Acute Dysphagia Following Reperfusion Therapies: A Prospective Pilot Cohort Study

Dysphagia is a well-documented sequela of stroke. Recent advancements in medical treatments for stroke include reperfusion therapies (endovascular thrombectomy (EVT) and thrombolysis). As outcomes following reperfusion therapies are typically measured via general functional scales, the pattern and progression of acute dysphagia following reperfusion therapies is less known. To determine the progression of acute dysphagia (0-72 h) following reperfusion therapies and relationships between various stroke parameters and dysphagia, twenty-six patients were prospectively recruited across two EVT and thrombolysis centres in Brisbane, Australia. Dysphagia was screened via the Gugging Swallowing Screen (GUSS) at the bedside at three timepoints: 0-24 h, 24-48 h, and 48-72 h post-reperfusion therapies. Across three groups (EVT only, thrombolysis only, or both), the incidence of any dysphagia within the first 24 h of reperfusion therapy was 92.31% (n = 24/26), 91.30% (n = 21/23) by 48 h, and 90.91% (n = 20/22) by 72 h. Fifteen patients presented with severe dysphagia at 0-24 h, 10 at 24-48 h, and 10 at 48-72 h. Whilst dysphagia was not significantly correlated to infarct penumbra/core size, dysphagia severity was significantly related to the number of passes required during EVT (p = 0.009).Dysphagia continues to persist in the acute stroke population despite recent advancements in technology aimed to reduce morbidity and mortality post-stroke. Further research is required to establish protocols for management of dysphagia post-reperfusion therapies.

Speech-language pathologists' perspectives of dysphagia following reperfusion therapies: An Australian mixed-methods study

PURPOSE

To investigate speech-language pathologists' (SLPs) perceptions and clinical experiences of dysphagia management following reperfusion therapies.

METHOD

A multi-staged mixed approach involving a two-phase cross-sectional design was used. Data generated during phase 1 (a purpose-built, online survey) guided the development of phase 2 (semi-structured interviews). Sixty-two SLPs participated in phase 1 and six SLPs participated in phase 2.

RESULT

SLPs in both phases reported perceived changes in dysphagia presentation according to the success of reperfusion therapy administered and had concerns regarding worsened dysphagia following unsuccessful procedures. Fluctuations in dysphagia were more frequently reported in the acute stage post-stroke. SLPs reported increased workload demands due to increased interhospital transfers between ECR/thrombolysis centres and referring facilities. The optimal timing for swallowing screening and assessment was not identified, with initial SLP involvement ranging from during the administration of thrombolysis to up to 24 hours post-reperfusion therapy.

CONCLUSION

Preliminary evidence suggests that SLPs perceive that the presentation of post-stroke dysphagia is changing, with increasing fluctuations and complexities in the acute stage of post-stroke care, within the context of increasing use of reperfusion therapies. There is a critical need for research investigating the trajectory of dysphagia in the acute stage to inform dysphagia management within this patient population.

The use of augmented reality for patient and significant other stroke education: a feasibility study

BACKGROUND

Stroke education is a key factor in minimising secondary stroke risk, yet worldwide stroke education rates are low. Technology has the potential to increase stroke education accessibility. One technology that could be beneficial is augmented reality (AR). We developed and trialled a stroke education lesson using an AR application with stroke patients and significant others.

METHODS

A feasibility study design was used. Following development of the AR stroke education lesson, 19 people with stroke and three significant others trialled the lesson then completed a customised mixed method questionnaire. The lesson involved narrated audio while participants interacted with a model brain via a tablet. Information about participant recruitment and retention, usage, and perceptions were collected.

RESULTS

Fifty-eight percent (n = 22) of eligible individuals consented to participate. Once recruited, 100% of participants (n = 22) were retained. Ninety percent of participants used the lesson once. Most participants used the application independently (81.82%, n = 18), had positive views about the lesson (over 80% across items including enjoyment, usefulness and perception of the application as a good learning tool) and reported improved confidence in stroke knowledge (72.73%, n = 16). Confidence in stroke knowledge post-lesson was associated with comfort using the application (p = 0.046, Fisher's exact test) and perception of the application as a good learning tool (p = 0.009, Fisher's exact test).

