectively treated. However, AF is under-diagnosed because it is frequently paroxysmal and asymptomatic. Additionally, although many abnormalities can be detected within the first few days of monitoring, prolonged screening may be required to detect others. In the Systematic MONitoring for Detection of Atrial Fibrillation in patients with acute Ischaemic Stroke (MonDAFIS) Trial, Haeusler et al. (2021) randomized 3,465 patients with no history of AF, admitted to 38 stroke units with an acute stroke or TIA to receive usual diagnostic procedures for AF detection, which included a baseline 12-lead ECG on admission and at least 24 hours of ECG monitoring (control group) or additional Holter-ECG recording for up to 7 days in hospital (intervention group). At 12 months, there was no significant difference between groups in the number of patients on oral anticoagulants (13.7% vs. 11.8%, OR=1·2, 95% CI 0·9–1·5), although AF was newly detected in significantly more patients in hospital in the intervention group (5.8% vs. 4.0%, HR=1·4, 95% CI 1·0–2·0). The Finding Atrial Fibrillation in Stroke – Evaluation of Enhanced and Prolonged Holter Monitoring FIND-AF trial, (Wachter et al,. 2017) recruited 398 patients, admitted with acute ischemic stroke, within 7 days of symptom onset, in sinus rhythm at admission, and without a history of AF. Patients were randomized to receive prolonged Holter ECG monitoring for 10 days, starting in the first week post-stroke, and repeated at 3 and 6 months or standard care (an average of 73 hours of inpatient telemetry plus an average of 24 hours of Holter monitoring). At both 6 and 12 months, detection of AF was significantly higher in the prolonged monitoring group (13.5% vs. 4.5% and 13.5% vs. 6.1%, respectively). The associated numbers needed to screen were 11 and 13. There were no significant differences between groups in stroke recurrence (2.5 vs. 4.5%, p=0.28) or death (3.0 vs. 4.5%, p=0.45). A systematic review (Kishore et al., 2014) including the results from 32 studies (5,038 patients) of patients with acute ischemic stroke or TIA who had undergone invasive or non-invasive cardiac monitoring for a minimum of 12 hours following the event. The different types of cardiac monitoring evaluated included inpatient cardiac monitoring; 24, 48, 72 hour, and 7-day Holter; external loop recorder; invasive cardiac monitoring; and mobile cardiac outpatient telemonitoring. The overall detection rate of AF was 11.5% (95% CI 8.9%-14.3%) and was higher in selected (pre-screened or cryptogenic) patients (13.4%, 95% CI 9.0%-18.4%) compared with unselected patients (6.2%, 95% CI 4.4%-8.3%). The detection rate of AF in cryptogenic stroke was 15.9% (95% CI 10.9%-21.6%).

The use of transesophageal echocardiography (TEE) has been shown to be more sensitive compared with transthoracic echocardiography (TTE) for detecting cardiac abnormalities following ischemic stroke or TIA, although it is costlier and less acceptable to patients. Common TEE findings following stroke have included atheromatosis, PFO, and atrial septal aneurysm (Marino et al., 2016; Katsanos et al,. 2015). Marino et al. (2016) reported that 42.6% of 263 patients admitted following an acute ischemic stroke had a TEE finding which could explain the etiology of stroke/TIA. De Bruijn et al. (2006) included 231 patients with recent stroke (all types) or TIA whose stroke etiology remained in question following initial ECG, ultrasound assessments, and blood tests. All patients had a TEE followed by a TTE and the identification of major and minor cardiac sources of embolism were compared between the two diagnostic tools. A potential cardiac source of embolism was detected in 55% of the patients. Significantly more abnormalities were identified using TEE. A cardiac source was detected in 39% of patients where TEE was positive and the TTE negative. A major cardiac risk factor was detected based on TEE in 16% of patients. The detection of possible cardiac sources of embolism was statistically significantly greater using TEE compared to TTE in both patients aged ≤45 years and >45 years.

