Medical complications of stroke …

Adrian Marchidann MD

Stroke & Vascular Disorders

Updated 02.05.2025
Released 06.07.2001
Expires For CME 02.05.2028

Medical complications of stroke

Author: Adrian Marchidann MD

See Contributor Disclosures

Editor: Steven R Levine MD

Cite this article

Medical complications of stroke

In This Article

Quick Link

Introduction

Overview

Medical complications of stroke account for significant morbidity and mortality. Early recognition and management result in a more favorable outcome. During the first week, the direct effects of ischemic stroke are responsible for most deaths. Other medical complications, including cardiac, infectious, and venous thromboembolism, increase mortality thereafter. In this article, the author discusses the medical complications of stroke-related deficits, their workup, and treatment modalities.

Key points

	• Venous thromboembolism is one of the most common and serious complications of stroke.
	• Although promising, the new oral anticoagulants require further testing.
	• During acute stroke, thrombolysis for the treatment of pulmonary embolism is contraindicated.
	• Limited mobility following stroke is associated with osteoporosis, fractures, pressure sores, painful arthritis, and peripheral neuropathy.
	• Post-stroke pain may be severely debilitating and refractory to conventional analgesics. Invasive neurosurgical procedures and noninvasive transcranial magnetic stimulation have shown promising results but require further testing.

Classification scheme for medical complications of stroke

Prospective studies suggest that direct effects of ischemic stroke, such as hemorrhagic conversion or cerebral edema, account for most deaths within the first week. However, medical complications account for at least 50% of mortality thereafter (163; 66).

Medical complications of stroke decrease survival by several years (07). Admission to stroke units significantly reduces these complications, including immobility and mortality within the first 4 weeks (05). Later, the predominant complications are venous thromboembolism, pneumonia, urosepsis, cardiac arrhythmias, and myocardial infarction. Other late complications include falls, pressure sores, psychiatric disorders, and central poststroke pain. Some of the most beneficial measures are swallowing evaluation to prevent aspiration, avoidance of urinary catheters, and prophylaxis of thromboembolism (163).

Table 1 outlines the medical complications of stroke (91). The topics discussed in this article are listed in Table 2. Several of these topics are discussed in other MedLink Neurology articles.

Table 1. Medical Complications of Stroke: A Classification Scheme

I. Neurologic complications
	(A) Seizures (B) Vascular dementia
II. Infections
	(A) Urinary tract infection (B) Dysphagia, aspiration pneumonia
III. Complications of immobility
	(A) Falls (B) Hemiosteoporosis, fractures (C) Pressure ulcer (D) Spasticity
IV. Thromboembolism
	(A) Deep venous thrombosis (B) Pulmonary embolism
V. Pain
	(A) Shoulder pain (B) Central post-stroke pain
VI. Psychological complications
	(A) Depression (B) Anxiety (C) Confusion (D) Emotional incontinence
VII. Miscellaneous
	(A) Gastrointestinal hemorrhage (B) Constipation (C) Cardiac failure, arrhythmias (D) Arthritis (E) Sleep apnea (F) Nutritional deficiencies
Adapted from (91).

Table 2. Medical Complications of Stroke

I. Disorders of immobility

(A) Deep venous thrombosis and pulmonary embolus
(B) Hemiosteoporosis and hip fractures
(C) Falls
(D) Pressure sores, skin ulcers
(E) Peripheral nerve injury

II. Pain

(A) Shoulder pain
(B) Central post-stroke pain

III. Incontinence

Deep venous thrombosis and pulmonary embolism

Epidemiology. Venous thromboembolism after acute ischemic stroke is a significant cause of morbidity and mortality. Deep venous thrombosis appears on the second day after stroke onset. At 2 weeks, deep venous thrombosis occurs in up to 50% of patients (16). In a case series of 30 patients with stroke, only four of whom received deep venous thrombosis prophylaxis, sudden death occurred in 50% of patients with pulmonary embolism (197).

Among patients with ischemic stroke discharged between 1979 and 2003, 1.17% had venous thromboembolism, 0.74% had deep venous thrombosis, and 0.51% had pulmonary embolism. Hemorrhagic stroke was associated with higher rates: 1.93%, 1.37%, and 0.68%, respectively (164).

The etiology of venous thromboembolism is multifactorial: endothelial damage, blood flow stasis, and hypercoagulability (158). Endothelial damage promotes coagulation. Thrombosis risk factors include severe paralysis and hypercoagulability (89).

Virchow triad

In 1862, Rudolf Virchow proposed the pathophysiology triad of thrombosis: blood vessel wall lesion, blood flow stasis, and alterations in blood coagulability. (Contributed by Dr. Steven Lentz.)

Following a stroke, the paretic leg is preferentially affected due to immobility, venous stasis, accumulation of activated coagulation factors, and repeated trauma (77). A systematic review of Medline and Embase searches from January 1990 onwards, including 26 studies, identified the venous thromboembolism risk factors reported by two or more studies as previous venous thromboembolism, pre-stroke disability, large infarct, low Barthel index, age, dehydration, delayed preventing measures, infection, prolonged hospital stay, cancer, infection, elevated C-reactive protein, and D-dimer (179).

Pulmonary embolism may be asymptomatic, but if severe, it may cause respiratory failure and sudden death. In patients with asymptomatic deep venous thrombosis, 40% of lung scans detect pulmonary emboli (125). Although 90% of pulmonary emboli originate in the legs, ultrasound is positive in only 29% of cases (180).

Venous thromboembolism increases the risk of cardiovascular death. A systematic review and meta-analysis that included 13 observational studies enrolling 22,251 patients found that cardiovascular death is more frequent in patients with venous thromboembolism than in the general population without venous thromboembolism (risk ratio: 3.85, 95% CI: 2.75–5.39) (134).

Differential diagnosis. Edema of the paretic limb may mimic deep venous thrombosis. Respiratory failure may be caused by cerebral herniation or a brainstem lesion. The post-thrombotic syndrome (PTS) attributed to venous hypertension and abnormal microcirculation is characterized by edema and pain with or without venous ulceration (15; 77).

Diagnostic workup. Most patients with pulmonary embolism have at least one of these symptoms: sudden onset dyspnea, chest pain, syncope, and hemoptysis (120).

Further studies may be needed depending on the pretest clinical probability of pulmonary embolism (Tables 3 and 4) and several scoring systems (190; 121; 192). A normal D-dimer level combined with low pretest clinical probability excludes thrombotic disease.

A high pretest probability should not affect the clinical decision (191). A normal D-dimer level does not exclude venous thromboembolism if the clinical probability is high. Lower limb ultrasound or helical chest CT is needed to exclude venous thromboembolism (157). However, CT alone may not be sensitive enough to exclude pulmonary embolism in these patients (153).

Table 3. Wells Prediction Rule for Diagnosing Deep Venous Thrombosis

Clinical Features	Score
Recently bedridden for more than 3 days or major surgery within 12 weeks Localized tenderness along the deep veins Paralysis or immobilization of lower extremities Entire leg swollen Calf swelling 3 cm larger than normal Pitting edema confined to symptomatic leg Active cancer Collateral superficial veins (non-varicose) Alternative diagnosis less likely to be deep venous thrombosis	+1 +1 +1 +1 +1 +1 +1 +1 -2
Clinical probability of deep venous thrombosis: Low = less than 0; intermediate = 1 to 2; high = 3 or higher From: (190)

Table 4. Wells Prediction Rule for Diagnosing Pulmonary Embolism

Clinical Features	Score
Previous pulmonary embolism or deep venous thrombosis Heart rate greater than 100/min Recent surgery or immobilization Deep venous thrombosis clinical signs Alternative diagnosis less likely than pulmonary embolism Hemoptysis Cancer	+1.5 +1.5 +1.5 +3 +3 +1 +1
Clinical probability of pulmonary embolism: Low = 0 to 1; intermediate = 2 to 6; high = 7 or higher From: (23)

Prevention of thromboembolism

General measures. Nonpharmacologic prevention includes early mobilization, graduated compression stockings, and pneumatic sequential compression devices. Bed rest following stroke should be limited to patients with large cerebellar or cerebral lesions and increased intracranial pressure, severe angina and myocardial infarction, deep venous thrombosis (before anticoagulation), and postural ischemia due to large-vessel carotid or vertebrobasilar artery disease. If possible, avoid intravenous lines in the paretic arm due to the increased risk of deep venous thrombosis.

Compression stockings. Thigh-length graduated compression stockings (GCS) failed to prevent proximal deep venous thrombosis after stroke and caused skin complications (30). However, intermittent compression stockings prevent deep venous thrombosis and increase survival in patients with acute stroke (29). In an observational study, sequential compression devices added to unfractionated heparin reduced the risk of deep vein thrombosis more than 40-fold (71). The American College of Chest Physicians recommends intermittent pneumatic compression devices or elastic stockings if anticoagulation is contraindicated (76).

Anticoagulation. During an acute stroke, either low-dose unfractionated heparin, low molecular weight heparin, or danaparoid may be used (76). Thromboprophylaxis for up to 4 to 5 weeks is more beneficial than short-term prophylaxis (182).

Unfractionated heparin 5000 IU sc thrice daily reduces the risk of venous thromboembolism after acute stroke from 73% to 22%, along with a decrease in the combined rate for deep venous thrombosis, pulmonary embolism, and death (113).

Low molecular weight heparin (LMWH) administered once daily is safer and more cost-effective than unfractionated heparin (70; 162; 149).

Fondaparinux, an indirect factor Xa inhibitor, is a safe alternative in patients at risk for heparin-induced thrombocytopenia (54).

Direct oral anticoagulation (DOAC) agents are easier to administer. However, DOACs are not superior to postoperative LMWH for venous thromboembolism prevention. For acute treatment and secondary prevention of venous thromboembolism, DOAC agents have a lower risk of hemorrhagic complications but are not more efficacious than warfarin (168).

After intracerebral hemorrhage, preventive anticoagulation is delayed until hemorrhage expansion stops. A meta-analysis of eight studies including 3893 patients found a decreased risk of pulmonary embolism, but the risk of deep venous thrombosis and venous thromboembolism was not modified (161). The risk of increased intracerebral hemorrhage, rebleeding, or poor outcome was not increased.

