Lesion location and other predictive factors of dysphagia and its complications in acute stroke

Correlation between lesion location and dysphagia characteristics in post-stroke patients

OBJECTIVE

To assess the correlation between lesion location and swallowing function characteristics in post-stroke dysphagia (PSD) patients.

MATERIALS AND METHODS

We enrolled 133 PSD. The patients were divided into supratentorial and infratentorial stroke groups. We compared the measurements in the videofluoroscopic swallowing study (VFSS) with 3ml and 5 ml of diluted and thickened barium liquid data between supratentorial and brainstem stroke groups. We further compared the difference of VFSS measurements between patients with left hemispheric or right hemispheric lesions (further divided into unilateral hemispheric cortical and subcortical subgroups) and brianstem leison stroke group.To explore the lesion location's effect on different bolus volume, the VFSS measurements of 3ml and 5ml in each subgroups were compared respectively. The measurements of VFSS included the oral transit time, soft palate elevation duration, hyoid bone movement duration (HMD), UES opening duration, pharyngeal transit duration (PTD), stage of ansition duration, and laryngeal closure duration (LCD), the upper esophageal sphincter opening (UESO), hyoid bone superior horizontal displacement, and hyoid bone anterior horizontal displacement. General swallowing function was assessed using the Penetration Aspiration Scale (PAS) and Functional Oral Intake Scale (FOIS). We performed the paired t-test, Spearman's correlation, and Kruskal-Wallis test analysis to characterize the parameters among the groups.

RESULTS

Fifty-eight patients were assessed in the final analysis. The HMD (p = 0.019), PTD (p = 0.048) and LCD (p = 0.013) were significantly different between the supratentorial and brainstem lesion groups in 5ml volume. The HMD was significantly different (p = 0.045) between the left cortical and brainstem lesion groups. Significant differences in the HMD (p = 0.037) and LCD (p = 0.032) between the left subcortical and brainstem lesion groups were found in 5ml volume bolus. There was no group different when taking the 3ml volume bolus. Regarding the relationship between food bolus volume and swallowing functions, only the UESO demonstrated a significant difference in the subcortical lesion of the right hemisphere (p = 0.0032) compared the 3 ml and 5 ml volume bolus. The PTD demonstrated a moderate correlation with the PAS scores (r = 0.38, p = 0.0044). The HMD (r = 0.32, p = 0.018) and LCD (r = 0.29, p = 0.039) demonstrated weak correlations with the PAS scores. We did not identify any correlation between the VFSS parameters and FOIS scores in each subgroup level.

CONCLUSION

The PSD with brainstem lesion shows more sever dysfunction in the pharyngeal phases. The left hemisphere was engaged in both the oral and pharyngeal phases. Lesions in the bilateral cortical, subcortical, and brainstem regions may impair sensory input.

Prevalence and Risk Factors of Poststroke Dysphagia: A Meta-Analysis

INTRODUCTION

In patients with stroke, poststroke dysphagia (PSD) is a common complication that plays an important role in morbidity and mortality. The aim of this paper was to assess the prevalence and risk factors of PSD using a systemic review and meta-analysis.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched for potentially eligible studies published until September 2023. Further, the pooled incidence and risk factors for PSD were determined using a random-effects model. Overall, 58 studies involving 37,404 patients with acute stroke were selected for the meta-analysis.

RESULTS

The pooled incidence of PSD in patients with acute stroke was 42% (95% confidence interval [CI]: 36-48%), which is the highest in South America (47%) and lowest in Asia (37%). Notably, older age (odds ratio [OR]: 2.13; 95% CI: 1.53-2.97; p < 0.001), hypertension (OR: 1.23; 95% CI: 1.06-1.44; p = 0.007), diabetes mellitus (OR: 1.22; 95% CI: 1.04-1.44; p = 0.014), stroke history (OR: 1.26; 95% CI: 1.04-1.53; p = 0.019), and atrial fibrillation (OR: 1.58; 95% CI: 1.02-2.44; p = 0.039) were found to be associated with an increased risk of PSD. Conversely, sex differences, smoking, alcoholism, obesity, hyperlipidemia, ischemic heart disease, stroke type, and the hemisphere affected were not associated with the risk of PSD.

CONCLUSION

The abstract reports the prevalence of PSD in patients with acute stroke and identified potential risk factors for PSD, including older age, hypertension, diabetes mellitus, stroke history, and atrial fibrillation.

