In order to prevent complications after stroke, it is important to identify which patients are at particularly high risk of complications. Davenport et al. identified a number of important factors that included older patients, pre-existing disability and handicap, diabetes mellitus, total anterior circulatory stroke, presence of urinary incontinence, and length of hospital stay beyond 30 days [6]. Other factors such as stroke severity measured by the functional independence measure (FIM) have been associated with higher risk of infections, pressure sores, anxiety, and depression [3]. Identification of these factors is crucial in order to implement preventative strategies and continue monitoring for further recognition and treatment early in the course of stroke.

The impact of post-stroke complications is considerable. It is associated with high mortality rates, increased disability, long lengths of stay, institutionalisation, and rising costs of stroke care [1, 5]. In-hospital mortality rates from medical complications vary between 29 and 40 % [6, 18]. Early deaths during the first week were associated with the direct insult of the stroke itself leading to cerebral oedema, but deaths in the following weeks were due to potentially preventable medical complications such as infections, venous thromboembolism, and cardiac complications [19, 20]. Over half the patients who died (14 %) at 3 months following recruitment into the RANTTAS study did so relating to their medical complications [1]. Population-based registers have also demonstrated that incurring at least one medical complication in hospital leads to increased length of stay and increased 30-day (12 %) and 1-year (35 %) mortality [21]. Medical complications may also impair recovery independently from age and stroke severity and can lead to worsening disability rates through a number of mechanisms including impeding restorative rehabilitation and precipitating depression, and thus lowering motivation [1, 10]. Physiological parameters such as hypoxia, pyrexia, dehydration, and low blood pressure can also affect neuronal cell function in the ischaemic penumbra and thus impair cerebral function, leading to stroke progression [22, 23].

What is evident is that many post-stroke complications are preventable through multidisciplinary assessment and close attention to detail through structured protocols [24]. Ingeman et al. demonstrated that high-quality processes of care tailored around stroke unit admission, early mobilisation, initiation of anti-platelet treatment, and early therapy assessments were associated with lower risks of medical complications [24]. The hallmark of organised stroke care in specialist stroke units lends support to this model whereby one of the main mechanisms of survival benefit is through the prevention of and early interventions for medical and physiological complications [25, 26]. In a systematic review, interventions to prevent aspiration, treat pyrexia, and improve oxygenation were shown to be used more frequently in stroke units compared to conventional settings. In addition to this, stroke unit care reduced complications associated with immobility, such as infections and thromboembolism [25]. We are now just beginning to understand and appreciate the effects of adverse medical and neurological complications after stroke. Improving the awareness of stroke clinicians and multidisciplinary professionals involved in stroke care of post-stroke complications is crucial, and ongoing education and training is paramount. Stroke specialists need to be aware of the significance of observations for post-stroke complications and be alert for atypical presentations of these complications. Staff also need to be committed to the use of protocols for the prevention and early detection of post-stroke complications. More research, through well-designed randomised controlled trials, is required to understand the best policies for preventing complications after stroke and for delivering interventions that may lessen the adverse effects on individuals.