Treatment of venous thromboembolism in stroke patients. If clinical suspicion of venous thromboembolism is high, intravenous anticoagulation is indicated while waiting for diagnostic confirmation. Intermediate suspicion warrants intravenous anticoagulation if confirmation of venous thromboembolism is delayed for more than 4 hours. In patients with a low suspicion, parenteral anticoagulation should be deferred if the confirmatory test result is expected within 24 hours.

Anticoagulation alone is the preferred treatment for acute leg deep venous thrombosis. Isolated, distal deep venous thrombosis without severe symptoms and unlikely to extend may be monitored by serial imaging for 2 weeks. However, severe symptoms and risk or evidence of proximal thrombus extension by ultrasound warrant anticoagulation.

Patients with acute pulmonary embolism and systolic blood pressure less than 90 mmHg, who do not have a high risk of bleeding, may benefit from intravenous thrombolysis. Catheter-directed thrombolysis is associated with fewer cerebral hemorrhagic complications than systemic thrombolysis but similar mortality (101). In the case of thrombolysis, failure or shock surgical thrombectomy may be beneficial (76).

DOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are the preferred anticoagulants for the treatment of acute deep venous thrombosis and pulmonary embolism as they are noninferior to warfarin and were associated with fewer hemorrhagic complications (159; 40; 41; 03; 59).

Bridging with LMWH or fondaparinux is initiated on the same day as warfarin. Parenteral anticoagulation is continued for a minimum of 5 days or at least 24 hours after INR is 2 or above. The ideal INR target is 2 to 3. Warfarin dosage should begin with 5 mg (56; 33). Anticoagulation clinics improve warfarin anticoagulation control, patient outcomes, and health care costs (25). If compliance is unreliable, long-term subcutaneous LMWH can be used.

Unprovoked venous thromboembolism is treated for 3 months if the risk of bleeding is high and for longer if the risk of bleeding is low or moderate. At the end of 3 months, the risk-benefit ratio should be reassessed. Provoked venous thromboembolism is treated for 3 months and for longer if the provoking factor persists. Extended anticoagulation is recommended at a lower dose with a DOAC or warfarin in those patients who are not candidates for DOAC. Malignancy requires extended anticoagulation regardless of the bleeding risk.

Warfarin is teratogenic. During pregnancy, heparin is used instead. Early mobilization and avoiding procoagulant agents (eg, hormone-replacement therapy or oral contraceptives) are advisable.

Intracerebral hemorrhage is a transient contraindication for thrombolysis and anticoagulation. A temporary inferior vena cava filter may be used instead until anticoagulation can be resumed. However, the inferior vena cava filter is not recommended in addition to anticoagulation.

Post-thrombotic syndrome development can be avoided by using systemic or catheter-directed thrombolysis. A trial of compression stockings is indicated in patients with post-thrombotic syndrome. Persisting post-thrombotic syndrome may benefit from an intermittent compression device.

Further recommendations on acute venous thromboembolism treatment are detailed by the American College of Chest Physicians (170).

Bone disease: osteoporosis and fractures

Stroke impairs mobility, leading to osteoporosis, falls, and fractures. Most fractures occur late, on the hemiplegic side (156). Sequential bilateral hip fractures were seen more frequently in institutionalized patients with a history of stroke and osteomalacia (26). Hip fractures are associated with an increased risk of institutionalization and death (43).

Epidemiology. Out of 130,000 discharged acute stroke patients, 2.0% suffered fractures in 1 year and 10.6% in 10 years (37). The risk of hip fracture increases 4-fold after stroke (72).

Pathophysiology. Bone strength is a composite of bone density and bone quality, with the latter thought to include bone architecture, bone damage (eg, microfractures), and mineralization. Immobilization after stroke leads to osteoporosis (156). After a stroke, approximately 30% of fractures occur in the upper extremities (140).

Clinical risk factors that contribute to fracture risk independent of bone mineral density are presented in Table 5 (73).

Table 5. Risk Factors for Osteoporotic Fractures in Women

• Age
• Premature menopause
• Primary amenorrhea or amenorrhea associated with low estrogen
• Asian or white ethnic origin
• Previous fragility fracture
• Low bone mineral density
• Glucocorticoid therapy
• High bone turnover
• Family history of hip fracture
• Poor visual acuity
• Low body weight
• Neuromuscular disorders
• Cigarette smoking
• Excessive alcohol consumption
• Long-term immobilization
• Low dietary calcium intake
• Vitamin D deficiency

Adapted from (73)

Bone loss in the paretic limb after stroke results from lack of exertion. A retrospective study of 1139 patients followed for a median time of 2.9 years found that most fractures occur in the paretic hip. Fracture incidence was two to four times higher than in the general population (156). In another study, the risk factors of fractures after stroke are weakness, numbness, neglect, imbalance, and decreased awareness (151).

Vitamin D deficiency increases the risk of fracture in disabled elderly patients (143). Nutrition, light exposure, and medications are additional contributors. Proton pump inhibitors increase the risk of osteoporosis (103). Dabigatran, a direct oral thrombin inhibitor, is associated with a lower risk of osteoporotic fractures compared to warfarin (92).

Clinical features. Vertebral fractures may cause back pain, spinal deformity, functional limitations, and increased risk of hospitalization and mortality (69; 44).

Osteoporosis is defined as bone mineral density of 2.5 SD or more below the average value for premenopausal women (T score, less than -2.5 SD). In the presence of one or more fragility fractures, osteoporosis is considered severe (73).

Table 6. World Health Organization (WHO) Definition of Osteoporosis

Diagnostic Category	T-score	Bone Mineral Density
Normal	Greater than –1	Within 1 SD of a young normal adult
Low bone mass	–1 to –2.5	Between 1 and 2.5 SD below that of a young normal adult
Osteoporosis	Less than –2.5	More than 2.5 SD below that of a young normal adult
Severe osteoporosis	Less than –2.5 and 1 or more fragility fractures	More than 2.5 SD below that of a young normal adult and one or more osteoporotic fractures

Treatment. Osteoporosis management aims to prevent fractures by increasing bone strength and physical function (133). A single-center registry database of 1307 consecutively registered patients with acute ischemic stroke shows that osteoporosis pharmacotherapy may improve the functional outcomes at 3 months and 1 year after ischemic stroke onset (165).

A pyramidal approach has been recommended. The base is represented by lifestyle changes: calcium and vitamin D intake, physical activity, and fall prevention (135). Physical activity promotes bone formation and maintenance. However, walking alone is insufficient. Exercises that improve mobility, muscle function, and balance may reduce the fracture risk (46). Reversal of osteoporosis after hemiplegia requires daily weight training for a minimum of 60 and 90 minutes for males and females, respectively (55).

Calcium and vitamin D supplementation help prevent fractures (36). The recommended intake of calcium is 1000 mg/day for men and women aged 50 years or younger and 1200 mg/day for those older than 50 years of age (NIH Dietary Supplement Fact Sheet--Calcium). The recommended dose of vitamin D is 400 IU/day for men and women aged 51 to 70 years and 600 IU/day for those 71 years or older (NIH Dietary Supplement Fact Sheet—Vitamin D). The second level includes addressing and treating secondary causes of osteoporosis. The third level includes pharmacotherapeutic interventions to improve bone density and reduce the risk of fracture.

Bisphosphonates inhibit bone resorption. Zoledronate administered as a single dose of 4 mg intravenously within 5 weeks of stroke onset helps preserve bone mineral density (150).

Denosumab is a monoclonal antibody with an affinity for the receptor activator of nuclear factor-kappaB ligand (RANKL). Denosumab given as a subcutaneous injection every 6 months inhibits osteoclastic activity and increases bone mass in patients with osteoporosis (114).

Several antiresorptive agents increase the risk of thromboembolism and are contraindicated in patients with stroke. These include raloxifene, strontium ranelate, and romosozumab (99; 186; 90).

Complications of stroke

Falls. Traumatic brain injury is responsible for 78% of fall-related deaths and 79% of the cost (169). Stroke doubles the risk of falling (67). Most falls occurred during transfers between the wheelchair and bed (145). Predictors of falls are executive dysfunction, imbalance while dressing, and depression (88; 107; 171). Depression and anxiety predominantly affect young women with low socioeconomic status (17). Comorbidities, polypharmacy, decreased vision, and decreased cognition in stroke patients often increase the risk of falling.

The Postural Assessment Scale for Stroke (PASS) and the Postural Control and Balance for Stroke test (PCBS) evaluate postural control and assess the risk of fall after stroke (09; 152).

Fall prevention programs emphasize supervision of high-risk patients, proper seating, wheelchair transfers, and regular toileting.

Pressure sores. Pressure sores may develop rapidly in bedridden stroke patients. Sustained pressure due to limited mobility results in skin ischemia over the weight-bearing points, usually the bony prominences. If infected, they can result in significant morbidity and mortality (20).

A Swedish retrospective study of 161 patients with stroke recorded 116 pressure ulcers, 30 of whom had multiple ulcers (57). The sacrum and the lower body are most often affected (52).

Other risk factors include diabetes, peripheral vascular disease, urinary incontinence, and low body mass index (11).

Pressure sores are classified according to stages (129):

	Stage I—non-blanchable erythema on intact skin.
	Stage II—partial thickness skin loss of the dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough.
	Stage III—full thickness tissue loss involving the subcutaneous tissue or fascia. Bone, tendon, and muscle are not exposed.
	Stage IV—full thickness tissue loss with exposed bone, tendon, or muscle.

The Braden Scale predicts the risk of developing pressure sores. The scores range from 6 to 23, with higher risk associated with lower scores (10; 14).

Bed sores can be prevented by turning every 2 hours. A Cochrane review found that higher‐specification foam mattresses, rather than standard hospital foam mattresses, or the use of medical grade sheepskin reduce the incidence of pressure ulcers (117). Managing incontinence, daily checks, and high protein nutritional intake help maintain the skin barrier integrity (177). Pressure sore treatment consists of wound dressing and cleaning to prevent infection (50).

