Stroke-unit care and early complications

01Purpose and principlesWhat the treatment does and how it fits into care.

Stroke-unit care begins at admission and operates as a repeated cycle: define the neurological injury, stabilise physiology, prevent predictable complications, detect change and start person-centred recovery. Core assessments include consciousness and focal neurology, swallow, nutrition and hydration, continence, pressure risk, mobility, communication, cognition, mood and pre-stroke function. Family or carers contribute baseline information and communication support, while the team sets realistic early goals and explains uncertainty.

Many early complications are preventable. Dysphagia leads to aspiration, dehydration and poor medicine delivery. Immobility leads to venous thromboembolism, pressure injury, contracture, constipation and deconditioning. Fever, hyperglycaemia, hypoxia and hypotension worsen injured brain. Urinary catheters and unnecessary cannulae increase infection risk. Prevention requires correctly timed screening, nursing positioning and mouth care, appropriate routes for hydration and medicines, intermittent pneumatic compression and regular multidisciplinary review rather than reflex antibiotics or prolonged bed rest.

Cerebral complications need pattern recognition. Decline after thrombolysis suggests haemorrhage until urgent imaging proves otherwise. Progressive drowsiness after a large hemispheric infarct suggests swelling; cerebellar swelling may cause headache, vomiting, gaze abnormalities, hydrocephalus or sudden reduced consciousness. Seizures can be subtle, and delirium may reflect infection, retention, constipation, metabolic illness or the stroke itself. Decisions about decompressive surgery, artificial nutrition and escalation of care should be timely, multidisciplinary and aligned with the person's premorbid function and values.

Key points

Admission to a specialist stroke unit improves outcomes through coordinated nursing, medical, therapy, nutrition and discharge care rather than through one isolated intervention.
Screen swallowing with a validated process by a trained professional before oral food, fluid or medication; a patient who talks clearly can still aspirate silently.
Give aspirin 300 mg after haemorrhage is excluded in acute ischaemic stroke, but wait at least 24 hours after thrombolysis and obtain the required follow-up imaging first.
Maintain oxygenation, hydration, normoglycaemia and temperature while avoiding routine oxygen in a non-hypoxic patient, excessive intravenous fluid and intensive insulin that causes hypoglycaemia.
Use intermittent pneumatic compression for an immobile acute-stroke patient when appropriate; routine graduated compression stockings are not an effective substitute.
Mobilisation and rehabilitation should be individualised and started by the multidisciplinary team when clinically stable; very early high-dose mobilisation is not a universal target.
Neurological deterioration requires immediate reassessment for haemorrhagic transformation, recurrent or extending ischaemia, cerebral oedema, seizure, infection, metabolic disturbance and medication effects.
Large middle cerebral artery or cerebellar infarction can produce life-threatening swelling and needs early neurosurgical discussion before irreversible herniation or brainstem compression develops.

02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.

Dysphagia and aspiration

Coughing, wet voice, drooling, prolonged oral transit or recurrent desaturation is suggestive, but absence of these signs does not exclude silent aspiration after stroke.

Malignant hemispheric oedema

Worsening headache, vomiting, declining consciousness, gaze change and progressive deficit over the first several days may follow a large MCA infarct.

Cerebellar swelling

Increasing occipital headache, vomiting, ataxia, cranial nerve abnormalities or drowsiness can herald fourth-ventricular compression and obstructive hydrocephalus.

Post-stroke seizure

Convulsion is obvious, but recurrent staring, facial twitching or unexplained reduced responsiveness may represent focal or non-convulsive seizure.

Aspiration pneumonia

Fever, tachypnoea, oxygen requirement, cough or new infiltrates after dysphagia should prompt clinical assessment while recognising that early fever can have non-infectious causes.

Delirium and depression

Fluctuating attention suggests delirium from acute illness, while persistent low mood, anhedonia or hopelessness deserves structured post-stroke mood assessment and safeguarding review.