Venous Thromboembolism Prophylaxis

The use of LMWHs has been shown to be more effective for the prevention of venous thromboembolism compared with UFH), and is associated with a lower risk of serious bleeding events. A Cochrane review (Sandercock et al., 2017) included the results from 9 randomized controlled trials (RCTs) (n= 3,137) of patients with acute ischemic stroke who were randomized within 14 days of stroke onset to receive LMWHs or heparinoids, or UFH for an average of 10 to 12 days. The odds of DVT occurrence during the treatment period were significantly lower in the LMWH/heparinoid group (OR=0.55, 95% CI 0.44 -0.70, p<0.0001). There was no difference between groups in mortality during the treatment period or follow-up, nor in the odds of any ICH/hemorrhagic transformation during treatment (OR= 0.75, 95% CI 0.46- 1.23, p=0.25). The authors cautioned that the event rates for serious events (pulmonary embolus, death, and serious bleeding) were too low to provide reliable estimates of the risk and benefits. 

The use of external compression stockings/devices has been investigated in a series of 3 large, related RCTs: the Clots in Legs Or sTockings after Stroke (CLOTS) trials. In CLOTS 1 (Dennis et al., 2009), 2,518 patients, admitted to hospital within 1 week of acute ischemic stroke or ICH and who were immobile, were randomized to either routine care plus thigh-length graded compression stockings (GCS) or to routine care plus avoidance of GCS. Patients wore the garments day and night until the patient became mobile, was discharged, or there were concerns with skin breakdown. At 30 days there was no significant difference between groups in the incidence of proximal DVT (GCS 10.0% vs. avoid GCS 10.5%). GCS use was associated with a non-significant absolute reduction in risk of 0.5% (95% CI -1.9% to 2.9%). The incidence of any DVT or PE was non-significantly lower in the GCS group (17.0% vs. 18.4%, OR=0.91, 95% CI 0.74-1.11), but the frequency of skin ulcers or breakdown were significant higher in the GCS group (5.1% vs. 1.3%, OR=4.18, 95% CI 2.40-7.27). The inclusion criteria for the CLOTS 2 trial (The CLOTS Trials Collaboration, 2010) were similar to those of CLOTS 1. In this trial, 3,114 patients were randomized to wear thigh-length stockings or below-knee stockings while they were in the hospital, in addition to routine care, which could have included early mobilization, hydration, and/or the use of anticoagulants/antiplatelets. At 30 days, there was a significant reduction in the incidence of proximal DVT associated with thigh-length GCS (6.3% vs. 8.8%, adj OR=0.69, 95% CI 0.53-0.91, p=0.008). The incidence of asymptomatic DVT was also lower in the thigh-length GCS group (3.2% vs. 4.8%, adj OR=0.64, 95% CI 0.44-0.93, p=0.02). The use of thigh-length GCS was associated with an increased risk of skin breakdown (9.0% vs. 6.9%, OR=1.33, 95% CI 1.031.73, p=0.03). Finally, in CLOTS 3 (Dennis et al., 2013) 2,876 patients were randomized to wear a thigh-length IPC)device or to no IPC at all times except for washing and therapy, for a minimum of 30 days. The mean duration of IPC use was 12.5 days and 100% adherence to treatment was achieved in only 31% in the IPC group. The incidence of proximal DVT within 30 days was significantly lower for patients in the IPC group (8.5% vs. 12.1%, OR=0.65, 95% CI 0.51-0.84, p=0.001, ARR=3.6%, 95% CI 1.4%-5.8%). There were no significant differences between groups for the outcomes of: death at 30 days (10.8% vs. 13.1%, p=0.057), symptomatic proximal DVT (2.7% vs. 3.4%, p=0.269), or PE (2.0% vs. 2.4%, p=0.453). The incidence of any DVT (symptomatic, asymptomatic, proximal or calf) was significantly lower for the IPC group (16.2% vs. 21.1%, OR=0.72, 95% CI 0.60-0.87, p=0.001). Skin breakdown was more common in the IPC group (3.1% vs. 1.4%, OR=2.23, 95% CI 1.31-3.81, p=0.002). At 6 months, the incidence of any DVT remained significantly lower in the IPC group (16.7% vs. 21.7%, OR=0.72, 95% CI 0.60-0.87, p=0.001). The incidence of any DVT, death, or PE also remained significantly lower for the IPC group (36.6% vs. 43.5%, OR=0.74, 95% CI 0.63-0.86, p<0.0001).