Prevalence, recovery and phenotype of dysphagia in patients with ischaemic cerebellar stroke

BACKGROUND AND PURPOSE

Swallowing is a complex task, moderated by a sophisticated bilateral network including multiple supratentorial regions, the brainstem and the cerebellum. To date, conflicting data exist about whether focal lesions to the cerebellum are associated with dysphagia. Therefore, the aim of the study was to evaluate dysphagia prevalence, recovery and dysphagia pattern in patients with ischaemic cerebellar stroke.

METHODS

A retrospective analysis of patients consecutively admitted to an academic stroke centre with ischaemic stroke found only in the cerebellum was performed. The presence of dysphagia was the primary end-point and was assessed by a speech-language pathologist, according to defined criteria. Dysphagia pattern was evaluated by analysing the videos of the flexible endoscopic evaluation of swallowing. Brain imaging was used to identify lesion size and location associated with dysphagia.

RESULTS

Between January 2016 and December 2021, 102 patients (35.3% female) with a mean age of 52.8 ± 17.3 years were included. Thirteen (12.7%) patients presented with dysphagia. The most frequently observed flexible endoscopic evaluation of swallowing phenotype was premature spillage (n = 7; 58.3%), whilst significant residues or aspiration did not occur. One patient died (7.7%); the other patients showed improvement of dysphagia and one patient (7.7%) was discharged with dietary restrictions.

CONCLUSIONS

Although the involvement of the cerebellum in deglutition has become increasingly evident, isolated lesions to the cerebellum are less likely to cause clinically relevant and persisting dysphagia compared to other brain regions. The observed dysphagia pattern shows a lack of coordination and control, resulting in premature spillage or fragmented bolus transfer in some patients.

Health Factors Associated With Development and Severity of Poststroke Dysphagia: An Epidemiological Investigation

BACKGROUND

Dysphagia after stroke is common and can impact morbidity and death. The purpose of this population-based study was to determine specific epidemiological and health risk factors that impact development of dysphagia after acute stroke.

METHODS AND RESULTS

Ischemic and hemorrhagic stroke cases from 2010 and 2015 were identified via chart review from the GCNKSS (Greater Cincinnati Northern Kentucky Stroke Study), a representative sample of ≈1.3 million adults from southwestern Ohio and northern Kentucky. Dysphagia status was determined on the basis of clinical assessments and necessity for alternative access to nutrition via nasogastric or percutaneous endoscopic gastrostomy tube placement. Comparisons between patients with and without dysphagia were made to determine differences in baseline characteristics and premorbid conditions. Multivariable logistic regression determined factors associated with increased risk of dysphagia. Dysphagia status was ascertained from 4139 cases (1709 with dysphagia). Logistic regression showed that increased age, Black race, higher National Institutes of Health Stroke Scale score at admission, having a hemorrhagic stroke (versus infarct), and right hemispheric stroke increased the risk of developing dysphagia after stroke. Factors associated with reduced risk included history of high cholesterol, lower prestroke modified Rankin Scale score, and white matter disease.

CONCLUSIONS

This study replicated previous findings of variables associated with dysphagia (older age, worse stroke, right-sided hemorrhagic lesions), whereas other variables identified were without clear biological rationale (eg, Black race, history of high cholesterol, and presence of white matter disease) and should be investigated in future studies to determine biological relevance and potential influence in stroke recovery.

Prognostic Value of Dysphagia for Activities of Daily Living Performance and Cognitive Level after Stroke

Objectives

The purpose of this study was to examine the association between baseline dysphagia and the improvement of activities of daily living performance and cognitive level among inpatients after stroke.

Methods

This was a retrospective cohort study of patients undergoing convalescent rehabilitation after stroke. Dysphagia was assessed using the Food Intake LEVEL Scale. Outcomes were the motor and cognitive scores of the Functional Independence Measure (FIM) at discharge. Multiple regression analysis was performed to examine the association between dysphagia at admission and these outcomes.

Results

There were 499 participants with a median age of 74 years. A multiple regression analysis was carried out after adjusting for potential confounders including age and sex. Dysphagia at admission was independently and negatively associated with motor (β=-0.157, P<0.001) and cognitive (β=-0.066, P=0.041) FIM scores at discharge.

Conclusions

Baseline dysphagia in patients after stroke was negatively associated with improvement in performance of activities of daily living and cognitive level.

Transcranial direct current stimulation for post-stroke dysphagia: a meta-analysis

BACKGROUND

Strokes may cause some swallowing difficulty or associated dysphagia in 25-80% of patients. This phenomenon has been linked to increased morbidity and mortality. Therefore, the aim of this study was to evaluate the efficacy of transcranial direct current stimulation in patients with dysphagia in post-stroke patients.