Peripheral nerve injury. Compression peripheral nerve injury in stroke patients results from limb malposition and may cause additional disability or pain. The risk is increased by sensory loss, weakness, neglect, and limb edema. In addition, using a manual wheelchair increases the likelihood of median and ulnar nerve injury in the arm nerve (12). Hematoma, a complication of anticoagulation, may result in brachial plexus injury or femoral nerve entrapment (42).

Electrodiagnostic studies help establish the injury site and severity and the need for surgical intervention. In most cases, splinting and other supportive devices as well as pain management may be sufficient.

Pain syndromes

After a stroke, many patients experience pain that affects their quality of life. A prospective study of 443 patients with stroke showed that 29.56% suffered from pain (14.06% in acute, 42.73% in the subacute, and 31.90% in the chronic stroke stage). Headache after stroke manifests acutely. Musculoskeletal and central pain occurs more often in the subacute and chronic stages, whereas spasticity-related pain appears in the chronic stage (141).

Central post-stroke pain. Central nervous system pain has a burning, aching, throbbing, cramping, or combination character. Central pain triggers may be innocuous stimuli. Elderly patients tend to experience nonburning pain. Characteristically, the sensitivity to pinprick and temperature is decreased in the same region. However, the spinothalamic sensation may persist in many patients (86).

In a systematic review of 69 papers, central pain was reported in 11% of strokes in any location and in 50% of patients with medulla and thalamus strokes. Central pain coincides with acute stroke in 26% of patients and may appear up to 12 months later (100).

Lesions of the ventral posterolateral, ventral medial, and medial dorsal nucleus and the trigeminal and spinothalamocortical pathways, including the brainstem, and cerebral cortex lead to post-stroke pain (13; 32; 131). Pure central post-stroke pain, sometimes mistaken for malingering or psychogenic pain, is related to the spinothalamic tracts from the posterolateral mesencephalon (31). Central post-stroke pain should be considered after other causes of pain are excluded.

Medial lemniscus has a modulatory role. Well-controlled central pain due to lateral medullary stroke may recur after a second infarct involving the ipsilateral medial medullary region (79). Lesions of the ventral caudal nucleus suggest a role of other pathways in central pain development (122; 78).

The pattern of central pain correlates with the site of the lesion. Ventroposterior thalamic nuclear lesions are more likely to produce half-body pain. The supratentorial lesions cause the most severe pain in the extremities, whereas the infratentorial lesions cause pain in the face (13). Imaging injured spinothalamic strokes may be achieved with diffusion tensor tractography (62).

There is a lack of high-quality clinical trials of central pain treatment. Post-stroke pain may be refractory to standard analgesics and opioids.

Amitriptyline has been effective in a small, randomized controlled study (95); however, there is a need for more data (123).

Pregabalin is effective at escalating doses of 150, 300, and 600 mg/day (187). In addition, it may improve pain-related anxiety and sleep disturbances (81). Duloxetine was also studied with success in a small study (83), but a prior clinical randomized double-blind placebo-controlled trial did not show a significant decrease in pain intensity (188).

Carbamazepine is probably effective for chronic neuropathic pain, but there is a lack of information beyond 4 weeks (195). The effect of gabapentin on neuropathic pain is probably not superior to carbamazepine (193).

Lamotrigine in a dose of 200 mg daily was moderately effective in a small, randomized study (185), but a Cochrane review provided no convincing evidence of benefit at doses of 200 to 400 mg/day. In addition, its titration is difficult because of the risk of rash (194).

Levetiracetam is not effective for post-stroke pain treatment (68; 196).

Intravenous lidocaine and morphine have a limited role in treating central pain due to the delivery method and side effects (06). Intrathecal baclofen improved central post-stroke pain in a small case series (173). Fluvoxamine and mexiletine may also be used as adjuvants for pain treatment (80). Botulinum toxin, BTX-A, has been used with some success for neuropathic pain; however, a clinical trial is needed to confirm the initial results (60).

Graded motor imagery, like limb laterality recognition, imagined movements, mirror movements, and mirror therapy may improve pain and function in patients with phantom limb and complex regional pain syndrome type 1 (124; 176).

Cold caloric stimulation modulates the nociceptive evoked potentials (116; 45). In small studies, caloric stimulation improved central pain (154; 115; 116; 130). However, controlled randomized studies are needed to validate this observation.

Stellate ganglion blockade can reduce refractory thalamic pain (102). In one case report, the stellate ganglion blockade with lidocaine analgesia persisted for 9 months (106).

Scrambler therapy, a form of noninvasive electroanalgesia, showed a reduction of post-stroke pain in a small study of 20 patients (172).

Repetitive transcranial magnetic stimulation (rTMS) is a potentially useful noninvasive method for pain control (96). Fiber tracking with diffusion tensor imaging may predict response to rTMS (49). However, there is a significant publication bias (38). A systematic review of transcranial direct current stimulation (tDCS) on neuropathic pain in patients with stroke shows promise, but there is high heterogeneity (35; 155). rTMS may control chronic as well as acute pain after stroke (97; 109). A systematic review of five studies, including 119 patients who underwent rTMS, found that stimulation of the M1 area only reduced central pain significantly (112).

Prefrontal cortex stimulation is preferred because it is less invasive and more effective than deep brain and spinal cord stimulation (75). Motor cortex stimulation is also useful for central pain from the brainstem and spinal cord lesions (174). Pain relief may persist for 12 months (167; 184). Long-term, over 80% reduction in pain was seen in 31% of patients, 50% to 80% reduction in 23% of patients, and no improvement in 15% of patients (166). The main complications are epidural hematoma and subdural effusion. The presumed mechanism is increased regional blood flow to the ipsilateral corticothalamic connections or reduced inflammation (18; 160).

For nonthalamic lesions, spinal cord stimulation achieved relief for more than 12 months in 44.4% of patients (175). Other useful locations for electrical stimulation include periventricular grey matter and the centromedian thalamic nucleus (128; 148; 04).

The data on neurosurgical management of central post-stroke pain are limited, and further studies are needed to confirm these findings (34; 47).

Shoulder pain. Shoulder pain occurs in 22% of patients within the first 4 months of the first stroke; 79% have moderate to severe pain. Weakness and a high NIHSS score correlate with pain. Pain is disabling and limits rehabilitation (105). Shoulder pain frequency has decreased over the last 15 years, suggesting an improvement in stroke care and rehabilitation (119).

The causes of shoulder pain are adhesive capsulitis, subluxation, spasticity, local trauma, shoulder-hand syndrome, and complex regional pain syndrome. The severity and stage of paralysis alter the shoulder joint configuration and the type of pain differently (181). Adhesive capsulitis and shoulder subluxation are the most common causes of shoulder pain (108). They occur in 50% and 44% of patients, respectively A meta-analysis of 23 studies found that ultrasound of the hemiparetic shoulder may reveal pathology in the biceps long head tendon (41.4%), followed by the supraspinatus tendon (33.2%). These abnormalities occur more often than in the contralateral shoulder (104).

In the flaccid stage, inferior subluxation may benefit from shoulder support and muscle electrical stimulation. In the spastic stage, muscle relaxants and range of motion improve mobility (181). Pain resolves spontaneously only in some patients despite similar functional status. Persistence of shoulder pain suggests a decreased adaptation to pain (74).

Shoulder subluxation. Shoulder subluxation results from the inferior displacement of the paretic arm (181). Glenohumeral subluxation was present in nearly 50% of patients in a case-control study of 107 hemiplegic adults with stroke (138).

Subluxation is diagnosed by palpation, plain radiographs of the shoulder, or ultrasonography (142). Careful manipulation of the weak limb during transfers is important for preventing subluxation (189). Support slings have produced mixed results (137). Moreover, one study showed that subluxation correction was impaired by wearing an arm sling (183). Observational studies suggest that shoulder orthoses reduce vertical subluxation and pain (127). In a multicenter randomized controlled trial, the elastic dynamic sling was superior to the Bobath sling (82).

Theoretical benefits of electrical stimulation of the shoulder include maintenance of muscle bulk and tone and enhancement of functional recovery (181). Long-term follow-up was limited, however. A meta-analysis of seven clinical trials showed that electrical stimulation added to conventional therapy reduced subluxation early, but not late, after stroke (01). A randomized pilot study of 31 stroke survivors showed that the addition of kinesio-tape or neuromuscular electric stimulation (NEMS) to conventional therapy did not further improve shoulder pain (58). Another randomized controlled study of 28 patients showed that adding NMES to standard therapy and external shoulder support improved the subluxation and arm function but not the pain level (93).

Intramuscular electrical stimulation in 61 chronic stroke survivors with shoulder pain and subluxation significantly reduced pain levels up to 12-month follow-up (22). Another single-blind randomized trial of 38 patients with subacute or chronic stroke showed better pain control with EMG-triggered neuromuscular electric stimulation compared to transcutaneous electrical nerve stimulation (TENS), both immediately and at 1-month follow-up (28). In a case series of five patients, a fully implantable peripheral nerve stimulator was safe and significantly reduced shoulder pain after 12 months (198).

A systematic review of neuromuscular electric stimulation showed a reduction of shoulder subluxation in the acute and subacute phase but not in the chronic stroke or reduction of shoulder pain (94).

Spasticity. Spasticity of the shoulder following stroke is painful and disabling. The arm posture is adducted and rotated medially with flexion at the elbow, wrist, and fingers. Analgesics and muscle relaxants may alleviate the symptoms.

Botulinum toxin type A injection has been assessed in several small short-term studies with mixed results. Injection in the pectoralis major reduced pain caused by spasticity in the first week after stroke in a double-blind, randomized clinical trial of 31 patients (111). Injection in the subscapularis muscle improved pain control (200). A prospective randomized, double-blind, placebo-controlled trial found that botulinum toxin A reduced disability but not the pain (110). Moreover, a meta-analysis of 950 patients showed that the overall effectiveness of botulinum toxin type A does not differ from placebo for post-stroke patients with upper limb spasticity (63). A higher dose of botulinum toxin A was also studied; however, there are insufficient data to recommend this approach (61).