Temperature Management

Elevated body temperature in the early post-stroke period has been associated with worse clinical outcomes. A meta-analysis conducted by Prasad & Krishnan (2010), including the results from six studies demonstrated that fever within the first 24 hours of ischemic stroke onset was associated with twice the risk of short-term mortality (OR= 2.20, 95% CI 1.59–3.03). Fever may result from a secondary infection, such as pneumonia, or may have occurred as a cause of stroke (e.g. infective endocarditis). While interventions to reduce temperature may improve the viability of brain tissue and/or prevent other medical complications post stroke, efforts to reduce fever, through a wide range of modalities including pharmacological agents (e.g., paracetamol) and physical interventions (e.g., cooling blankets and helmets and endovascular treatments) have not been convincingly shown to be effective in reducing or avoiding poorer outcomes. The largest trial examining the use of pharmacological agents for the reduction of fever was Paracetamol (Acetaminophen) In Stroke (PAIS) trial (den Hertog et al., 2009). In this trial, 1,400 patients were randomized to receive one gram of paracetamol, 6 times daily for 3 days or placebo within 12 hours of symptom onset. While treatment with paracetamol did significantly lower body temperature by a mean of 0.26°C, it was not associated with improvement beyond expectation (adjusted OR=1.20, 95% CI 0.96-1.50), nor did it increase the odds of a favourable outcome. Treatment with paracetamol was associated with a decrease in 14-day mortality (OR=0.60, 95% CI 0.36-0.90), but there was no difference at 3 months (OR=0.90, 95% CI 0.68-1.18). The PAIS 2 trial (De Ridder et al., 2017) was terminated after enrolling 26 of 1,500 planned patients. In this trial, high-dose (2 grams) or placebo was given for 3 days to patients with a temperature of ≥36.5o C. There was no significant difference between groups in the shift in mRS scores at 90 days associated with paracetamol (common adj OR=1.15, 95% CI 0.74-1.79). 
In a Cochrane review, den Hertog et al. (2009) included the results from 8 RCTs, 5 of which examined pharmacological agents (paracetamol, n=3, metamizole n=1, ibuprofen placebo n=1) versus placebo. Pharmacological treatment significantly reduced temperature at 24 hours following treatment (mean difference of -0.21o C 95% CI -0.28, -0.15, p<0.0001), but was not associated with a reduction in the odds of death or dependency at 1 to 3 months (OR= 0.92, 95% CI 0.59- 1.42, p=0.69).

Mobilization

Early mobilization post-stroke is intended to reduce the risk of medical complications including DVT, pressure sores, and respiratory infections. The potential benefits of early mobilization have been examined in several RCTs, with ambiguous results. Recently, a Cochrane review (Langhorne et al., 2018) included the results from 9 RCTs (n= 2,958) of participants who had sustained an acute stroke and could be mobilized within 48 hours. Trials included the AVERT trials (Bernhardt et al., 2008, 2015), AKEMIS (Sundseth, 2012), SEVEL (Herisson et al., 2016) and VERITAS (Langhorne et al., 2010). The median delay to starting mobilization after stroke onset was 12.7 hours shorter in the early mobilization group (18.5 vs. 33.3 hours). There were no significant differences in the odds of death or poor outcome at 3 months between groups (51% vs. 49%; OR= 1.08, 95% CI 0.92 to 1.26, p = 0.36), or the odds of death (7% vs. 8.5%; OR=1.27, 95% CI 0.95 to 1.70; p = 0.11). These results were supported by medium quality of evidence. The mean Barthel Index (20-point scale) was significantly higher in the early mobilization group (mean difference of 1.94, 95% CI 0.75 to 3.13, p = 0.001) at a median follow-up of 3 months. The mean length of hospital stay was 1.44 days shorter in the early mobilization group. Additional analysis of the AVERT 3 trial (Bernhardt et al., 2016) indicate that after controlling for age and stroke severity, regardless of group assignment, keeping time to first mobilization and frequency constant, every extra 5 minutes of out-of-bed activity per day reduced the odds of a favourable outcome by 6%, while increasing the frequency of each out-of-bed session improved the odds of favourable outcome by 13%, In 2021, Bernhardt et al. reported that by day 14, the risk of mortality was significantly higher in the very early mobilization group (OR=1.76, 95% CI 1.06-2.92). 

