Correlação entre a lesão encefálica e a disfagia em pacientes adultos com acidente vascular encefálico

Nunes, Maria Cristina de Alencar; Jurkiewicz, Ari Leon; Santos, Rosane Sampaio; Furkim, Ana Maria; Massi, Giselle; Pinto, Gisele Sant´Ana; Lange, Marcos Christiano
Int. Arch. Otorhinolaryngol. 16(3): 313-321, TAB. 2012 Sep.

RESUMO

INTRODUÇÃO: A incidência da disfagia orofaríngea, em pacientes com acidente vascular encefálico (AVE), varia de 20% a 90% na literatura. Estudos correlacionam a localização do AVE com a presença de disfagia e outros não a correlacionam.
OBJETIVO: Correlacionar a lesão encefálica com a disfagia em pacientes com diagnóstico de AVE, considerando-se o tipo e a localização do AVE.
MÉTODO: Estudo prospectivo realizado no Hospital de Clínicas com 30 pacientes com AVE, sendo 18 do sexo feminino e 12 do masculino. Todos realizaram avaliações clínica e nasolaringofibroscópica da deglutição (FEES®) e divididos pela localização da lesão: córtex cerebral, córtex cerebelar e áreas subcorticais e tipo: hemorrágico, isquêmico ou transitório.
RESULTADOS: Dos 30, 18 apresentaram AVE tipo isquêmico, dois hemorrágico e 10 transitório. Sobre a localização, 10 a apresentaram no córtex cerebral, três nos córtices cerebral e cerebelar, três no córtex cerebral e subcortical, um nos córtices cerebral, cerebelar e subcortical e três subcortical. Na avaliação clínica houve predomínio da disfagia oral em pacientes com lesão no córtex cerebral e subcortical do tipo isquêmico. No FEES® a diminuição da sensibilidade laríngea predominou no córtex cerebral e tipo isquêmico. Os resíduos faríngeos em valéculas epiglóticas associadas com recessos piriformes predominaram no córtex cerebral em todas as consistências e tipo isquêmico. Um paciente com lesão nos córtices cerebral e cerebelar apresentou penetração laríngea e aspiração traqueal nas consistências líquida e mel, do tipo isquêmico.
CONCLUSÃO: Houve predomínio da disfagia na localização da lesão no córtex cerebral e do tipo isquêmico.

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Assessments in Australian stroke rehabilitation units: a systematic review of the post-stroke validity of the most frequently used

Kitsos G; Harris D; Pollack M; Hubbard IJ

Disabil Rehabil;33(25-26):2620-32, 2011.

PURPOSE: In Australia, stroke is the leading cause of adult disability. For most stroke survivors, the recovery process is challenging, and in the first few weeks their recovery is supported with stroke rehabilitation services. Stroke clinicians are expected to apply an evidence-based approach to stroke rehabilitation and, in turn, use standardised and validated assessments to monitor stroke recovery. In 2008, the National Stroke Foundation conducted the first national audit of Australia’s post acute stroke rehabilitation services and findings identified a vast array of assessments being used by clinicians. This study undertook a sub-analysis of the audit’s assessment tools data with the aim of making clinically relevant recommendations concerning the validity of the most frequently selected assessments. METHOD: Data reduction ranked the most frequently selected assessments across a series of sub-categories. A serial systematic review of relevant literature using Medline and the Cumulative Index to Nursing and Allied Health Literature identified post-stroke validity ranking. RESULTS: The study found that standardised and non-standardised assessments are currently in use in stroke rehabilitation. It recommends further research in the sub-categories of strength, visual acuity, dysphagia, continence and nutrition and found strengths in the sub-categories of balance and mobility, upper limb function and mood. CONCLUSIONS: This is the first study to map national usage of post-stroke assessments and review that usage against the evidence. It generates new knowledge concerning what assessments we currently use post stroke, what we should be using and makes some practical post stroke clinical recommendations.