IncobotulinumtoxinA is a highly purified form of botulinum toxin with lower immunogenicity. A pooled analysis of data from six phase 2 or 3 studies, including 415 patients treated with incobotulinumtoxinA, showed that it is effective against spastic shoulder pain, especially if used in multiple injection cycles (199).

Although botulinum toxin A may reduce spasticity and pain associated with stroke, it is unknown if it improves the functional capacity (98). Botulinum toxin is not indicated for non-spastic causes of shoulder pain (85).

Other promising therapeutic modalities include repetitive transcranial magnetic stimulation (27), suprascapular nerve block (02; 147), modified wheelchair arm support (139), extracorporeal shock wave therapy (64), and mirror therapy (126).

Frozen shoulder. Also known as adhesive capsulitis, frozen shoulder is caused by recurrent local injuries and is characterized by shoulder pain and limited motion in all directions. It may be exacerbated by immobility and is often associated with rotator cuff tear. Contrast arthrogram is diagnostic in 50% of hemiplegic patients with shoulder pain (108). A placebo-controlled study showed that intra-articular injection of a corticosteroid in addition to physiotherapy improves pain control and mobility (21).

Shoulder-hand syndrome. This form of complex regional pain syndrome following stroke is characterized by severe shoulder and hand pain associated with dysautonomia (edema, changes in skin color and temperature, and excessive sweating). Atrophy of the skin and muscles of the shoulder and hand with sparring of the elbow often follows. The mechanism is probably central and peripheral sensitization due to stroke. However, involvement of the sympathetic system has not been demonstrated (146). Furthermore, shoulder subluxation and peripheral nerve damage increase the likelihood of developing complex regional pain syndrome (48).

The diagnosis of complex regional pain syndrome is primarily clinical. Bone scintigraphy may show increased periarticular uptake, particularly at the shoulder and wrist, and decreased bone mineral density in the paretic limb when compared to matched healthy controls (51; 87).

Preventative measures consist of avoidance of shoulder trauma. Treatment consists of physical therapy and pain management. Mirror therapy may reduce pain and improve the function of the upper limb (19).

Severe sympathetic dysfunction may benefit from regional block, although strong evidence is lacking. Investigations into neuromodulation through spinal cord stimulation and administration of intrathecal analgesia have been undertaken in patients with complex regional pain syndrome (87).

Two systematic reviews of acupuncture found several heavily biased studies, suggesting the need for further randomized clinical studies (24; 144).

Heterotopic ossification. Heterotopic ossification of the soft tissue of the paretic limb contributes to post-stroke pain and dysfunction (136). Calcification may also occur in the nonparetic limb (84; 53). Nonsteroidal anti-inflammatory drugs and radiation therapy may prevent its occurrence (08). If heterotopic ossification impairs rehabilitation and medical treatment fails, surgical resection is an option (118).

Urinary incontinence. Urinary incontinence within the first 7 days of stroke was noted in 53% of patients. One third of these patients remained incontinent at 12-month follow-up. Furthermore, those who were incontinent in the acute phase were four times more likely to be institutionalized after 1 year and a predictor of death (65).

Post-stroke urinary incontinence can be described based on etiology (169):

(1) Urge urinary incontinence: urgency followed by involuntary leakage that can result from a lesion of the central micturition pathways.

(2) Functional urinary incontinence: inability to achieve self-toileting due to impaired mobility from stroke.

(3) Stress urinary incontinence: involuntary leakage during effort such as coughing. This is usually present before stroke onset but is exacerbated by coughing associated with dysphagia and aspiration.

There are insufficient data from clinical trials to guide incontinence care in patients with stroke (178). Urinary incontinence after stroke is managed similarly to the general population. Treatment begins with behavioral interventions like timed voiding, prompted voiding, bladder retraining with urge suppression, pelvic floor muscle retraining, and compensatory rehabilitation approaches (39). Pharmacological treatment and urologic consultation with surgical intervention may be necessary. OnabotulinumtoxinA decreases the neurogenic detrusor overactivity and control of the overactive bladder (132).

