Stroke: Pillars of Outpatient Care

Stroke is a leading cause of disability, and poststroke challenges for patients include spasticity and impaired mobility, seizures, cognitive deficits, poor mental health, and disordered sleep. In this issue of Practical Neurology, we explore a range of common complications associated with stroke and discuss pragmatic approaches to address these issues in the outpatient setting.

Poststroke complications may be a patient’s primary concern during their clinical visit due to the impact of these complications on quality of life. Neurologists must address these issues quickly and efficiently, while also addressing other factors such as control of vascular risk factors and other secondary stroke prevention measures. As such, it is important for neurologists to have a comprehensive understanding of common poststroke complications and to be able to employ a multidisciplinary approach to effectively manage these issues.

Management of poststroke mobility impairment and spasticity frequently involves a collaborative approach between physical and rehabilitative medicine, neurology, and therapy services. Although a multidisciplinary approach is critical, it is key for the outpatient neurologist to have a strong understanding of rehabilitation timelines and to help advocate for connecting the patient to appropriate resources. In the article, Management of Poststroke Mobility and Spasticity, Drs. Baskar, Jadoon, and Naqvi explore key poststroke recovery epochs and highlight the optimal approach to maximize return of function. They also provide a comprehensive approach to minimize debilitating symptoms such as spasticity, including discussion of oral systemic medications, botulinum toxin type A injections, neurolysis, intrathecal baclofen therapy, and surgical management.

Stroke is the most common cause of new-onset epilepsy in adults aged >65 years and seizures have been associated with cognitive decline, poor stroke outcomes, and increased mortality. In Management of Poststroke Epilepsy: An Update, Yuki Kawamura and Drs. Beriwal, Misra, and Mishra, discuss predictors for the development of poststroke epilepsy, the approach to prophylaxis, and prospects for future research.

Although cognitive impairment and dementia affect a significant percentage of poststroke patients, cognitive outcomes have been missing from many large clinical trials and treatment options for these individuals remain sparse. In the article, Poststroke Cognitive Impairment and Dementia, Drs. Yang and Aggarwal highlight the need to adopt unified screening and diagnostic tools, elucidate key biomarkers, discuss limitations in current treatment options, and explore evolving areas of research, including the potential of community-based Brain Health Program interventions to optimize cognitive and functional outcomes.

Depression and anxiety adversely affect quality of life for both poststroke patients and their caregivers. Due to a nationwide shortage of mental health providers, it is important for neurologists and primary care physicians to feel empowered to treat these common and debilitating symptoms. In the article, Diagnosis and Treatment of Depression and Anxiety in People Who Have Experienced a Stroke and Their Caregivers, Drs. Comer and Jones discuss predictors of and health outcomes associated with poststroke anxiety and depression. Key topics include the importance of outpatient screening tools, the effects of mental health on stroke recovery and secondary prevention, options for treatment, and the important but often overlooked connection between patient and caregiver mental health.

In their article, The Bidirectional Relationship Between Sleep Disorders and Stroke, Drs. Joza and Boulos call attention to the importance of identifying sleep disorders as a contributing factor to stroke and the need to increase screening for obstructive sleep apnea and other sleep disorders to both maximize poststroke quality of life and to improve secondary stroke prevention. The article includes a comprehensive discussion of the most common poststroke sleep disorder, obstructive sleep apnea, including pathophysiologic mechanisms, effects on poststroke outcomes, and innovative solutions to increase screening and diagnosis. The article also reviews the effects of insomnia and sleep duration on stroke risk and highlights the increased risk of restless legs syndrome and periodic limb movements of sleep in stroke survivors.

A strong understanding of these poststroke complications can help neurologists maximize their patients’ quality of life. Comprehensive care for these issues requires skill in providing initial treatments as well as collaboration with colleagues across a wide range of specialties. Revolutionary advances in acute stroke interventions have increased patient outxomes. Addressing the common poststroke conditions highlighted in this issue can help ensure that individuals are not just surviving, but thriving.

Thank you to all the authors for their excellent contributions to this issue.