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Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial

Middleton S; McElduff P; Ward J; Grimshaw JM; Dale S; D’Este C; Drury P; Griffiths R; Cheung NW; Quinn C; Evans M; Cadilhac D; Levi C; QASC Trialists Group

Lancet;378(9804):1699-706, 2011 Nov 12.

BACKGROUND: We assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence-based management of fever, hyperglycaemia, and swallowing dysfunction in acute stroke units (ASUs). METHODS: In the Quality in Acute Stroke Care (QASC) study, a single-blind cluster randomised controlled trial, we randomised ASUs (clusters) in New South Wales, Australia, with immediate access to CT and on-site high dependency units, to intervention or control group. Patients were eligible if they spoke English, were aged 18 years or older, had had an ischaemic stroke or intracerebral haemorrhage, and presented within 48 h of onset of symptoms. Intervention ASUs received treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction with multidisciplinary team building workshops to address implementation barriers. Control ASUs received only an abridged version of existing guidelines. We recruited pre-intervention and post-intervention patient cohorts to compare 90-day death or dependency (modified Rankin scale [mRS] ≥2), functional dependency (Barthel index), and SF-36 physical and mental component summary scores. Research assistants, the statistician, and patients were masked to trial groups. All analyses were done by intention to treat. This trial is registered at the Australia New Zealand Clinical Trial Registry (ANZCTR), number ACTRN12608000563369. FINDINGS: 19 ASUs were randomly assigned to intervention (n=10) or control (n=9). Of 6564 assessed for eligibility, 1696 patients’ data were obtained (687 pre-intervention; 1009 post-intervention). Results showed that, irrespective of stroke severity, intervention ASU patients were significantly less likely to be dead or dependent (mRS ≥2) at 90 days than control ASU patients (236 [42%] of 558 patients in the intervention group vs 259 [58%] of 449 in the control group, p=0·002; number needed to treat 6·4; adjusted absolute difference 15·7% [95% CI 5·8-25·4]). They also had a better SF-36 mean physical component summary score (45·6 [SD 10·2] in the intervention group vs 42·5 [10·5] in the control group, p=0·002; adjusted absolute difference 3·4 [95% CI 1·2-5·5]) but no improvement was recorded in mortality (21 [4%] of 558 in intervention group and 24 [5%] of 451 in the control group, p=0·36), SF-36 mean mental component summary score (49·5 [10·9] in the intervention group vs 49·4 [10·6] in the control group, p=0·69) or functional dependency (Barthel Index ≥60: 487 [92%] of 532 patients vs 380 [90%] of 423 patients; p=0·44). INTERPRETATION: Implementation of multidisciplinary supported evidence-based protocols initiated by nurses for the management of fever, hyperglycaemia, and swallowing dysfunction delivers better patient outcomes after discharge from stroke units. Our findings show the possibility to augment stroke unit care. FUNDING: National Health & Medical Research Council ID 353803, St Vincent’s Clinic Foundation, the Curran Foundation, Australian Diabetes Society-Servier, the College of Nursing, and Australian Catholic University.

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Which cortical area is related to the development of dysphagia after stroke? A single photon emission computed tomography study using novel analytic methods

Momosaki R; Abo M; Kakuda W; Uruma G

Eur Neurol;67(2):74-80, 2012.

PURPOSE: The purpose of this study is to clarify cortical areas related to the development of dysphagia in poststroke patients using novel analytic methods for single photon emission computed tomography (SPECT) imaging. SUBJECTS AND METHODS: Twenty poststroke patients (age: 66.1 ± 5.1 years) with a left hemispheric lesion were studied. According to clinical evaluation, patients were divided into a dysphagia group (n = 10) and a control group (n = 10). In each patient, measurement of regional cerebral blood flow (rCBF) was performed by SPECT imaging with a 99mTc-ethylcysteinate dimer. For the analysis, an easy Z-score imaging system and voxel-based stereotactic extraction estimation were applied, with placing regions of interest segmented into the Brodmann area level. We compared rCBF in each area between the two groups, and receiver operating characteristic analysis to calculate the area under the curve was also performed. RESULTS: The rCBF in Brodmann areas 4 and 24 was significantly lower in the dysphagia group. The highest area under the curve was found in Brodmann area 4. In this area, 80% sensitivity and 60% specificity for discriminating dysphagia were achieved with an optimal cutoff value. CONCLUSIONS: When analyzed with novel methods, SPECT imaging can be useful for predicting the risk of dysphagia and subsequent aspiration in poststroke patients.