Red flags requiring action

Any new neurological deficit, fall in consciousness, severe headache or vomiting requires immediate senior stroke review and urgent repeat brain imaging.
Stridor, inability to handle secretions, repeated aspiration or worsening hypoxia requires airway and critical-care assessment rather than repeated bedside oral trials.
Painful swollen leg, sudden hypoxia, pleuritic pain or haemodynamic collapse raises venous thromboembolism and needs urgent diagnostic and treatment review.
A large infarct with evolving oedema or cerebellar mass effect requires early neurosurgical contact; waiting for fixed pupils loses the opportunity for benefit.
Fever with hypotension, rising oxygen need or reduced urine output suggests sepsis or another systemic emergency and should not be attributed automatically to stroke.

03Assessment before treatmentTests and checks that guide safe selection.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Trained swallow screenFirst step
Why
Identify patients who need restriction of oral intake and formal swallowing assessment before food, fluid or medicines.
Interpretation and limitations
Failure or inability to participate means use a safe alternative route and refer to speech and language therapy; repeated informal sips do not constitute clearance.
02
Repeat non-contrast CT brain
Why
Investigate neurological decline, headache or reduced consciousness for haemorrhage, infarct extension, swelling or hydrocephalus.
Interpretation and limitations
Compare with baseline imaging and clinical timing; urgent findings may require reversal treatment, critical care or neurosurgery rather than observation alone.
03
Physiological and laboratory assessment
Why
Find hypoxia, fever, glucose disturbance, dehydration, electrolyte imbalance, infection or anaemia contributing to decline.
Interpretation and limitations
Treat significant abnormalities while avoiding overcorrection; trends and clinical context are more useful than attributing every abnormal value to the stroke.
04
Chest imaging and microbiology when indicated
Why
Evaluate suspected aspiration pneumonia or another respiratory infection in a deteriorating patient.
Interpretation and limitations
Imaging may lag clinical aspiration and colonised sputum can mislead; use the whole clinical syndrome and local antimicrobial guidance.
05
Venous thromboembolism imaging
Why
Confirm suspected deep-vein thrombosis or pulmonary embolism when new limb or respiratory features occur.
Interpretation and limitations
Use compression ultrasound or CTPA through the usual urgent pathway, but coordinate anticoagulation timing with infarct size and haemorrhagic transformation risk.
06
Nutritional assessment
Why
Quantify malnutrition risk and guide safe enteral support when swallowing remains impaired.
Interpretation and limitations
Include weight history, intake, hydration, electrolytes and refeeding risk; route and timing are individualised with dietetic and swallowing input.

04Treatment approachPreparation, options, escalation and aftercare.

01SWALLOWUnsafe or uncertain oral intakeFirst stepA new stroke patient has not passed a trained swallowing screen or shows clinical dysphagia.

1AlternativeKeep the patient nil by mouth, including routine tablets and water, while providing mouth care and an alternative safe route for essential hydration and medicines.
2Arrange prompt specialist swallowing assessment and communicate posture, texture and supervision recommendations to every staff member and carer.
3If oral intake will remain inadequate, discuss nasogastric feeding, medicine formulations, nutrition targets and refeeding risk with the multidisciplinary team.
4Review swallowing serially because recovery and fatigue alter safety; do not leave restrictions or tubes in place without reassessment.

02IMMOBILEPrevent complications of immobilityStroke-related weakness, consciousness or instability prevents independent mobilisation.

1Assess venous thrombosis, bleeding, skin, joint position, continence and manual-handling risk on admission and after clinical change.
2Apply intermittent pneumatic compression when appropriate and check skin and device fit regularly; avoid routine graduated compression stockings for stroke prophylaxis.
3Use pressure-relieving surfaces, repositioning, limb support, hydration, bowel care and passive or active movement within the agreed therapy plan.
4Begin graded multidisciplinary mobilisation when stable and stop or modify activity for neurological or physiological deterioration.

03DECLINENeurological deteriorationConsciousness or focal deficit worsens at any time during stroke-unit admission.

1Repeat ABC assessment, observations, glucose and focused neurology, and identify recent thrombolysis, anticoagulation, seizures, falls or sedating medicines.
2Call the stroke clinician immediately and obtain urgent repeat brain imaging while treating hypoxia, hypoglycaemia or hypotension.
3EscalationEscalate confirmed haemorrhage, malignant swelling, hydrocephalus, seizure or re-occlusion to the appropriate haematology, neurosurgical, critical-care or neuroradiology pathway.
4Update family and the documented ceiling of care once reversible causes and treatment options have been assessed.