References

01: Ada L, Foongchomcheay A. Efficacy of electrical stimulation in preventing or reducing subluxation of the shoulder after stroke: a meta-analysis. Aust J Physiother 2002;48(4):257-67. PMID 12443520
02: Adey-Wakeling Z, Crotty M, Shanahan EM. Suprascapular nerve block for shoulder pain in the first year after stroke: a randomized controlled trial. Stroke 2013;44(11):3136-41. PMID 23970790
03: Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med 2013;369(9):799-808. PMID 23808982
04: Alves RV, Asfora WT. Deep brain stimulation for Dejerine-Roussy syndrome: case report. Minim Invasive Neurosurg 2011;54(4):183-6. PMID 21922448
05: Anonymous. How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke Unit Trialists Collaboration. Stroke 1997;28(11):2139-44. PMID 9368554
06: Attal N, Gaude V, Brasseur L, et al. Intravenous lidocaine in central pain: a double-blind, placebo-controlled, psychophysical study. Neurology 2000;54(3):564-74. PMID 10680784
07: Bae HJ, Yoon DS, Lee J, et al. In-hospital medical complications and long-term mortality after ischemic stroke. Stroke 2005;36(11):2441-5. PMID 16224097
08: Balboni TA, Gobezie R, Mamon HJ. Heterotopic ossification: pathophysiology, clinical features, and the role of radiotherapy for prophylaxis. Int J Radiat Oncol Biol Phys 2006;65(5):1289-99. PMID 16863921
09: Benaim C, Perennou DA, Villy J, Rousseaux M, Pelissier JY. Validation of a standardized assessment of postural control in stroke patients: the Postural Assessment Scale for Stroke Patients (PASS). Stroke 1999;30(9):1862-8. PMID 10471437
10: Bergstrom N, Demuth PJ, Braden BJ. A clinical trial of the Braden Scale for Predicting Pressure Sore Risk. Nurs Clin North Am 1987;22(2):417-28. PMID 3554150
11: Berlowitz DR, Brandeis GH, Anderson JJ, et al. Evaluation of a risk-adjustment model for pressure ulcer development using the Minimum Data Set. J Am Geriatr Soc 2001;49(7):872-6. PMID 11527477
12: Boninger ML, Impink BG, Cooper RA, Koontz AM. Relation between median and ulnar nerve function and wrist kinematics during wheelchair propulsion. Arch Phys Med Rehabil 2004;85(7):1141-5. PMID 15241765
13: Bowsher D, Leijon G, Thuomas KA. Central poststroke pain: correlation of MRI with clinical pain characteristics and sensory abnormalities. Neurology 1998;51(5):1352-8. PMID 9818859
14: Braden BJ, Maklebust J. Preventing pressure ulcers with the Braden scale: an update on this easy-to-use tool that assesses a patient's risk. Am J Nurs 2005;105(6):70-2. PMID 15930875
15: Brandjes DP, Buller HR, Heijboer H, et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349(9054):759-62. PMID 9074574
16: Brandstater ME, Roth Ej, Siebens HC. Venous thromboembolism in stroke: literature review and implications for clinical practice. Arch Phys Med Rehabil 1992;73(5-S):S379-91. PMID 1301012
17: Broomfield NM, Quinn TJ, Abdul-Rahim AH, Walters MR, Evans JJ. Depression and anxiety symptoms post-stroke/TIA: prevalence and associations in cross-sectional data from a regional stroke registry. BMC Neurol 2014;14:198. PMID 25269762
18: Brown JA. Motor cortex stimulation. Neurosurg Focus 2001;11(3):E5. PMID 16519425
19: Cacchio A, De Blasis E, De Blasis V, Santilli V, Spacca G. Mirror therapy in complex regional pain syndrome type 1 of the upper limb in stroke patients. Neurorehabil Neural Repair 2009;23(8):792-9. PMID 19465507
20: Capon A, Pavoni N, Mastromattei A, Di Lallo D. Pressure ulcer risk in long-term units: prevalence and associated factors. J Adv Nurs 2007;58(3):263-72. PMID 17474915
21: Carette S, Moffet H, Tardif J, et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis Rheum 2003;48(3):829-38. PMID 12632439
22: Chae J, Yu DT, Walker ME, et al. Intramuscular electrical stimulation for hemiplegic shoulder pain: a 12-month follow-up of a multiple-center, randomized clinical trial. Am J Phys Med Rehabil 2005;84(11):832-42. PMID 16244520
23: Chagnon I, Bounameaux H, Aujesky D, et al. Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism. Am J Med 2002;113(4):269-75. PMID 12361811
24: Chau JPC, Lo SHS, Yu X, et al. Effects of acupuncture on the recovery outcomes of stroke survivors with shoulder pain: a systematic review. Front Neurol 2018;9:30. PMID 29445354
25: Chiquette E, Amato MG, Bussey HI. Comparison of an anticoagulation clinic with usual medical care: anticoagulation control, patient outcomes, and health care costs. Arch Intern Med 1998;158(15):1641-7. PMID 9701098
26: Chiu KY, Pun WK, Luk KD, Chow SP. Sequential fractures of both hips in elderly patients--a prospective study. J Trauma 1992;32(5):584-7. PMID 1588646
27: Choi GS, Chang MC. Effects of high-frequency repetitive transcranial magnetic stimulation on reducing hemiplegic shoulder pain in patients with chronic stoke: a randomized controlled trial. Int J Neurosci 2018;128(2):110-6. PMID 28805107
28: Chuang LL, Chen YL, Chen CC, et al. Effect of EMG-triggered neuromuscular electrical stimulation with bilateral arm training on hemiplegic shoulder pain and arm function after stroke: a randomized controlled trial. J Neuroeng Rehabil 2017;14(1):122. PMID 29183339
29: CLOTS Trials Collaboration, Dennis M, Sandercock P, et al. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet 2013;382(9891):516-24. PMID 23727163
30: CLOTS Trials Collaboration, Dennis M, Sandercock PA, et al. Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet 2009;373(9679):1958-65. PMID 19477503
31: Convers P, Creac'h C, Beschet A, Laurent B, Garcia-Larrea L, Peyron R. A hidden mesencephalic variant of central pain. Eur J Pain 2020;24(7):1393-99. PMID 32419231
32: Craig AD. Distribution of trigeminothalamic and spinothalamic lamina I terminations in the macaque monkey. J Comp Neurol 2004;477(2):119-48. PMID 15300785
33: Crowther MA, Ginsberg JB, Kearon C, et al. A randomized trial comparing 5-mg and 10-mg warfarin loading doses. Arch Intern Med 1999;159(1):46-8. PMID 9892329
34: Cruccu G, Aziz TZ, Garcia-Larrea L, et al. EFNS guidelines on neurostimulation therapy for neuropathic pain. Eur J Neurol 2007;14(9):952-70. PMID 17718686
35: David MCMM, Moraes AA, Costa MLD, Franco CIF. Transcranial direct current stimulation in the modulation of neuropathic pain: a systematic review. Neurol Res 2018:1-9. PMID 29600889
36: Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med 1997;337(10):670-6. PMID 9278463
37: Dennis MS, Lo KM, McDowall M, West T. Fractures after stroke: frequency, types, and associations. Stroke 2002;33(3):728-34. PMID 11872896
38: Dufka FL, Munch T, Dworkin RH, Rowbotham MC. Results availability for analgesic device, complex regional pain syndrome, and post-stroke pain trials: comparing the RReADS, RReACT, and RReMiT databases. Pain 2015;156(1):72-80. PMID 25599303
39: Dumoulin C, Korner-Bitensky N, Tannenbaum C. Urinary incontinence after stroke: does rehabilitation make a difference? A systematic review of the effectiveness of behavioural therapy. Top Stroke Rehabil 2005;12(3):66-76. PMID 16110429
40: EINSTEIN Investigators, Bauersachs R, Berkowitz SD, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 2010;363(26):2499-2510. PMID 21128814
41: EINSTEIN-PE Investigators, Büller HR, Prins MH, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 2012;366(14):1287-97. PMID 22449293
42: Elesber AA, Kent PD, Jennings CA. Compressive neuropathy of the brachial plexus and long thoracic nerve: a rare complication of heparin anticoagulation. Chest 2001;120(1):309-11. PMID 11451857
43: Empana JP, Dargent-Molina P, Breart G, EPIDOS Group. Effect of hip fracture on mortality in elderly women: the EPIDOS prospective study. J Am Geriatr Soc 2004;52(5):685-90. PMID 15086646
44: Ensrud KE, Thompson DE, Cauley JA, et al. Prevalent vertebral deformities predict mortality and hospitalization in older women with low bone mass. Fracture Intervention Trial Research Group. J Am Geriatr Soc 2000;48(3):241-9. PMID 10733048
45: Ferre ER, Haggard P, Bottini G, Iannetti GD. Caloric vestibular stimulation modulates nociceptive evoked potentials. Exp Brain Res 2015;233(12):3393-401. PMID 26282602
46: Fiatarone MA, Marks EC, Ryan ND, Meredith CN, Lipsitz LA, Evans WJ. High-intensity strength training in nonagenarians. Effects on skeletal muscle. JAMA 1990;263(22):3029-34. PMID 2342214
47: Fontaine D, Hamani C, Lozano A. Efficacy and safety of motor cortex stimulation for chronic neuropathic pain: critical review of the literature. J Neurosurg 2009;110(2):251-6. PMID 18991496
48: Gokkaya NK, Aras M, Yesiltepe E, Koseoglu F. Reflex sympathetic dystrophy in hemiplegia. Int J Rehabil Res 2006;29(4):275-9. PMID 17106342
49: Goto T, Saitoh Y, Hashimoto N, et al. Diffusion tensor fiber tracking in patients with central post-stroke pain; correlation with efficacy of repetitive transcranial magnetic stimulation. Pain 2008;140(3):509-18. PMID 19004554
50: Grey JE, Harding KG, Enoch S. Pressure ulcers. BMJ 2006;332(7539):472-5. PMID 16497764
51: Greyson ND, Tepperman PS. Three-phase bone studies in hemiplegia with reflex sympathetic dystrophy and the effect of disuse. J Nucl Med 1984;25(4):423-9. PMID 6544813
52: Groeneveld A, Anderson M, Allen S, et al. The prevalence of pressure ulcers in a tertiary care pediatric and adult hospital. J Wound Ostomy Continence Nurs 2004;31(3):108-20; quiz 121-2. PMID 15867739
53: Gurcay E, Ozturk EA, Erdem T, Gurcay AG, Cakci A. Heterotopic ossification as rare complication of hemiplegia following stroke: two cases. Brain Inj 2013;27(13-14):1727-31. PMID 24088051
54: Hackett CT, Ramanathan RS, Malhotra K, et al. Safety of venous thromboembolism prophylaxis with fondaparinux in ischemic stroke. Thromb Res 2015;135(2):249-54. PMID 25554497
55: Han L, Li SG, Zhai HW, Guo PF, Chen W. Effects of weight training time on bone mineral density of patients with secondary osteoporosis after hemiplegia. Exp Ther Med 2017;13(3):961-5. PMID 28450926
56: Harrison L, Johnston M, Massicotte MP, Crowther M, Moffat K, Hirsh J. Comparison of 5-mg and 10-mg loading doses in initiation of warfarin therapy. Ann Intern Med 1997;126(2):133-6. PMID 9005747
57: Hede GW, Faxén-Irving G, Olin AÖ, Ebbeskog B, Crisby M. Nutritional assessment and post-procedural complications in older stroke patients after insertion of percutaneous endoscopic gastrostomy - a retrospective study. Food Nutr Res 2016;60:30456. PMID 27487849
58: Hochsprung A, Domínguez-Matito A, López-Hervás A, et al. Short- and medium-term effect of kinesio taping or electrical stimulation in hemiplegic shoulder pain prevention: A randomized controlled pilot trial. NeuroRehabilitation 2017;41(4):801-10. PMID 29254115
59: Hokusai-VTE Investigators. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med 2013;369(15):1406-15. PMID 23991658
60: Intiso D, Basciani M, Santamato A, Intiso M, Di Rienzo F. Botulinum toxin type A for the treatment of neuropathic pain in neuro-rehabilitation. Toxins (Basel) 2015;7(7):2454-80. PMID 26134256
61: Intiso D, Centra AM, Gravina M, Chiaramonte A, Bartolo M, Di Rienzo F. Botulinum toxin-A high-dosage effect on functional outcome and spasticity-related pain in subjects with stroke. Toxins (Basel) 2023;15(8):509. PMID 37624266
62: Jang SH, Lee J, Yeo SS. Central post-stroke pain due to injury of the spinothalamic tract in patients with cerebral infarction: a diffusion tensor tractography imaging study. Neural Regen Res 2017;12(12):2021-4. PMID 29323041
63: Jia S, Liu Y, Shen L, et al. Botulinum toxin type A for upper limb spasticity in poststroke patients: a meta-analysis of randomized controlled trials. J Stroke Cerebrovasc Dis 2020a;29(6):104682. PMID 32305277
64: Jia G, Ma J, Wang S, et al. Long-term effects of extracorporeal shock wave therapy on poststroke spasticity: a meta-analysis of randomized controlled trials. J Stroke Cerebrovasc Dis 2020b;29(3):104591. PMID 31899073
65: John G, Bardini C, Mégevand P, Combescure C, Dällenbach P. Urinary incontinence as a predictor of death after new-onset stroke: a meta-analysis. Eur J Neurol 2016;23(10):1548-55. PMID 27425212
66: Johnston KC, Li JY, Lyden PD, et al. Medical and neurological complications of ischemic stroke: experience from the RANTTAS trial. RANTTAS Investigators. Stroke 1998;29(2):447-53. PMID 9472888
67: Jorgensen L, Engstad T, Jacobsen BK. Higher incidence of falls in long-term stroke survivors than in population controls: depressive symptoms predict falls after stroke. Stroke 2002;33(2):542-7. PMID 11823667
68: Jungehulsing GJ, Israel H, Safar N, et al. Levetiracetam in patients with central neuropathic post-stroke pain--a randomized, double-blind, placebo-controlled trial. Eur J Neurol 2013;20(2):331-7. PMID 22925226