METHODS

A systematic search in PubMed, Scopus, Web of Science and MEDLINE was conducted. The articles must have to evaluate an intervention that included transcranial direct current stimulation; the sample had to consist exclusively of patients with post-stroke dysphagia; and the experimental design consisted of randomized controlled trial. Difference in mean differences and their 95% confidence interval were calculated as the between-group difference in means divided by the pooled standard deviation. The I2 statistic was used to determine the degree of heterogeneity.

RESULTS

Of the 9 investigations analyzed, all applied transcranial direct current stimulation in combination with conventional dysphagia therapy to the experimental group. All the studies analyzed identified improvements in swallowing function and meta-analysis confirmed their strong effect on reducing the risk of penetration and aspiration (Hedges's g = 0.55). The results showed that participants who received transcranial direct current stimulation significantly improved swallowing function.

CONCLUSIONS

Transcranial direct current stimulation has positive effects in the treatment of poststroke dysphagia by improving swallowing function, oral and pharyngeal phase times and the risk of penetration and aspiration. Furthermore, its combination with conventional dysphagia therapy, balloon dilatation with catheter or training of the swallowing muscles ensures improvement of swallowing function. PROSPERO registration ID CRD42022314949.

Dysphagia following cerebellar stroke: analyzing the contribution of the cerebellum to swallowing function

Swallowing is essential for human health, and the cerebellum is crucial for motor movement regulation. Cerebellar strokes may cause dysphagia, but their exact effects remain unexplored in swallowing function. Therefore, the aim of this study was to analyze the precise clinical characteristics of the oral and pharyngeal phases of swallowing after cerebellar stroke and to critically discuss the cerebellum's contribution to swallowing. The study involved 34 participants with cerebellar strokes, gathered through convenience sampling. Neurologists diagnosed isolated strokes, and a speech and language pathologist examined swallowing ability using the Mann Assessment of Swallowing Ability. The study found that 52.9% of people experienced dysphagia after a cerebellar stroke. Dysphagia was significantly associated with a higher risk of aspiration. Age was also significantly correlated with dysphagia. No significant correlation was found between swallowing ability and sex. In conclusion, this study suggests isolated cerebellar stroke can adversely affect the motor and non-motor aspects of swallowing and cause severe dysphagia and aspiration risk. Thus, early diagnosis and timely management of dysphagia following a cerebellar stroke can help prevent serious consequences.

The assessment of dysphagia after stroke: state of the art and future directions

Dysphagia is a major complication following an acute stroke that affects the majority of patients. Clinically, dysphagia after stroke is associated with increased risk of aspiration pneumonia, malnutrition, mortality, and other adverse functional outcomes. Pathophysiologically, dysphagia after stroke is caused by disruption of an extensive cortical and subcortical swallowing network. The screening of patients for dysphagia after stroke should be provided as soon as possible, starting with simple water-swallowing tests at the bedside or more elaborate multi-consistency protocols. Subsequently, a more detailed examination, ideally with instrumental diagnostics such as flexible endoscopic evaluation of swallowing or video fluoroscopy is indicated in some patients. Emerging diagnostic procedures, technical innovations in assessment tools, and digitalisation will improve diagnostic accuracy in the future. Advances in the diagnosis of dysphagia after stroke will enable management based on individual patterns of dysfunction and predisposing risk factors for complications. Progess in dysphagia rehabilitation are essential to reduce mortality and improve patients' quality of life after a stroke.

Health factors associated with development and severity of post-stroke dysphagia: an epidemiological investigation

Background and Purpose

Dysphagia is a common post-stroke occurrence and has been shown to impact patients' morbidity and mortality. The purpose of this study was to use a large population-based dataset to determine specific epidemiological and patient health risk factors that impact development and severity of dysphagia after acute stroke.

Methods

Using data from the Greater Cincinnati Northern Kentucky Stroke Study, GCNKSS, involving a representative sample of approximately 1.3 million people from Southwest Ohio and Northern Kentucky of adults (age ≥18), ischemic and hemorrhagic stroke cases from 2010 and 2015 were identified via chart review. Dysphagia status was determined based on bedside and clinical assessments, and severity by necessity for alternative access to nutrition via nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube placement. Comparisons between patients with and without dysphagia were made to determine differences in baseline characteristics and pre-morbid conditions. Multivariable logistic regression was used to determine factors associated with increased risk of developing dysphagia.