04RECOVERStart coordinated rehabilitationThe patient is medically and neurologically stable enough for active assessment and goal setting.

1Assess mobility, upper-limb function, speech, language, swallowing, cognition, vision, continence, mood and activities of daily living with the relevant disciplines.
2Agree goals that are specific to the person's priorities and deliver therapy at an intensity they can tolerate, rather than imposing one uniform dose.
3Identify equipment, carer training, communication support, work and driving implications and likely discharge environment early.
4Handover secondary prevention, rehabilitation goals and unresolved risks to community and primary-care teams with named follow-up responsibility.

05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.

Reduces early recurrent ischaemic events before the definitive long-term antithrombotic regimen is established.

Aspirin

After haemorrhage is excluded, give 300 mg once daily by an appropriate safe route for acute ischaemic stroke; after thrombolysis wait 24 hours and obtain follow-up imaging first.

Consider bleeding, allergy, thrombocytopenia and planned anticoagulation; never bypass swallowing precautions to deliver an oral tablet.

Treats clinically relevant fever or pain that may impair comfort, participation and physiological stability after stroke.

Paracetamol

Use an adult oral, enteral or intravenous regimen within the product maximum when fever or pain requires treatment, accounting for body weight, frailty and liver disease.

Avoid duplicate combination products and dose reduction may be required in low body weight or hepatic risk; investigate the cause of fever rather than masking sepsis.

Treats established aspiration pneumonia, urinary infection or another bacterial complication rather than preventing infection routinely.

Antibiotic therapy

Start only when bacterial infection is clinically suspected, selecting agent, route and duration from the current local pneumonia or infection guideline and culture context.

Prophylactic antibiotics do not replace swallow and catheter care; account for allergy, renal function, Clostridioides difficile risk and antimicrobial review results.

06Complications, monitoring and follow-upAdverse effects, response and longer-term review.

Use a defined neurological observation schedule and escalate any change rather than recording a lower score without action.
Monitor oxygen saturation, temperature, blood pressure, pulse rhythm, hydration, renal function and glucose with targets adapted to treatment and comorbidity.
Document swallow status and permitted food, fluid and medicine routes at the bedside and at every transfer between clinical areas.
Inspect skin, heels and areas under compression devices, and review repositioning, seating and limb support every shift.
Record nutritional intake, weight trend, bowel and bladder function and tube position or tolerance when enteral support is used.
Review VTE prophylaxis daily as mobility, bleeding risk, imaging and anticoagulation plans change.
Screen communication, cognition, vision and mood before discharge and ensure findings shape rehabilitation and safety planning.

07Special situationsVariants, exceptions and circumstances that change the usual approach.

Speech does not prove swallow

A patient can converse fluently while pharyngeal sensation and airway protection are impaired, allowing aspiration without cough.

Stroke units are active treatment

Outcome benefit comes from organised specialist processes, early complication detection and coordinated therapy, not simply from the ward label.

Cerebellar infarcts can compress

A relatively small posterior fossa volume permits swelling to obstruct cerebrospinal fluid flow and injure the brainstem quickly.

Fever needs a source

Temperature worsens brain injury, but routine antibiotics without infection evidence miss non-infectious causes and promote harm.

Mobilisation needs dosage

Starting rehabilitation early is beneficial, whereas frequent prolonged out-of-bed sessions in the first unstable hours may not suit every severe stroke.

Communication affects capacity

Aphasia can obstruct expression without abolishing decision-making capacity; use supported communication before assuming incapacity.

08Common pitfallsFrequent interpretation and management errors.

01
Do not give water, food or tablets before trained swallowing screening simply because the patient appears alert or asks to drink.
02
Do not use routine graduated compression stockings as the main VTE prevention method for an immobile stroke patient.
03
Do not prescribe prophylactic antibiotics for dysphagia without evidence of infection or omit mouth care and positioning.
04
Do not attribute new drowsiness to fatigue or sedatives until haemorrhage, oedema, seizure and systemic deterioration have been assessed.
05
Do not delay neurosurgical discussion for malignant swelling until brainstem signs or fixed pupillary changes appear.
06
Do not use prolonged urinary catheterisation or bed rest for staff convenience when safer continence and mobilisation plans are possible.