Seizure Management

The incidence of post-stroke seizure ranges from 5%-15%, depending on stroke etiology, severity, and location (Gilad, 2012). Hemorrhagic events and cortical lesions are associated with the highest risk of both first and recurrent seizure (Gilad et al. ,2013). Evidence on the effectiveness of pharmacological treatment for post- stroke seizures is limited. A recent Cochrane review (Chang et al., 2022) sought studies including patients of any age recovering from ischemic stroke or intracerebral hemorrhage that evaluated antiepileptic drugs compared with a placebo or no drug for the primary and secondary prevention of post stroke seizures. Two publications were included. Gilad et al. (2011) randomized 72 patients to receive 800 mg/day valproic acid or placebo daily for one month. In the second trial, based on data presented in an abstract (Tujil et al., 2021), 784 patients were randomized to receive 10 mg diazepam or placebo, which was given within 12 hours after stroke onset, followed by oral 10 mg tablets twice daily for 3 days. The use of antiepileptic drugs was not associated with a significant reduction in the risk of primary seizure prevention at the end of follow-up, the durations of which were 3 months and 1 year (RR= 0.65, 95% CI 0.34 to 1.26). The certainty of the associated evidence was low to moderate.

Nutrition and Dysphagia

A standardized program for screening, diagnosis, and treatment of dysphagia following acute stroke has been shown to reduce the incidence of pneumonia and feeding tube dependency. Bedside screening may include components related to a patient’s level of consciousness, an evaluation of the patient’s oral motor function and oral sensation, as well as the presence of a cough. It may also include trials of fluid. Coughing during and up to 1 minute following test completion and/or “wet” or hoarse voice are suggestive of an abnormal swallow. A recent Cochrane review (Boaden et al. 2021), evaluated the test characteristics of 37 dysphagia screening tests. Tests evaluated water only, water + other consistencies and water swallow test combined with an instrumental assessment. Among these three categories, the best performing screening tests were the Toronto Bedside Swallowing Screening Test (water only), the Gugging Swallowing Screen (water + other consistencies) and the Bedside Aspiration test (combined water + an instrumental assessment). The sensitivity of all tests was 100% with specificities of 64%, 69% and 71%. 

Silent aspiration may occur in patients who do not cough or complain of any problems with swallowing or have no wet-sounding voice, highlighting the importance of dysphagia screen for all patients as soon as possible following stroke. A prospective study (Ouyang et al., 2020) of 11,093 patients with acute stroke included in the HeadPoST trial examined the association between dysphagia screening and assessment, and outcome. In 362 (3.3%) patients who developed pneumonia, compared to patients who passed a dysphagia screen, screen-fail patients had a significantly higher risk of pneumonia (1.5% vs. 10.0%; adj OR= 3.00, 95% CI 2.19–4.10) and poor outcome at 90 days (68.1% vs. 30.8%, adj OR= 1.66, 95% CI 1.41–2.95). Using United Kingdom registry data, Bray et al. (2017) reported a higher risk of stroke-associated pneumonia with increasing times to dysphagia screening and assessment. The overall incidence of stroke-associated pneumonia was 8.7% (13.8% for patients who were not screened, 8.0% for patients who were screened, and 14.7% for patients who received a comprehensive assessment). 