Results

Dysphagia status was ascertained from 4139 cases (1709 with dysphagia). Logistic regression showed: increased age, Black race, higher NIHSS score at admission, having a hemorrhagic stroke (vs infarct), and right hemispheric stroke increased risk of developing dysphagia after stroke. Factors associated with reduced risk included history of high cholesterol, lower pre-stroke mRS score, and white matter disease.

Conclusions

This study replicated many previous findings of variables associated with dysphagia (older age, worse stroke, right sided hemorrhagic lesions), while other variables identified were without clear biological rationale (e.g. Black race, history of high cholesterol and presence of white matter disease). These factors should be investigated in future, prospective studies to determine biological relevance and potential influence in stroke recovery.

Incidence and Risk Factors for Dysphagia Following Cerebellar Stroke: a Retrospective Cohort Study

The cerebellum is known to play a supportive role in swallowing-related functions; however, wide discrepancies about the incidence rate of swallowing disorders following cerebellar strokes exist within the literature. This study aimed to investigate the incidence rate of dysphagia and the factors which may affect the presence of dysphagia and clinical recovery in individuals diagnosed with cerebellar stroke. A retrospective chart audit of 1651 post-stroke patients (1049 males and 602 females) admitted with a cerebellar stroke to a comprehensive tertiary hospital in China was conducted. Data on demographics, medical, along with swallowing function assessment were collected. Differences between dysphagic and non-dysphagic groups were evaluated using t-tests and Pearson's chi-square test. Univariate logistic regression analysis was performed to establish factors associated with the presence of dysphagia. A total of 11.45% of participants were identified with dysphagia during inpatient admission. Individuals with mixed types of stroke, multiple lesions in the cerebellum, and ages older than 85 years old were more likely to develop dysphagia. Moreover, the prognosis of dysphagia following a cerebellar stroke was associated with lesions in different parts of the cerebellum. The cumulative recovery rates from the best to worse were the right hemisphere group, the cerebellum vermis or peduncle group, and both the hemisphere group and the left hemisphere group, respectively.

The Role of the Cerebellum in Swallowing

Swallowing is a complex activity requiring a sophisticated system of neurological control from neurones within the brainstem, cerebral cortices and cerebellum. The cerebellum is a critical part of the brain responsible for the modulation of movements. It receives input from motor cortical and sensory areas and fine tunes these inputs to produce coordinated motor outputs. With respect to swallowing, numerous functional imaging studies have demonstrated increased activity in the cerebellum during the task of swallowing and damage to the cerebellum following differing pathological processes is associated with dysphagia. Single pulses of transcranial magnetic stimulation (TMS) have been applied to the cerebellum and have been shown to evoke motor responses in the pharynx. Moreover, repetitive TMS (rTMS) over the cerebellum can modulate cerebral motor (pharyngeal) cortical activity. Neurostimulation has allowed a better understanding of the connections that exist between the cerebellum and cerebral swallowing motor areas in health and provides a potential treatment for neurogenic dysphagia in illness. In this review we will examine what is currently known about the role of the cerebellum in the control of swallowing, explore new findings from neurostimulatory and imaging studies and provide an overview of the future clinical applications of cerebellar stimulation for treating dysphagia.

Factors Contributing to Complete Oral Intake in Dysphagic Stroke Patients with Enteral Feeding Tubes in Convalescent Rehabilitation Wards

Objectives:

This study investigated the factors contributing to complete oral intake (COI) in dysphagic stroke patients with enteral feeding tubes in the local clinical setting.

Methods:

Data of patients with percutaneous endoscopic gastrostomy (PEG) or nasogastric tube (NGT) feeding on admission to convalescent rehabilitation wards (CRWs) were extracted from the Kaga Regional Cooperation Clinical Pathway for Stroke database for multiple centers including 19 acute care hospitals and 11 hospitals with CRWs. Patients were divided into two groups based on their status regarding COI or incomplete oral intake (ICOI) at discharge. Logistic regression analysis with forced-entry variables was used to identify factors contributing to COI.

Results:

On discharge from CRWs, COI and ICOI were observed in 140 and 207 cases, respectively. The COI group was younger, had a higher rate of initial stroke, higher Functional Oral Intake Scale (FOIS) scores, higher Functional Independence Measure (FIM) motor and cognitive scores, higher Body Mass Index (BMI), lower rate of patients with PEG, and shorter stays in acute care wards. Logistic regression analysis with forced entry revealed that younger age; initial stroke; higher FOIS score, FIM cognitive score, and BMI; and shorter stay in the acute care ward contributed to COI.

Conclusions:

The primary factors contributing to COI in dysphagic stroke patients with enteral feeding tubes were younger age, initial stroke, higher swallowing and cognitive function, good nutritional status, and shorter stay in the acute care ward.