69: Kado DM, Browner WS, Palermo L, Nevitt MC, Genant HK, Cummings SR. Vertebral fractures and mortality in older women: a prospective study. Study of Osteoporotic Fractures Research Group. Arch Intern Med 1999;159(11):1215-20. PMID 10371229
70: Kamphuisen PW, Agnelli G. What is the optimal pharmacological prophylaxis for the prevention of deep-vein thrombosis and pulmonary embolism in patients with acute ischemic stroke. Thromb Res 2007;119(3):265-74. PMID 16674999
71: Kamran SI, Downey D, Ruff RL. Pneumatic sequential compression reduces the risk of deep vein thrombosis in stroke patients. Neurology 1998;50(6):1683-8. PMID 9633711
72: Kanis J, Oden A, Johnell O. Acute and long-term increase in fracture risk after hospitalization for stroke. Stroke 2001;32(3):702-6. PMID 11239190
73: Kanis JA. Diagnosis of osteoporosis and assessment of fracture risk. Lancet 2002;359(9321):1929-36. PMID 12057569
74: Kashi Y, Ratmansky M, Defrin R. Deficient Pain Modulation in patients with chronic hemiplegic shoulder pain. Pain Pract 2018;18(6):716-28. PMID 29136315
75: Katayama Y, Yamamoto T, Kobayashi K, et al. Motor cortex stimulation for post-stroke pain: comparison of spinal cord and thalamic stimulation. Stereotact Funct Neurosurg 2001;77(1-4):183-6. PMID 12378074
76: Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 Suppl):e419S-94S. PMID 22315268
77: Kelly J, Rudd A, Lewis R, Hunt BJ. Venous thromboembolism after acute stroke. Stroke 2001;32(1):262-7. PMID 11136946
78: Kim JH, Greenspan JD, Cognill RC, Ohara S, Lenz FA. Lesions limited to the human thalamic principal somatosensory nucleus (ventral caudal) are associated with loss of cold sensations and central pain. J Neurosci 2007a;27(18):4995-5004. PMID 17475808
79: Kim JS. Medial medullary infarct aggravates central poststroke pain caused by previous lateral medullary infarct. Eur Neurol 2007b;58(1):41-3. PMID 17483584
80: Kim JS. Pharmacological management of central post-stroke pain: a practical guide. CNS Drugs 2014;28(9):787-97. PMID 25112542
81: Kim JS, Bashford G, Murphy TK, Martin A, Dror V, Cheung R. Safety and efficacy of pregabalin in patients with central post-stroke pain. Pain 2011;152(5):1018-23. PMID 21316855
82: Kim MG, Lee SA, Park EJ, et al. Elastic dynamic sling on subluxation of hemiplegic shoulder in patients with subacute stroke: a multicenter randomized controlled trial. Int J Environ Res Public Health 2022;19(16):9975. PMID 36011613
83: Kim NY, Lee SC, Kim YW. Effect of duloxetine for the treatment of chronic central poststroke pain. Clin Neuropharmacol 2019;42(3):73-6. PMID 31085946
84: Kocaağa Z, Bal S, Gurgan A. Hemiplegia and heterotopic ossification on the non-paretic extremity: a case report. J Rehabil Med 2007;39(6):500-2. PMID 17624486
85: Kong KH, Neo JJ, Chua KS. A randomized controlled study of botulinum toxin A in the treatment of hemiplegic shoulder pain associated with spasticity. Clin Rehabil 2007;21(1):28-35. PMID 17213238
86: Kumar A, Bhoi SK, Kalita J, Misra UK. Central post stroke pain can occur with normal sensation. Clin J Pain 2016;21(11):955-60. PMID 26710220
87: Kumar V, Kalita J, Gujral RB, Sharma VP, Misra UK. A study of bone densitometry in patients with complex regional pain syndrome after stroke. Postgrad Med J 2001;77(910):519-22. PMID 11470933
88: Lamb SE, Ferrucci L, Volapto S, Fried LP, Guralnik JM, Women’s Health and Aging Study. Risk factors for falling in home-dwelling older women with stroke: the Women's Health and Aging Study. Stroke 2003;34(2):494-501. PMID 12574566
89: Landi G, D’Angelo A, Boccardi E, et al. Venous thromboembolism in acute stroke. Prognostic importance of hypercoagulability. Arch Neurol 1992;49(3):279-83. PMID 1536631
90: Langdahl BL, Hofbauer LC, Forfar JC. Cardiovascular safety and sclerostin inhibition. J Clin Endocrinol Metab 2021;106(7):1845-53. PMID 33755157
91: Langhorne P, Stott DJ, Robertson L, et al. Medical complications after stroke: a multicenter study. Stroke 2000;31(6):1223-9. PMID 10835436
92: Lau WC, Chan EW, Cheung CL, et al. Association between dabigatran vs warfarin and risk of osteoporotic fractures among patients with nonvalvular atrial fibrillation. JAMA 2017;317(11):1151-8. PMID 28324091
93: Lavi C, Elboim-Gabyzon M, Naveh Y, Kalichman L. A combination of long-duration electrical stimulation with external shoulder support during routine daily activities in patients with post-hemiplegic shoulder subluxation: a randomized controlled study. Int J Environ Res Public Health 2022;19(15):9765. PMID 35955118
94: Lee JH, Baker LL, Johnson RE, Tilson JK. Effectiveness of neuromuscular electrical stimulation for management of shoulder subluxation post-stroke: a systematic review with meta-analysis. Clin Rehabil 2017;31(11):1431-44. PMID 28343442
95: Leijon G, Boivie J. Central post-stroke pain--a controlled trial of amitriptyline and carbamazepine. Pain 1989;36(1):27-36. PMID 2465530
96: Leung A, Donohue M, Xu R, et al. rTMS for suppressing neuropathic pain: a meta-analysis. J Pain 2009;10(12):1205-16. PMID 19464959
97: Leung A, Shirvalkar P, Chen R, et al. Transcranial magnetic stimulation for pain, headache, and comorbid depression: INS-NANS Expert Consensus Panel Review and Recommendation. Neuromodulation 2020;23(3):267-90. PMID 32212288
98: Levy J, Molteni F, Cannaviello G, Lansaman T, Roche N, Bensmail D. Does botulinum toxin treatment improve upper limb active function? Ann Phys Rehabil Med 2019;62(4):234-240. PMID 29960017
99: Lewiecki EM, Miller PD, Harris ST, et al. Understanding and communicating the benefits and risks of denosumab, raloxifene, and teriparatide for the treatment of osteoporosis. J Clin Densitom 2014;17(4):490-5. PMID 24206867
100: Liampas A, Velidakis N, Georgiou T, et al. Prevalence and management challenges in central post-stroke neuropathic pain: a systematic review and meta-analysis. Adv Ther 2020;37(7):3278-91. PMID 32451951
101: Liang NL, Avgerinos ED, Singh MJ, Makaroun MS, Chaer RA. Systemic thrombolysis increases hemorrhagic stroke risk without survival benefit compared with catheter-directed intervention for the treatment of acute pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2017;5(2):171-6.e1. PMID 28214483
102: Liao C, Yang M, Liu P, Zhong W, Zhang W. Thalamic pain alleviated by stellate ganglion block: a case report. Medicine (Baltimore). 2017;96(5):e6058. PMID 28151918
103: Lin SM, Yang SH, Liang CC, Huang HK. Proton pump inhibitor use and the risk of osteoporosis and fracture in stroke patients: a population-based cohort study. Osteoporos Int 2018;29(1):153-62. PMID 29032384
104: Lin TY, Shen PC, Chang KV, Wu WT, Özçakar L. Shoulder ultrasound imaging in the post-stroke population: a systematic review and meta-analysis. J Rehabil Med 2023;55:jrm13432. PMID 37615388
105: Lindgren I, Jonsson AC, Norrving B, Lindgren A. Shoulder pain after stroke: a prospective population-based study. Stroke 2007;38(2):343-8. PMID 17185637
106: Liu Q, Zhong Q, Tang G, Ye L. Ultrasound-guided stellate ganglion block for central post-stroke pain: a case report and review. J Pain Res 2020;13:461-4. PMID 32161490
107: Liu-Ambrose T, Pang MY, Eng JJ. Executive function is independently associated with performances of balance and mobility in community-dwelling older adults after mild stroke: implications for falls prevention. Cerebrovasc Dis 2007;23(2-3):203-10. PMID 17143004
108: Lo SF, Chen SY, Lin HC, Jim YF, Meng NH, Kao MJ. Arthrographic and clinical findings in patients with hemiplegic shoulder pain. Arch Phys Med Rehabil 2003;84(12):1786-91. PMID 14669184
109: Malfitano C, Rossetti A, Scarano S, Malloggi C, Tesio L. Efficacy of repetitive transcranial magnetic stimulation for acute central post-stroke pain: a case study. Front Neurol 2021;12:742567. PMID 34858311
110: Marciniak CM, Harvey RL, Gagnon CM, et al. Does botulinum toxin type A decrease pain and lessen disability in hemiplegic survivors of stroke with shoulder pain and spasticitiy? A randomized, double-blind, placebo-controlled trial. Am J Phys Med Rehabil 2012;91(12):1007-19. PMID 23064478
111: Marco E, Duarte E, Vila J, et al. Is botulinum toxin type A effective in the treatment of spastic shoulder pain in patients after stroke. A double-blind randomized clinical trial. J Rehabil Med 2007;39(6):440-7. PMID 17624477
112: Mayor RS, Ferreira NR, Lanzaro C, et al. Noninvasive transcranial brain stimulation in central post-stroke pain: a systematic review. Scand J Pain 2024;24(1). PMID 38956966
113: McCarthy ST, Turner J. Low-dose subcutaneous heparin in the prevention of deep-vein thrombosis and pulmonary emboli following acute stroke. Age Ageing 1986;15(2):84-8. PMID 3962762
114: McClung MR, Lewiecki EM, Cohen SB, et al. Denosumab in postmenopausal women with low bone mineral density. N Engl J Med 2006;354(8):821-31. PMID 16495394
115: McGeoch PD, Williams LE, Lee RR, Ramachandran VS. Behavioural evidence for vestibular stimulation as a treatment for central post-stroke pain. J Neurol Neurosurg Psychiatry 2008;79(11):1298-301. PMID 18550629
116: McGeoch PD, Williams LE, Song T, Lee RR, Huang M, Ramachandran VS. Post-stroke tactile allodynia and its modulation by vestibular stimulation: a MEG case study. Acta Neurol Scand 2009;119(6):404-9. PMID 18853944
117: McInnes E, Jammali-Blasi A, Bell-Syer SE, et al. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev 2015;2015(9):CD001735. PMID 26333288
118: Melamed E, Robinson D, Halperin N, Wallach N, Keren O, Groswasser Z. Brain injury-related heterotopic bone formation: treatment strategy and results. Am J Phys Med Rehabil 2002;81(9):670-4. PMID 12172519
119: Menoux D, Jousse M, Quintaine V, Tlili L, Yelnik AP. Decrease in post-stroke spasticity and shoulder pain prevalence over the last 15 years. Ann Phys Rehabil Med 2019;62(6):403-8. PMID 29604351
120: Miniati M, Cenci C, Monti S, Poli D. Clinical presentation of acute pulmonary embolism: survey of 800 cases. PLoS One 2012;7(2):e30891. PMID 22383978
121: Miniati M, Prediletto R, Formichi B, et al. Accuracy of clinical assessment in the diagnosis of pulmonary embolism. Am J Respir Crit Care Med 1999;159(3):864-71. PMID 10051264
122: Montes C, Magnin M, Maarrawi J, et al. Thalamic thermo-algesic transmission: ventral posterior (VP) complex versus VMpo in the light of a thalamic infarct with central pain. Pain 2005;113(1-2):223-32. PMID 15621383
123: Moore RA, Derry S, Aldington D, Cole P, Wiffen PJ. Amitriptyline for neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev 2012;12:CD008242. PMID 23235657
124: Moseley GL. Graded motor imagery for pathologic pain: a randomized controlled trial. Neurology 2006;67(12):2129-34. PMID 17082465
125: Moser KM, Fedullo PF, LitteJohn JK, Crawford R. Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis. JAMA 1994;271(3):223-5. PMID 8277550
126: Munoz-Gomez E, Inglés M, Aguilar-Rodríguez M, Sempere-Rubio N, Mollà-Casanova S, Serra-Añó P. Effects of mirror therapy on spasticity and sensory impairment after stroke: systematic review and meta-analysis. PM R 2023;15(11):1478-92. PMID 36787183
127: Nadler M, Pauls M. Shoulder orthoses for the prevention and reduction of hemiplegic shoulder pain and subluxation: systematic review. Clin Rehabil 2017;31(4):444-53. PMID 27184582
128: Nandi D, Smith H, Owen S, Joint C, Stein J, Aziz T. Peri-ventricular grey stimulation versus motor cortex stimulation for post stroke neuropathic pain. J Clin Neurosci 2002;9(5):557-61. PMID 12383415
129: National Pressure Ulcer Advisory Panel. Library of Medicine. Pressure Ulcer Stages. Revised by NPUAP. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5098472/. Accessed October 2007.
130: Ngo TT, Barsdell WN, Lew PCF, et al. Bedside neuromodulation of persistent pain and allodynia with caloric vestibular stimulation. Biomedicines 2024;12(10):2365. PMID 39457677
131: Nicholson BD. Evaluation and treatment of central pain syndromes. Neurology 2004;62(5 Suppl 2):S30-6. PMID 15007162
132: Nitti V, Haag-Molkenteller C, Kennelly M, Chancellor M, Jenkins B, Schurch B. Treatment of neurogenic detrusor overactivity and overactive bladder with Botox (onabotulinumtoxinA): development, insights, and impact. Medicine (Baltimore) 2023;102(S1):e32377. PMID 37499088
133: North American Menopause Society. Management of osteoporosis in postmenopausal women: 2006 position statement of The North American Menopause Society. Menopause 2006;13(3):340-67;quiz 368-9. PMID 16735931