Dietary modifications, including altered texture of solids and fluids and the use of restorative swallowing therapy, and compensatory techniques, are the most commonly used treatments for the management of dysphagia in patients who are still safe to continue oral intake. Unfortunately, there is little direct evidence of their benefit. Carnaby et al. (2006) randomized 306 patients with dysphagia admitted to hospital within 7 days of acute stroke, to receive usual care, standard low-intensity intervention (composed of environmental modifications, safe swallowing advice, and appropriate dietary modifications), or standard high-intensity intervention and dietary prescription (daily direct swallowing exercises, dietary modification), for up to 1 month. When the results from the high-intensity and low-intensity groups were combined and compared with the usual care group, patients in the active therapy group regained functional swallow sooner and had a lower risk of chest infections at 6 months. 

For patients who cannot obtain nutrient and fluid needs orally, enteral nutrition may be required. The decision to use enteral support should be made within the first 7 days post-stroke. The largest trial that addresses both the issues of timing of initiation of enteral feeding and the choice of feeding tube was the FOOD trial (Dennis et al., 2005), which included 1,210 patients admitted within 7 days of stroke from 47 hospitals in 11 countries. In one arm of the trial, patients were randomized to receive either a percutaneous endoscopic gastrostomy or nasogastric feeding tube within 3 days of enrollment into the study. Percutaneous endoscopic gastrostomy feeding was associated with an absolute increase in risk of death of 1.0% (–10.0 to 11.9, p=0.9) and an increased risk of death or poor outcome of 7.8% (0.0 to 15.5, p=0.05) at 6 months. In the second part of the trial patients were randomized to receive feeds as early as possible or to avoid feeding for 7 days. Early tube feeding was associated with non-significant absolute reductions in the risk of death or poor outcome (1.2%, 95% CI -4.2 to 6.6, p=0.7) and death (15.8%, 95% CI -0.8 to 12.5, p=0.09) at 6 months.

Incontinence

To avoid the onset of UTIs, the use of indwelling catheters is largely discouraged in clinical settings and is typically limited to patients with incontinence that cannot be managed any other way. If used, the catheter should be changed or removed as soon as possible. Ersoz et al. (2007) reported that among 110 patients consecutively admitted for rehabilitation following stroke, 30 developed a symptomatic UTI during hospitalization. UTIs occurred more frequently in patients with indwelling catheters, compared with patients who could void spontaneously (7/14 vs. 23/96, p=0.041) and in patients with residual urine volumes of >50 mL (41.2% vs. 19.5%, p=0.039). Several infection prevention strategies that have been identified to prevent or delay the onset of catheter-associated UTIs include inserting the catheter using aseptic technique, correctly positioning the drainage tube and the collection bag, maintaining uncompromising closed drainage, achieving spontaneous voiding, and administering intermittent catheterizations. The effectiveness of bladder-training programs, which typically include timed/prompted voiding, bathroom training, pelvic floor exercises, and/or drug therapy, has been evaluated in a small number of studies. In one study, 42 patients admitted to a single acute stroke unit were each was prescribed an individualized bladder program consisting of bladder scanning, intermittent catheterizations/ post-void residual regimen, non-invasive voiding strategies (e.g., pelvic muscle exercises) and/or drug therapy. The regimen was continued until the post-void urine residual was below 100 ml for three consecutive days (Chan et al., 1997). Eighty-four percent of all patients achieved urinary continence within the first month of stroke. Among this group, all females became continent, while 23% of the male patients did not. In a Cochrane review, Eustice et al. (2000) included the results of 9 RCTs (n= 674), examining the potential benefit of prompted voiding (vs. no prompted voiding) provided for 10 days to 13 weeks. Prompted voiding was associated with a reduction in the number of incontinent episodes in 24 hours (MD= -0.92, 95% CI -1.32 to -0.53, p<0.0001). Thomas et al. (2014) conducted a cluster feasibility trial, Identifying Continence Options after Stroke (ICONS). Compared with usual care, the systematic voiding program was not associated with significantly increased odds of being continent at 6 or 12 weeks.