Predictive Factors for Nasogastric Tube Removal in Post-Stroke Patients

Background and Objectives: Stroke patients have different levels of functional impairment, and rehabilitation is essential to achieving functional recovery. Many post-stroke patients transition from acute treatment to post-acute care (PAC) with nasogastric tubes (NGTs) for rehabilitation. However, long-term NGT placement can lead to several complications, and its earlier removal can effectively reduce the incidence of mortality. This study aimed to use a PAC-cerebrovascular disease (CVD) program and physical functional evaluation scale tools to demonstrate the factors associated with NGT removal before post-stroke patient discharge. Materials and Methods: In this retrospective cohort study, data were collected between January 2017 and August 2022. We divided patients who had NGTs at admission into discharged with and without NGT groups to compare their baseline characteristics and physical functional status. Logistic regression analysis was used to detect the predictive factors for NGT removal. Results: There were 63 participants: 22 without NGT removal and 41 with NGT removal. The NGT removal rate was 65%. Age and scores for the activities of daily living by the Barthel index (BI), Functional Oral Intake Scale (FOIS), Mini-Mental State Examination, and Concise Chinese Aphasia Test were significantly different in terms of NGT removal status, but only the BI and FOIS were significantly correlated with NGT removal. Patients' BI scores indicating severe to moderate dependence (21-90) had a 4.55 times greater chance of NGT removal (odds ratio, 4.55; p < 0.05) than patients who had total dependence (<20). Every one-point increase in FOIS score indicated a 3.07 times greater chance of NGT removal (odds ratio, 3.07; p < 0.05). Conclusions: The BI and FOIS evaluations may indicate the probability of NGT removal in patients.

Predicting Failure to Recover Swallowing in Patients with Severe Post-stroke Dysphagia: The DIsPHAGIc Score

In post-stroke dysphagia, early identification of patients at highest risk of failing swallowing recovery (SR) would be useful to decide which of them should undergo percutaneous endoscopic gastrostomy. The studies on this subject were numerous but generally based on small statistical samples. In this retrospective study, 1232 patients with ischemic or hemorrhagic stroke (73.7 ± 13.0 years, 51% men) were assessed: 593 non-dysphagic, 351 partially dysphagic and 288 totally dysphagic. Among the latter, 45.1% could not recover oral intake. A score to assess the risk of failing SR was obtained from the group with total dysphagia, and further 210 patients with total post-stroke dysphagia were utilized for validation. A regular progression of stroke severity markers, complications and mortality was observed from non-dysphagic, to partially dysphagic, up to totally dysphagic patients. Among the latter, seven variables were independently associated with failure of SR, and formed the "DIsPHAGIc score": cerebral lesion Diameter ≥ 6 cm (+ 1), left frontal Ischemia (- 1), Partial anterior circulation syndrome (- 1), Hypoxia (+ 1), Antiplatelet drug (+ 1), GCS verbal reaction < 4 (+ 1), Internal capsule ischemia (- 1). The area under the ROC curve was 0.79 (95% CI 0.74-0.85). For total scores ≥ 2 there was a high risk of failing SR, with specificity 76.9%, sensitivity 72.1% and accuracy 74.7%. The application of the DIsPHAGIc score to the validation sample provided almost identical results. The evolution of post-stroke dysphagia towards irreversibility can be predicted by a simple, reproducible and robust scoring system based on 7 variables commonly available during hospitalization.

Physiological Mechanisms and Associated Pathophysiology of Dysphagia in Older Adults

Dysphagia can be a common secondary sequela of neurological and neurodegenerative disorders in older adults. Early screening, identification, and management of dysphagia is essential to avoid serious complications, including malnutrition, dehydration, aspiration pneumonia; and promote quality of life. Although individuals of all ages may experience swallowing difficulties, dysphagia and its complications are more common in older adults. This literature review aims to provide an overview of the physiological mechanisms of normal swallowing in healthy individuals and age-related changes to swallowing function, the pathophysiology of dysphagia associated with three common neurological disorders affecting older adults (stroke, Parkinson's disease, and dementia), and implications for interdisciplinary clinical practice. Increased awareness of these issues may contribute to a more timely and efficient identification of older adults with dysphagia and to improve overall dysphagia management.

The efficacy and safety of catheter balloon dilatation in the treatment of dysphagia after stroke: A protocol for systematic review and meta-analysis

BACKGROUND

Dysphagia is a serious complication after stroke, which has a significant influence on the health as well as life quality of global people. Patients with dysphagia tend to be a higher risk rate of an aspiration than general person. Catheter balloon dilatation is an additional therapy for treating dysphagia in recent years, which can improve the symptom of achalasia of cricopharyngeal muscle. This research will be used for confirming the efficacy and safety of the catheter balloon dilatation for resolving dysphagia.