CONCLUSIONS

Technology-enhanced instruction in the form of AR is feasible for educating patients and significant others about stroke. Further research following refinement of the lesson is required.

What do stroke survivors want in stroke education and information provision in Australia?

Despite evidence that stroke education is important and effective, low rates of stroke education are reported worldwide. Many stroke survivors and carers report that current stroke information does not meet their needs. The aim of the current study was to explore the perceptions of stroke survivors and carers towards stroke education in an Australian health context. A qualitative descriptive approach using focus groups was used to explore education received and preferred content, format and timing of education. Data were analysed inductively using qualitative content analysis to identify key categories, sub-categories and an overarching theme. Fifteen stroke survivors and four carers participated. Four categories emerged: the timing of stroke education, the content of stroke education, the format of stroke education, and reactions to stroke education. Each category contained a number of sub-categories. One overarching theme was woven through the transcripts: everyone is different and has different needs. Overall, participants generally expressed positive attitudes towards stroke education. Participants reported that education should occur at multiple timepoints and in a mixed format. All participants reported receiving stroke education in hospital, but not in the community. Stroke survivors preferred group education, while carers did not share this preference. Both stroke survivors and carers desired information about post-stroke physical changes and computer use; however, stroke survivors desired additional information spanning a variety of areas such as motivation and driving. Tailoring of stroke education for each individual is critical to ensure that education meets the needs of stroke survivors and carers from the hospital to the community.

The effects of endovascular clot retrieval and thrombolysis on dysphagia in an Australian quaternary hospital: A retrospective review

Dysphagia (impaired swallowing) is known to contribute to decreased quality of life, and increased length of hospital stay and mortality post-stroke. Despite the advancements in stroke treatment with the introduction of thrombolysis and endovascular clot retrieval (ECR), patients continue to present with high rates of dysphagia. Speech and language therapists and stroke teams should consider the presence of haemorrhagic transformation, success of reperfusion and presence of communication deficits as risk factors for dysphagia post-ECR and/or thrombolysis.

PURPOSE

To establish incidence rates and patterns of dysphagia following the administration of reperfusion therapies in acute ischaemic stroke management.

METHOD

A retrospective review of 193 patients admitted with acute ischaemic stroke to a quaternary stroke unit in Australia over a three year period was completed. Clinical information extracted included demographics, type (thrombolysis and/or endovascular clot retrieval) and success of reperfusion therapy, and the progression of dysphagia and related factors.

RESULTS

Over half of all patients treated with reperfusion therapies presented with dysphagia on initial assessment by speech-language pathology (SLP). The type of reperfusion therapy administered was not significantly correlated with the presence of dysphagia. Dysphagia on initial assessment was significantly correlated with the presence of aphasia on initial assessment, the presence of haemorrhagic transformation, and the success of reperfusion. Increased rates of enteral feeding were also found in this study compared to figures reported in literature.

CONCLUSION

This study identified ongoing high rates of dysphagia amongst this patient population regardless of treatment type, demonstrating the need for ongoing SLP management post stroke. Further research is required in this area to develop an evidence-base for SLPs and the wider medical team and to inform clinical practice guidelines.

WHAT THIS PAPER ADDS

What is already known on the subject Stroke is one of the leading causes of disability and death internationally. Dysphagia (impaired swallowing), a common sequalae of stroke, is known to contribute to decreased quality of life, increased length of hospital stay and mortality. With advancements in technology, treatments for acute ischaemic stroke (endovascular clot retrieval and thrombolysis) are increasing in popularity. However, limited research exists exploring the impact of these therapies on dysphagia. What this paper adds Despite the advancements in stroke treatment, patients continue to present with high rates of dysphagia. Dysphagia following thrombolysis and/or ECR was found to be significantly correlated to the presence of aphasia, haemorrhagic transformation, and the success of reperfusion (regardless of treatment type). Additionally, increased rates of enteral feeding were found amongst this patient population compared to figures reported in the literature for patients following traditional stroke management. Clinical implications of this study Speech-language pathologists and the wider medical team should consider dysphagia as an ongoing consequence of stroke following reperfusion therapies, with consideration for success of reperfusion and adverse outcomes i.e., haemorrhagic transformation. Further research is required to provide an evidence-base and specific guidelines for the management of dysphagia post reperfusion therapies, including use of enteral feeding.