Medications with few side effects are preferred, especially those that produce less sedation and have few anticholinergic side effects. Selective serotonin reuptake inhibitors have favorable side effect profiles and have expanded the range of treatment options. Shoulder pain and dislocation are especially likely to occur in the patient with a flaccid upper extremity, because the joint capsule is normally stabilized by the surrounding muscles. Prevention of these complications includes supporting the shoulder in a normal position, using a pull sheet rather than the underarm to reposition the patient in bed, and restricting range of motion to 90 of flexion and abduction. Reflex sympathetic dystrophy occurs in as many as 25 percent of patients with hemiplegia.
Early signs are exquisite cutaneous sensitivity and diffuse swelling of the hands.
Treatment includes the use of compression gloves, anti-inflammatory agents, steroids, analgesics, and injections for sympathetic nerve blockade. The patient who has had a stroke has an annual recurrence risk of seven to 10 percent. In the patient who continues to have substantial neurologic capacity after a stroke, screening and intervention to prevent recurrence must be considered. Carotid endarterectomy may be indicated if stenosis of 70 percent or more is detected in a vessel that feeds a large area of viable brain tissue. Anticoagulation with warfarin for prevention of stroke in patients with atrial fibrillation has been proved to significantly reduce the risk.