METHODS

We intend to search literature related to the research in different databases, for instance, China National Knowledge Infrastructure, Wanfang Data, PubMed, Cochrane Library, and Embase up to January 2022. Literature selection, data collection, as well as assessment of bias risk, will be carried out by 2 independent researchers. Data analysis will be conducted by using Stata and review manager 5.4.

RESULTS

The results will be submitted to a peer-reviewed journal.

CONCLUSION

The research will verify whether or not catheter balloon dilatation can improve dysphagia by submitting high-quality data syntheses.

REGISTRATION NUMBER

CRD42022358433.

Prevalence of dysphagia and risk of pneumonia and mortality in acute stroke patients: a meta-analysis

Background

Post-stroke dysphagia (PSD) has been associated with high risk of aspiration pneumonia and mortality. However, limited evidence on pooled prevalence of post-stroke dysphagia and influence of individual, disease and methodological factors reveals knowledge gap. Therefore, to extend previous evidence from systematic reviews, we performed the first meta-analysis to examine the pooled prevalence, risk of pneumonia and mortality and influence of prognostic factors for PSD in acute stroke.

Methods

Our search was conducted in CINAHL, Cochrane Library, EMBASE, Ovid-Medline, PubMed, and Web of Science an initial search in October 2020 and a follow-up search in May 2021. Data synthesis was conducted using the Freeman-Tukey double-arcsine transformation model for the pooled prevalence rate and the DerSimonian-Lard random-effects model for prognostic factors and outcomes of PSD.

Results

The pooled prevalence of PSD was 42% in 42 studies with 26,366 participants. PSD was associated with higher pooled odds ratio (OR) for risk of pneumonia 4.08 (95% CI, 2.13–7.79) and mortality 4.07 (95% CI, 2.17–7.63). Haemorrhagic stroke 1.52 (95% CI, 1.13–2.07), previous stroke 1.40 (95% CI, 1.18–1.67), severe stroke 1.38 (95% CI, 1.17–1.61), females 1.25 (95% CI, 1.09–1.43), and diabetes mellitus 1.24 (95% CI, 1.02–1.51) were associated with higher risk of PSD. Males 0.82 (95% CI, 0.70–0.95) and ischaemic stroke 0.54 (95% CI, 0.46–0.65) were associated with lower risk of PSD. Haemorrhagic stroke, use of instrumental assessment method, and high quality studies demonstrated to have higher prevalence of PSD in the moderator analysis.

Conclusions

Assessment of PSD in acute stroke with standardized valid and reliable instruments should take into account stroke type, previous stroke, severe stroke, diabetes mellitus and gender to aid in prevention and management of pneumonia and thereby, reduce the mortality rate.

Trial registration

https://osf.io/58bjk/?view_only=26c7c8df8b55418d9a414f6d6df68bdb.

Supplementary information

The online version contains supplementary material available at 10.1186/s12877-022-02960-5.

Voxel-based lesion symptom mapping analysis for dysphagia in stroke patients with isolated cerebellar lesions

Because the cerebellum plays a role in motor coordination, timing, sequencing, and feedback, it is hypothesized to be involved in swallowing-related functions. The role of the cerebellum in deglutition has become increasing evident, but the exact nature of this role remains inconclusive because of limited data from pure cerebellar lesions. Therefore, we conducted location analysis in isolated cerebellar lesions to complement previous findings and provide additional information. We reviewed 40 stroke patients with isolated cerebellar lesion. Lesion location and volume were measured on brain magnetic resonance images. We generated statistical maps of lesions related to VDS using voxel-based lesion symptom mapping (VLSM). We also created an overlay map of subgroups according to VDS score, those who have low risk and those who have high risk. Patients with cerebellar lesion had difficulty swallowing, both in the oral and pharyngeal phases. Multivariate analysis of cognitive function was selected as an independent predictor. In the group of high-risk patients, the overlay map showed some bilateral asymmetry, with a wider distribution in the left hemisphere and involvement of deep cerebellar nuclei. Using VLSM, we found that lesion location was associated with dysphagia. Although these results were not statistically significant, they showed a lesion pattern with predominant distribution in the left posterior lobe. Our results suggest that damage to the posterior lobe of the left cerebellum tends be related to severity of dysphagia in patients with isolated cerebellar lesion.