Oral Care 

Physical weakness following stroke may prevent patients from independently completing their activities of daily living, including oral care. Poor oral care, combined with potential side effects of medication (e.g., dry mouth, oral ulcers, stomatitis), may contribute to a greater amount of bacteria in the mouth, leading to the development of pneumonia. Patients have also reported lower oral health-related quality of life as a result of poor or inadequate dental care following stroke (Schimmel et al., 2011). Therefore, on admission to hospital, all patients should have an oral/dental assessment to examine mastication, tooth wear, oral disease, and use of appliances following stroke. However, few studies have examined interventions to improve oral hygiene in patients following stroke. A Cochrane review conducted by Brady et al. (2006) included the results of three RCTs (n=470) that included patients receiving some form of assisted oral healthcare in a healthcare facility following stroke. Treatments evaluated included oral healthcare plus timed tooth brushing, healthcare education, and selective decontamination of digestive tract using an antimicrobial gel applied to the mucous membranes of the mouth several times per day. Due to the small number of studies and variability in treatments, pooled analyses were not possible. The use of decontamination gel was associated with a reduction in the incidence of pneumonia (OR=0.20, CI 95% 0.05 to 0.84). A single education session was not associated with a reduction in dental plaque tooth coverage, the presence of gingivitis, or denture-induced stomatitis at 1 or 6 months following training, but was associated with a significant reduction in denture plaque at both assessment points and higher knowledge scores among care providers. 

Sex and Gender Considerations

Medical Complications

Otite et al. (2017) reported sex differences in the frequencies of various post stoke complications. Urinary tract infections, the most common complication, was reported in 19.8% of women compared with 9.9% in men. Acute renal failure was more commonly reported in men (10.6% vs. 5.9% in women). Overall, the risks of other complications including pneumonia, DVT and pulmonary embolism were approximately 30% greater in men. Older age and female sex were identified as risk factors for urinary tract infection in a systematic review of acute post-stroke infections (Westendorp et al. 2011).

Cardiovascular Investigations

In the FIND-AF trial (Wachter et al. 2017), in which patients were randomized to receive prolonged Holter ECG monitoring (10-days) and repeated at 3 and 6 months or standard care (minimum of 24 hours of cardiac monitoring), there were no interactions in subgroup analyses based on age, sex, baseline NIHSS, CHADS-2 score, symptoms at admission and imaging (lacunar vs. non-lacunar). Sex was not examined as a potential effect modifier in the MonDAFIS trial (Haeusler et al. 2021).

Venous Thromboembolism Prophylaxis

In the Cochrane review of (Sandercock et al. 2017) comparing LMWH with UFH, no subgroup analyses (including sex) were conducted. Sex was not a variable examined in prespecified subgroup analyses in the CLOTS trials (2009, 2010, 2013).

Temperature Management

Sex was not among the variables included in prespecified analysis of the PAIS 2 trial (De Ridder et al. 2017). However, in a systematic review (Carcel et al. 2019) including data from 5 acute randomized controlled trials examining sex differences on stroke outcomes, was the finding that women were less likely to be treated for fever (OR=0.82, 95% CI 0.70-0.95).

Mobilization

In the Cochrane review (Langhorne et al. 2018) comparing early mobilization with usual care, no subgroup analyses based on sex, were conducted. No subgroup analyses were conducted in any of the primary trials included in the review.

Seizure Management

The frequency of post-stroke seizures in the literature review was low. No subgroup analyses based on sex were conducted in trials examining the effectiveness of oral antiepileptic agents.

Nutrition and Dysphagia

The incidence of dysphagia post stroke and potential differences in treatment effectiveness in men versus women was not examined in any of the literature reviewed. No subgroup analyses based on sex were conducted in any of the trials of enteral feeding.

Incontinence

The effectiveness of behavioral interventions for the treatment of urinary incontinence, based on sex, was not examined in the literature reviewed.

Oral Care

The effectiveness of oral care protocols to promote oral hygiene, based on sex, was not examined in subgroup analyses in any of the literature reviewed.