134: Noumegni SR, Grangereau T, Demir A, Bressollette L, Couturaud F, Hoffmann C. Cardiovascular mortality after venous thromboembolism: a meta-analysis of prospective cohort studies. Semin Thromb Hemost 2022;48(4):481-9. PMID 34624912
135: Office of the Surgeon General. Bone health and osteoporosis: a report of the surgeon general. Rockville, MD: Office of the Surgeon General, 2004. PMID 20945569
136: Ozen S, Bölük Şenlikci H, Ümit Yemişci O. Post-stroke bilateral heterotopic ossification: an acute problem with long-lasting consequences. Jt Dis Relat Surg 2020;31(2):386-9. PMID 32584742
137: Paci M, Nannetti L, Rinaldi LA. Glenohumeral subluxation in hemiplegia: An overview. J Rehabil Res Dev 2005;42(4):557-68. PMID 16320150
138: Paci M, Nannetti L, Taiti P, Baccini M, Rinaldi L. Shoulder subluxation after stroke: relationships with pain and motor recovery. Physiother Res Int 2007;12(2):95-104. PMID 17536647
139: Pan R, Zhou M, Cai H, et al. A randomized controlled trial of a modified wheelchair arm-support to reduce shoulder pain in stroke patients. Clin Rehabil 2018;32(1):37-47. PMID 28629270
140: Pang MY, Eng JJ. Muscle strength is a determinant of bone mineral content in the hemiparetic upper extremity: implications for stroke rehabilitation. Bone 2005;37(1):103-11. PMID 15869927
141: Paolucci S, Iosa M, Toni D, et al. Prevalence and time course of post-stroke pain: a multicenter prospective hospital-based study. Pain Med 2016;17(5):924-30. PMID 26814255
142: Park GY, Kim JM, Sohn SI, Shin IH, Lee MY. Ultrasonographic measurement of shoulder subluxation in patients with post-stroke hemiplegia. J Rehabil Med 2007;39(7):526-30. PMID 17724551
143: Passeri G, Pini G, Troiano L, et al. Low vitamin D status, high bone turnover, and bone fractures in centenarians. J Clin Endocrinol Metab 2003;88(11):5109-15. PMID 14602735
144: Peng L, Zhang C, Zhou L, Zuo HX, He XK, Niu YM. Traditional manual acupuncture combined with rehabilitation therapy for shoulder hand syndrome after stroke within the Chinese healthcare system: a systematic review and meta-analysis. Clin Rehabil 2018;32(4):429-39. PMID 28901172
145: Perennou D, El Fatimi A, Masmoudi M, et al. [Incidence, circumstances and consequences of falls in patients undergoing rehabilitation after a first stroke]. Ann Readapt Med Phys 2005;48(3):138-45. PMID 15833261
146: Pertoldi S, Di Benedetto P. Shoulder-hand syndrome after stroke. A complex regional pain syndrome. Eura Medicophys 2005;41(4):283-92. PMID 16474282
147: Picelli A, Bonazza S, Lobba D, et al. Suprascapular nerve block for the treatment of hemiplegic shoulder pain in patients with long-term chronic stroke: a pilot study. Neurol Sci 2017;38(9):1697-701. PMID 28699104
148: Pickering AE, Thornton SR, Love-Jones SJ, Steeds C, Patel NK. Analgesia in conjunction with normalisation of thermal sensation following deep brain stimulation for central post-stroke pain. Pain 2009;147(1-3):299-304. PMID 19833434
149: Pineo GF, Lin J, Annemans L. The economic impact of enoxaparin versus unfractionated heparin for prevention of venous thromboembolism in acute ischemic stroke patients. Clinicoecon Outcomes Res 2012;4:99-107. PMID 22570556
150: Poole KES, Loveridge N, Rose CM, Warburton EA, Reeve J. A single infusion of zoledronate prevents bone loss after stroke. Stroke 2007;38(5):1519-25. PMID 17395868
151: Poole KES, Reeve J, Warburton EA. Falls, fractures, and osteoporosis after stroke: time to think about protection. Stroke 2002;33(5):1432-6. PMID 11988628
152: Pyoria O, Talvitie U, Nyrkko H, Kautianinen H, Pohjolainen T. Validity of the postural control and balance for stroke test. Physiother Res Int 2007;12(3):162-74. PMID 17631637
153: Qaseem A, Snow V, Barry P, et al. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med 2007;5(1):57-62. PMID 17261865
154: Ramachandran VS, McGeoch PD, Williams L, Arcilla G. Rapid relief of thalamic pain syndrome induced by vestibular caloric stimulation. Neurocase 2007;13(3):185-8. PMID 17786778
155: Ramger BC, Bader KA, Davies SP, et al. Effects of non-invasive brain stimulation on clinical pain intensity and experimental pain sensitivity among individuals with central post-stroke pain: a systematic review. J Pain Res 2019;12:3319-29. PMID 31853195
156: Ramnemark A, Nyberg L, Borssen B, Olsson T, Gustafson Y. Fractures after stroke. Osteoporos Int 1998;8(1):92-5. PMID 9692083
157: Righini M, Perrier A, De Moerloose P, Bounameaux H. D-dimer for venous thromboembolism diagnosis: 20 years later. J Thromb Haemost 2008;6(7):1059-71. PMID 18419743
158: Rosendaal FR. Venous thrombosis: a multicausal disease. Lancet 1999;353(9159):1167-73. PMID 10209995
159: Schulman S, Kearon C, Kakkar AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med 2009;361(24):2342-52. PMID 19966341
160: Silva GD, Lopes P, Fonoff ET, Pagano RL. The spinal anti-inflammatory mechanism of motor cortex stimulation: cause of success and refractoriness in neuropathic pain? J Neuroinflammation 2015;12(1):10. PMID 25600429
161: Shojaei F, Chi G, Memar Montazerin S, et al. Clinical outcomes of pharmacological thromboprophylaxis among patients with intracerebral hemorrhage: systematic review and meta-analysis. Clin Neurol Neurosurg 2022;212:107066. PMID 34883283
162: Shorr AF, Jackson WL, Sherner JH, Moores LK. Differences between low-molecular-weight and unfractionated heparin for venous thromboembolism prevention following ischemic stroke: a metaanalysis. Chest 2008;133(1):149-55. PMID 17925410
163: Silver FL, Norris JW, Lewis AJ, Hachinski VC. Early mortality following stroke: a prospective review. Stroke 1984;15(3):492-6. PMID 6729878
164: Skaf E, Stein PD, Beemath A, Sanchez J, Bustamante MA, Olson RE. Venous thromboembolism in patients with ischemic and hemorrhagic stroke. Am J Cardiol 2005;96(12):1731-3. PMID 16360366
165: Sohn JH, Kim C< Kim Y, Park SY, Lee SH. Impact of osteoporosis pharmacotherapy on functional outcomes after ischemic stroke. J Clin Med 2023;12(15):4905. PMID 37568307
166: Sokal P, Harat M, Zieliński P, Furtak J, Paczkowski D, Rusinek M. Motor cortex stimulation in patients with chronic central pain. Adv Clin Exp Med 2015;24(2):289-96. PMID 25931362
167: Son BC, Lee SW, Choi ES, Sung JH, Hong JT. Motor cortex stimulation for central pain following a traumatic brain injury. Pain 2006;123(1-2):210-6. PMID 16616421
168: Sterne JA, Bodalia PN, Bryden PA, et al. Oral anticoagulants for primary prevention, treatment and secondary prevention of venous thromboembolic disease, and for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess 2017;21(9):1-386. PMID 28279251
169: Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Inj Prev 2006;12(5):290-5. PMID 17018668
170: Stevens SM, Woller SC, Baumann Kreuziger L, et al. Antithrombotic therapy for VTE disease: compendium and review of CHEST Guidelines 2012-2021. Chest 2024;166(2):388-404. PMID 38458430
171: Stroke Unit Trialists Collaboration. How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke 1997;28(11):2139-44. PMID 9368554
172: Stowell-Campos R, Lawrence E, Marsh EB, Merbach D. Scrambler therapy for treatment of poststroke pain. Ann Clin Transl Neurol 2024;11(11):2904-11. PMID 39308135
173: Taira T, Tanikawa T, Kawamura H, Iseki H, Takakura K. Spinal intrathecal baclofen suppresses central pain after a stroke. J Neurol Neurosurg Psychiatry 1994;57(3):381-2. PMID 8158194
174: Tanei T, Kajita Y, Noda H, et al. Efficacy of motor cortex stimulation for intractable central neuropathic pain: comparison of stimulation parameters between post-stroke pain and other central pain. Neurol Med Chir (Tokyo) 2011;51(1):8-14. PMID 21273738
175: Tanei T, Kajita Y, Takebayashi S, Aoki K, Nakahara N, Wakabayashi T. Predictive factors associated with pain relief of spinal cord stimulation for central post-stroke pain. Neurol Med Chir (Tokyo) 2019;59(6):213-21. PMID 31061256
176: Thieme H, Mehrholz J, Pohl M, Behrens J, Dohle C. Mirror therapy for improving motor function after stroke. Cochrane Database Syst Rev 2012;(3):CD008449. PMID 22419334
177: Thomas LH, Barrett J, Cross S, et al. Prevention and treatment of urinary incontinence after stroke in adults. Cochrane Database Syst Rev 2005;(3):CD004462. PMID 16034933
178: Thomas LH, Coupe J, Cross LD, Tan AL, Watkins CL. Interventions for treating urinary incontinence after stroke in adults. Cochrane Database Syst Rev 2019;2:CD004462. PMID 30706461
179: Tondel BG, Morelli VM, Hansen JB, Braekkan SK. Risk factors and predictors for venous thromboembolism in people with ischemic stroke: a systematic review. J Thromb Haemost 2022;20(10):2173-86. PMID 35815351
180: Turkstra F, Kuijer PM, van Beek EJ, Brandjes DP, ten Cate JW, Buller HR. Diagnostic utility of ultrasonography of leg veins in patients suspected of having pulmonary embolism. Ann Intern Med 1997;126(10):775-81. PMID 9148650
181: Turner-Stokes L, Jackson D. Shoulder pain after stroke: a review of the evidence base to inform the development of an integrated care pathway. Clin Rehabil 2002;16(3):276-98. PMID 12017515
182: Valeriani E, Potere N, Candeloro M, et al. Extended venous thromboprophylaxis in patients hospitalized for acute ischemic stroke: a systematic review and meta-analysis. Eur J Intern Med 2022;95:80-6. PMID 34649783
183: Van Bladel A, Lambrecht G, Oostra KM, Vanderstraeten G, Cambier D. A randomized controlled trial on the immediate and long-term effects of arm slings on shoulder subluxation in stroke patients. Eur J Phys Rehabil Med 2017;53(3):400-9. PMID 28145396
184: Velasco F, Argüelles C, Carrillo-Ruiz JD, et al. Efficacy of motor cortex stimulation in the treatment of neuropathic pain: a randomized double-blind trial. J Neurosurg 2008; 108(4):698-706. PMID 18377249
185: Vestergaard K, Andersen G, Gottrup H, Kristensen BT, Jensen TS. Lamotrigine for central poststroke pain: a randomized controlled trial. Neurology 2001;56(2):184-90. PMID 11160953
186: Vestergaard P. New strategies for osteoporosis patients previously managed with strontium ranelate. Ther Adv Musculoskelet Dis 2014;6(6):217-25. PMID 25435924
187: Vranken JH, Dijkgraaf MG, Kruis MR, van der Vegt MH, Hollmann MW, Heesen M. Pregabalin in patients with central neuropathic pain: a randomized, double-blind, placebo-controlled trial of a flexible-dose regimen. Pain 2008;136(1-2):150-7. PMID 17703885
188: Vranken JH, Hollmann MW, van der Vegt MH, et al. Duloxetine in patients with central neuropathic pain caused by spinal cord injury or stroke: a randomized, double-blind, placebo-controlled trial. Pain 2011;152(2):267-73. PMID 21078545
189: Wanklyn P, Forster A, Young J. Hemiplegic shoulder pain (HSP): natural history and investigation of associated features. Disabil Rehabil 1996;18(10):497-501. PMID 8902421
190: Wells PS, Anderson DR, Bormanis J. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 1997;350(9094):1795-8. PMID 9428249
191: Wells PS, Owen C, Doucette S, Fergusson D, Tran H. Does this patient have deep vein thrombosis? JAMA 2006;295(2):199-207. PMID 16403932
192: Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med 2001;161(1):92-7. PMID 11146703
193: Wiffen P, Collins S, McQuay H, Carroll D, Jadad A, Moore A. Anticonvulsant drugs for acute and chronic pain. Cochrane Database Syst Rev 2005;20(3):CD001133. PMID 16034857
194: Wiffen PJ, Derry S, Moore RA. Lamotrigine for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev 2013;12:CD006044. PMID 24297457
195: Wiffen PJ, Derry S, Moore RA, Kalso EA. Carbamazepine for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev 2014a;4:CD005451. PMID 24719027
196: Wiffen PJ, Derry S, Moore RA, Lunn MP. Levetiracetam for neuropathic pain in adults. Cochrane Database Syst Rev 2014b;7:CD010943. PMID 25000215
197: Wijdicks EF, Scott JP. Pulmonary embolism associated with acute stroke. Mayo Clin Proc 1997;72(4):297-300. PMID 9121173
198: Wilson RD, Bennett ME, Nguyen VQC, et al. Fully implantable peripheral nerve stimulation for hemiplegic shoulder pain: a multi-site case series with two-year follow-up. Neuromodulation 2018;21(3):290-5. PMID 29164745
199: Wissel J, Camões-Barbosa A, Comes G, Althaus M, Scheschonka A, Simpson DM. Pain reduction in adults with limb spasticity following treatment with incobotulinumtoxinA: a pooled analysis. Toxins (Basel) 2021;13(12):887. PMID 34941725
200: Yelnik AP, Colle FM, Bonan IV, Vicaut E. Treatment of shoulder pain in spastic hemiplegia by reducing spasticity of the subscapular muscle: a randomised, double blind, placebo controlled study of botulinum toxin A. J Neurol Neurosurg Psychiatry 2007;78(8):845-8. PMID 17088333

Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Adrian Marchidann MD

Dr. Marchidann of Kings County Hospital has no relevant financial relationships to disclose.
See Profile

Editor

Steven R Levine MD

Dr. Levine of the SUNY Health Science Center at Brooklyn has no relevant financial relationships to disclose.
See Profile

Former Authors

Isaac E Silverman MD
Maysaa Merhi Basha MD
Seemant Chaturvedi MD
Wazim Mohamed MD
Ramesh Madhavan MD DM

This is an article preview.
Start a Free Account
to access the full version.

Nearly 3,000 illustrations, including video clips of neurologic disorders.
Every article is reviewed by our esteemed Editorial Board for accuracy and currency.
Full spectrum of neurology in 1,200 comprehensive articles.
Listen to MedLink on the go with Audio versions of each article.

Questions or Comment?

MedLink, LLC

3525 Del Mar Heights Rd, Ste 304
San Diego, CA 92130-2122

Toll Free (U.S. + Canada): 800-452-2400

US Number: +1-619-640-4660

Support: service@medlink.com

Editor: editor@medlink.com

ISSN: 2831-9125

Medical complications of stroke

Also Relevant

Anterior cerebral artery stroke syndromes
Complex regional pain syndrome
Depression after stroke
Hypertensive intracerebral hemorrhage
Ischemic stroke
- Nontraumatic intracerebral hemorrhage
- Stroke: supportive care
- Stroke therapy
- Vascular dementia

Clinical Categories

Stroke & Vascular Disorders

Patient Handouts

Stroke (hemorrhagic)

Web References

Guidelines

Medical complications of stroke …

Medical complications of stroke

Cite this article

Introduction

Overview

Key points

Classification scheme for medical complications of stroke

Table 1. Medical Complications of Stroke: A Classification Scheme

Table 2. Medical Complications of Stroke

Deep venous thrombosis and pulmonary embolism

Table 3. Wells Prediction Rule for Diagnosing Deep Venous Thrombosis

Table 4. Wells Prediction Rule for Diagnosing Pulmonary Embolism

Prevention of thromboembolism

Bone disease: osteoporosis and fractures

Table 5. Risk Factors for Osteoporotic Fractures in Women

Table 6. World Health Organization (WHO) Definition of Osteoporosis

Complications of stroke

Pain syndromes

Media

References

Contributors

Author

Editor

Former Authors

Patient Profile

This is an article preview.
Start a Free Account
to access the full version.

Questions or Comment?

Also in This Category

Stroke associated with cerebral angiography

Fibromuscular dysplasia

Brainstem hemorrhage

Cardiac catheterization: neurologic complications

Intracranial atherosclerosis

Cerebellar infarction and cerebellar hemorrhage

Lobar hemorrhage

Nontraumatic intracerebral hemorrhage

Medical complications of stroke

Cite this article

Introduction

Overview

Key points

Classification scheme for medical complications of stroke

Table 1. Medical Complications of Stroke: A Classification Scheme

Table 2. Medical Complications of Stroke

Deep venous thrombosis and pulmonary embolism

Table 3. Wells Prediction Rule for Diagnosing Deep Venous Thrombosis

Table 4. Wells Prediction Rule for Diagnosing Pulmonary Embolism

Prevention of thromboembolism

Bone disease: osteoporosis and fractures

Table 5. Risk Factors for Osteoporotic Fractures in Women

Table 6. World Health Organization (WHO) Definition of Osteoporosis

Complications of stroke

Pain syndromes

Media

References

Contributors

Author

Editor

Former Authors

Patient Profile

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Stroke associated with cerebral angiography

Fibromuscular dysplasia

Brainstem hemorrhage

Cardiac catheterization: neurologic complications

Intracranial atherosclerosis

Cerebellar infarction and cerebellar hemorrhage

Lobar hemorrhage

Nontraumatic intracerebral hemorrhage

This is an article preview.
Start a Free Account
to access the full version.