Predictors of nasogastric tube removal in patients with stroke and dysphagia

Dysphagia is present in 25-50% of patients with stroke. Therefore, studying the probability of nasogastric tube removal in such patients before discharge from the rehabilitation ward is crucial. In this study, we developed a model to predict the outcome of dysphagia in patients with stroke. A retrospective study was performed from May 2015 to December 2018. We reviewed the medical charts of all patients with a diagnosis of stroke receiving nasogastric tube feeding. Patients were divided into weaned and nonweaned groups to compare baseline characteristics and functional status. The weaned and nonweaned groups comprised 55 and 65 patients, respectively. In the final logistic regression analysis model, the Barthel index at admission, lip closing status, ability to answer simple questions and functional independence before stroke were used to develop a predictive model (Logit = 0.8942 × functional independence before this stroke + 1.1279 × ability to answer simple question + 0.5345 × lip-close status + 0.0546 × Barthel index at admission - 2.2805). The optimal cutoff point based on Youden's index was more than -0.8403 with a sensitivity and specificity of 85.45 and 73.85%, respectively. The positive predicted value was 73.44%. In patients with stroke and dysphagia, a high Barthel index, intact lip closing status, ability to answer simple questions and better functional status before stroke appeared to affect nasogastric tube removal before discharge from the rehabilitation ward. Based on the final regression model, the proposed equation will help physicians and speech pathologists in planning patient care.

A Systematic and a Scoping Review on the Psychometrics and Clinical Utility of the Volume-Viscosity Swallow Test (V-VST) in the Clinical Screening and Assessment of Oropharyngeal Dysphagia

(1) Background: The volume-viscosity swallow test (V-VST) is a clinical tool for screening and diagnosis of oropharyngeal dysphagia (OD). Our aims were to examine the clinical utility of the V-VST against videofluoroscopy (VFS) or fiberoptic endoscopic evaluation of swallow (FEES) and to map the V-VST usage with patients at risk of OD across the years since it was described for the first time, carrying a systematic and a scoping review. (2) Methods: We performed both a systematic review (SR) including studies that look at the diagnostic test accuracy, and a scoping review (ScR) with articles published from September 2008 to May 2020. Searches were done in different databases, including PubMed and EMBASE from September 2008 until May 2020, and no language restrictions were applied. A meta-analysis was done in the SR to assess the psychometric properties of the V-VST. Quality of studies was assessed by Dutch Cochrane, QUADAS, GRADE (SR), and STROBE (ScR) criteria. The SR protocol was registered on PROSPERO (registration: CRD42020136252). (3) Results: For the diagnostic accuracy SR: four studies were included. V-VST had a diagnostic sensitivity for OD of 93.17%, 81.39% specificity, and an inter-rater reliability Kappa = 0.77. Likelihood ratios (LHR) for OD were 0.08 (LHR-) and 5.01 (LHR+), and the diagnostic odds ratio for OD was 51.18. Quality of studies in SR was graded as high with low risk of bias. In the ScR: 34 studies were retrieved. They indicated that V-VST has been used internationally to assess OD's prevalence and complications. (4) Conclusions: The V-VST has strong psychometric properties and valid endpoints for OD in different phenotypes of patients. Our results support its utility in the screening and clinical diagnosis and management of OD.

Temporal muscle thickness is associated with the severity of dysphagia in patients with acute stroke

BACKGROUND

Post-stroke dysphagia is a common and expensive complication of acute stroke. The relationship between dysphagia and skeletal muscle loss (sarcopenia) has been recently highlighted. This study aimed to determine the relationship between temporal muscle thickness (TMT) measured by head magnetic resonance imaging (MRI) and dysphagia in patients with acute stroke.

METHODS

Seventy participants (43 men and 27 women; mean age, 75.6 ± 12.7 years) were included in this study. TMT was measured by T2-magnetic resonance images within seven days of hospitalization. The severity of dysphagia was assessed using the Functional Oral Intake Scale (FOIS). Participants were classified into three categories according to the severity of dysphagia (severe: FOIS score, 1-3; mild: FOIS score, 4-6; normal: FOIS score, 7). Linear regression analysis was used to determine the independent explanators of dysphagia severity.

RESULTS

Twenty participants (28.6%) had severe dysphagia, 31 participants (44.3%) had mild dysphagia, and 19 participants (27.1%) had normal swallowing function at discharge. The results of the linear regression analysis showed that TMT was a significant explanator of dysphagia severity following stroke, along with age and National Institute of Health Stroke Scale (NIHSS) score (P < 0.05, effect size: f² = 0.72).

