Effect of in-hospital and post-discharge complications on 1-year functional outcome after stroke and transient ischemic attack

Abstract Introduction Complications may secondarily impair functional outcome after stroke and transient ischemic attack (TIA). Here, we estimated the population-level impact of complications on long-term functional outcome to describe their combined impact and identify the most impactful complications. Patients and methods Patients admitted for acute ischemic stroke or TIA (ABCD2 score ⩾ 3) and discharged without severe disability were followed-up for occurence of 12 in-hospital and 26 post-discharge complications. Population-level impact of complications on the primary endpoint of non-excellent functional outcome (modified Rankin Scale (mRS) 1) at end of follow-up 12 months after stroke was assessed by population attributable fraction (PAF). This cohort study was performed at a single European comprehensive stroke center and nested within a randomized controlled trial of intensified post-stroke care, STROKE-CARD. Results Among 1705 patients aged 69.4 ± 13.6 years (59.8% male), 36.8% (95% confidence interval: 34.5, 39.2) had non-excellent outcome at 12 months, 21.3% (19.4, 23.3) had unfavorable outcome (mRS 2), and functional worsening occurred in-hospital in 2.6% (2.0, 3.6) and post-discharge in 20.3% (18.4, 22.3). Non-excellent 1-year functional outcome was predicted in-hospital by occurrence of recurrent stroke, neurological worsening, and infections (PAF: 0.6%–3.2%). Post-discharge, 12 complications significantly predicted outcome, and pain, severe fatigue, falls, and depression were most impactful (PAF: 5.4%–13.0%). Together, in-hospital complications accounted for 7.6% and post-discharge complications for 31.8% of non-excellent outcome, whereas acute therapy (thrombolysis and/or thrombectomy) and STROKE-CARD care accounted for 8.0% and 14.5% of excellent outcomes. In moderate and severe stroke (NIHSS 5), acute therapy was the strongest predictor of excellent outcome (PAF: 29.1%). Results were consistent or stronger in patients with TIA, without prestroke disability, or in the regional catchment area, and when focusing on unfavorable outcome or worsening in mRS. Discussion Complications were responsible for more than one third of non-excellent 1-year functional outcome with pain, severe fatigue, depression, and falls most impactful. Complications rivaled the impact of acute therapy and determined functional outcome after TIA as well as after stroke. Conclusion Effective prevention and treatment of complications may substantially improve long-term functional outcomes after stroke and TIA.