Prognosis

In 2021, there were 7.3 million deaths from stroke worldwide.[16]​ Stroke is a leading cause of serious long-term disability in the US and worldwide.[16]​​[199] Prognosis of functional outcome can be reliably performed by well-validated prognostic scores like the ASTRAL score or the iScore.[200] Intravenous thrombolysis and dedicated stroke units are the only interventions shown to improve stroke outcome.

Common medical complications of stroke include aspiration pneumonia, depression, and deep vein thrombosis.

A meta-analysis study on the efficacy of physiotherapy following stroke found that a variety of interventions improved functional outcomes, even when they were applied late after stroke.[201]

The risk of stroke within 90 days after a first stroke is ≈5%, but the risk can vary greatly from >10% to <1%, depending in part on mechanism.[202]​ In one registry-based study, the overall 1-year and 10-year risks of recurrence were 4% and 13% following first-time ischaemic stroke.[203]​ The risk of recurrence increased with age and was higher for men and following mild versus more severe stroke. For ischaemic stroke, the 1-year and 10-year risks of all-cause mortality were 17% and 56% after a first-time stroke, and 25% and 70% after a recurrent stroke.[203]​ The highest recurrence rate is seen in large artery atherosclerosis and cardioembolic stroke subtypes.[204]​ Studies examining decreasing trends in stroke recurrence over 20 years suggest secondary prevention measures have been effective, and effective secondary prevention can reduce the risk of recurrent events by up to 80%.[205]

Patients with atrial fibrillation

Patients with atrial fibrillation and first ischaemic stroke remain at increased risk of recurrent ischaemic stroke and death even while taking oral anticoagulation. Recurrent ischaemic stroke (cumulative incidence at 1 year: 7.0%) and cumulative incidence of mortality at 3 months after stroke was 12.4%.[206]​ This may be related to causes related to atrial fibrillation (i.e., inadequate intensity of anticoagulation due to underdosing, non-compliance, failure to account for food interaction, particularly for rivaroxaban, or drug-drug interactions, inappropriate perioperative management, and cardioembolism despite anticoagulation) and causes unrelated to atrial fibrillation (i.e., stroke caused by large vessel arteriosclerosis, cerebral small vessel disease, aortic arch disease, or occult cancer).[207]​ In these patients, non-atrial fibrillation related causes should be considered along with drug-related issues (non-adherence or inadequate dosing).[207]

Patients receiving alteplase

Patients treated with alteplase (if given within 4.5 hours of onset of symptoms) have a better functional outcome than patients not treated with alteplase. There is, however, an increased risk of intracerebral haemorrhage with alteplase; this does not seem to affect death or dependency at 3 months.[65][120][208]

Patients receiving tenecteplase

Tenecteplase within 4.5 hours of ischaemic stroke due to large vessel occlusion is non-inferior to alteplase in terms of excellent functional outcome (90-day modified Rankin Scale [mRS] scores of 0-1) and may be superior to alteplase in terms of good functional outcome (90-day mRS scores of 0-2), as supported by meta-analysis of several randomised controlled trials.[107][209][210][211][212]​​​​​[213][214][215][216]​​​​​​ Low-quality trial evidence suggests no significant differences in terms of mortality secondary to symptomatic intracerebral haemorrhage.[107]​ Tenecteplase is not recommended for patients with ischaemic stroke on awakening from sleep or of unknown onset who undergo no brain imaging other than computed tomography (CT). In a phase 3 randomised controlled trial of patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days versus the control group, and there was no difference in mortality between groups.[217]

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