CONCLUSIONS

TMT was an independent risk factor for dysphagia in patients with acute stroke. Skeletal muscle loss may be secondarily involved in dysphagia with acute stroke, and measurement of TMT with head MRI is a useful method to assess skeletal muscle loss.

[Influence of prior ischemic events on the nutritional status of patients hospitalized for stroke]

Introduction

Background and aims: a poor nutritional status may worsen the prognosis of stroke. We assessed which factors were associated with a worse nutritional status in patients with stroke at the time of hospitalization. Methods: a cross-sectional study in patients with stroke needing enteral nutritional support, from January 2014 to September 2016. Nutritional status was evaluated by the Mini-Nutritional Assessment tool, and the Subjective Global Assessment. We performed a multivariate regression analysis including demographic, baseline disability (modified Rankin scale), and clinical and anthropometric variables, and we stratified the sample based on median age. Results: we included 226 patients, 58.3 % male, with a median age of 77 (66.7-83) years. Forty-four percent were at risk of malnutrition, and 24 % were malnourished. The factors that were associated with a worse nutritional status were age (odds ratio (OR): 1.03; 95 % CI: 1.01-1.08) and modified Rankin scale score (OR: 1.96; 95 % CI: 1.32-2.67). In the stratified analysis, associated factors were, in the subgroup of patients older than 77 years, the baseline degree of disability (OR: 1.88; 95 % CI: 1.26-2.80), whereas in the subgroup of patients younger than 77 years, it was a prior history of ischemic events (OR: 2.86; 95 % CI: 1.01-8.16). Conclusion: in patients hospitalized due to stroke, older age and worse functional status were associated with a worse nutritional status at the time of hospitalization. In elderly patients, the main factor was prior functional status, while in younger patients it was a prior history of ischemic events.

Post-stroke Dysphagia: Recent Insights and Unanswered Questions

PURPOSE OF REVIEW

We explored themes in recent post-stroke dysphagia literature, focusing on the following questions: (1) What does post-stroke dysphagia look like?; (2) Who gets post-stroke dysphagia?; (3) What are the consequences of post-stroke dysphagia?; and (4) How can we improve treatment of post-stroke dysphagia?

RECENT FINDINGS

There have been several improvements in quantitative descriptions of swallowing physiology using standard and new evaluation techniques. These descriptions have been correlated with lesion locations, and several factors can predict development of post-stroke dysphagia and its sequelae. Novel treatment paradigms have leveraged post-stroke neuroplastic improvements using neurostimulation and biofeedback techniques. Despite recent findings, the field is limited by lack of standardization and unanswered questions on rehabilitation variables. Our improved understanding of post-stroke dysphagia will enhance our ability to prevent, identify, and treat it. Future work should be grounded in swallowing physiology and continue refining treatments, particularly in the acute stage.

The Modified Volume-Viscosity Swallow Test as a Predictor of Aspiration Pneumonia after Acute Ischemic Stroke

OBJECTIVES

Dysphagia is common in patients with acute ischemic stroke patients (AIS) and it increases the risk of aspiration pneumonia after AIS. The volume-viscosity swallow test (V-VST) is a useful dysphagia screening tool. Therefore, we aim to explore the association between dysphagia (using the modified V-VST) and aspiration pneumonia in acute ischemic stroke patients.

PATIENTS AND METHODS

All patients with acute ischemic stroke (AIS) admitted during 1 January 2018 and 31 December 2018 were screened in this study by completing the modified V-VST within 24 hours after admission. The information of aspiration pneumonia was obtained from electronic medical system (EMS) and discharge notes.

RESULTS

Among 624 AIS patient, there were 152(24.36%) patients who suffered from aspiration pneumonia (95% CI, 20.65% - 27.35%) during hospitalization. Among all of them, patients with both impaired safety and impaired efficacy (HR, 7.53, 95%CI, 3.42-16.58, P < 0.001)) had a higher risk of aspiration pneumonia than those with only safety impaired (HR, 2.38, 95%CI, 1.40-4.04, P < 0.001) or only efficacy impaired (HR, 2.47, 95%CI, 1.33-4.57, P = 0.004). The risk of aspiration pneumonia was also associated with their completed volume at each viscosity. The patients with all impairment of three viscosities were also found to be related to the higher risk of developing aspiration pneumonia (P = 0.029).

CONCLUSIONS

The Modified V-VST is an easy-hand on, reliable screening tool for dysphagia among patients with AIS. Patient subgroup analyses based on the modified V-VST might be able to predict the risk of aspiration pneumonia during hospitalization.