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Dysphagia in patients with acute striatocapsular hemorrhage

Suntrup S; Warnecke T; Kemmling A; Teismann IK; Hamacher C; Oelenberg S; Dziewas R

J Neurol;259(1):93-9, 2012 Jan.

Dysphagia is found in up to 80% of acute stroke patients. To date most studies have focused on ischemic stroke only. Little is known about the incidence and pattern of dysphagia in hemorrhagic stroke. Here we describe the characteristics of dysphagia in patients with striatocapsular hemorrhage. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) was carried out in 30 patients with acute striatocapsular hemorrhage. Dysphagia was classified according to the six-point Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) within 72 h after admission. Lesion volume, hemisphere and occurrence of ventricular rupture were determined from computer tomography scans. Data on initial NIH-SS, clinical symptoms, need for endotracheal intubation, diagnosis of pneumonia and feeding status on discharge were recorded. Swallowing impairment was observed in 76.7% of patients (n = 23). Mean FEDSS score was 3.1 ± 1.5. Main findings were penetration or aspiration of liquids as well as leakage to valleculae and piriform sinus. Incidence of pneumonia was 30.0% (n = 9). Age, NIH-SS and hematoma volume did not correlate with dysphagia severity. None of the clinical characteristics was predictive for dysphagia. On discharge after 12.9 ± 5.3 days, a two-point improvement on the FEDSS was seen in seven patients, (30.4%) and five patients (21.7%) had gained at least one point. In striatocapsular hemorrhage, dysphagia is a common and so far underrecognized symptom. FEES results indicate predominant impairment of oral motor control. Swallowing impairment is not related to other clinical deficits, stroke severity or lesion characteristics. Thus, detailed dysphagia assessment is indicated in all cases.

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Eating difficulties among patients 3 months after stroke in relation to the acute phase

Medin J; Windahl J; von Arbin M; Tham K; Wredling R

J Adv Nurs;68(3):580-9, 2012 Mar.

AIM: This paper is a report of a study comparing eating difficulties among patients 3 months after stroke in relation to the acute phase. BACKGROUND: There is limited knowledge of patients with eating problems early after stroke, hence the progress of eating abilities needs to be further explored. METHOD: From March 2007 to June 2008 36 stroke patients with 2-7 eating difficulties or problems with reduced alertness or swallowing in the acute phase were included. Eating difficulties were detected using a structured protocol of observation of meals. In addition, stroke severity (National Institute of Health Stroke Scale), functional status (Barthel Index), unilateral neglect (Line Bisection test and Letter Cancellation test), psychological well-being (The Well-being Questionnaire-12), nutritional status (Mini Nutritional Assessment) and oral status (Revised Oral Assessment Guide) were assessed. RESULTS: There were 36 participants (58% female) with a median age of 74·5 years. The proportion of eating difficulties decreased significantly from the acute phase to the 3-month follow-up in ‘sitting position’, ‘managing food on the plate’ and ‘manipulating food in the mouth’ and increased regarding inadequate food consumption. Improvements were shown at 3 months in stroke severity, functional status, nutritional status and neglect. Oral status and psychological well-being remained unchanged. CONCLUSION: The majority of eating problems persisted 3 months after stroke despite a marked improvement in most of the physical functions. The unchanged psychological well-being and sustained problems with food consumption indicate that factors other than physical function should be taken into account regarding eating difficulties poststroke.

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Avaliação da estimulação elétrica no tratamento da disfagia secundário ao acidente vascular encefálico

Soares, Thaís Miranda Curvelo; Conceição, Tatiana Maíta Alves; Cardoso, Fabrício; Beresford, Heron
Acta fisiátrica; 16(4)dez. 2009
ARTIGO DE REVISÃO
A disfagia neurogênica compreende as alterações da deglutição que ocorrem em virtude de uma doença neurológica, com os sintomas e complicações decorrentes do comprometimento sensório-motor dos músculos envolvidos no processo da deglutição. Este tipo de disfagia é particularmente debilitante, podendo levar a morte ou aumento do custo de saúde decorrentes da aspiração traqueal. Esta patologia é comum e consiste numa complicação potencialmente fatal para AVE agudo, ocorrendo em aproximadamente 50% desses pacientes. Dentre os possíveis tratamentos, a estimulação tátil-térmica e biofeedback têm um sucesso freqüente, variando de 0% a 83%. Estudos registram alto sucesso deste tratamento com pacientes que sofreram AVE, o que geralmente não incluem a mais severa forma de disfagia. Já o uso da estimulação elétrica no tratamento da disfagia foi primeiro descrito em 1996 por Freed et al e, posteriormente, por Park et al. O objetivo dessa estimulação elétrica era alcançar um ramo aferente do reflexo da deglutição em pacientes com atraso do início da deglutição. Sendo esta uma alternativa de tratamento ainda pouco explorada, o objetivo desse estudo foi realizar uma revisão bibliográfica sobre a utilização da estimulação elétrica no tratamento da disfagia em pacientes que sofreram acidente vascular encefálico. Conclusão: A disfagia neurogência, por estar diretamente associada ao aumento da morbi-mortalidade, necessita da atenção especial dos profissionais da Saúde. Sendo a eletroestimulação uma terapêutica importante a ser explorada já que possui uma eficácia significativa nesta patologia.

Correlação entre a lesão encefálica e a disfagia em pacientes adultos com acidente vascular encefálico

Nunes, Maria Cristina de Alencar; Jurkiewicz, Ari Leon; Santos, Rosane Sampaio; Furkim, Ana Maria; Massi, Giselle; Pinto, Gisele Sant´Ana; Lange, Marcos Christiano
Int. Arch. Otorhinolaryngol. 16(3): 313-321, TAB. 2012 Sep.

RESUMO

INTRODUÇÃO: A incidência da disfagia orofaríngea, em pacientes com acidente vascular encefálico (AVE), varia de 20% a 90% na literatura. Estudos correlacionam a localização do AVE com a presença de disfagia e outros não a correlacionam.
OBJETIVO: Correlacionar a lesão encefálica com a disfagia em pacientes com diagnóstico de AVE, considerando-se o tipo e a localização do AVE.
MÉTODO: Estudo prospectivo realizado no Hospital de Clínicas com 30 pacientes com AVE, sendo 18 do sexo feminino e 12 do masculino. Todos realizaram avaliações clínica e nasolaringofibroscópica da deglutição (FEES®) e divididos pela localização da lesão: córtex cerebral, córtex cerebelar e áreas subcorticais e tipo: hemorrágico, isquêmico ou transitório.
RESULTADOS: Dos 30, 18 apresentaram AVE tipo isquêmico, dois hemorrágico e 10 transitório. Sobre a localização, 10 a apresentaram no córtex cerebral, três nos córtices cerebral e cerebelar, três no córtex cerebral e subcortical, um nos córtices cerebral, cerebelar e subcortical e três subcortical. Na avaliação clínica houve predomínio da disfagia oral em pacientes com lesão no córtex cerebral e subcortical do tipo isquêmico. No FEES® a diminuição da sensibilidade laríngea predominou no córtex cerebral e tipo isquêmico. Os resíduos faríngeos em valéculas epiglóticas associadas com recessos piriformes predominaram no córtex cerebral em todas as consistências e tipo isquêmico. Um paciente com lesão nos córtices cerebral e cerebelar apresentou penetração laríngea e aspiração traqueal nas consistências líquida e mel, do tipo isquêmico.
CONCLUSÃO: Houve predomínio da disfagia na localização da lesão no córtex cerebral e do tipo isquêmico.

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