Arquivo da tag: avc

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.


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.


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.


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.


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.


Relação entre disfagia orofaríngea e aspectos clínicos em sujeitos pós acidente vascular cerebral avaliados ambulatorialmente

Heloisa Toller Bray

Biblioteca Digital da UNICAMP, 04-07-2012


A alteração na deglutição, em indivíduos após acidente vascular cerebral (AVC) é uma das sequelas mais encontradas e pode acarretar comprometimentos respiratórios, nutricionais, além de interferir negativamente no prazer em se alimentar, e na socialização. O presente estudo objetivou relacionar a disfagia orofaríngea e os aspectos clínicos, em sujeitos pós AVC, avaliados ambulatorialmente.Trata-se de um estudo transversal quantitativo com 38 sujeitos. Foram analisados os aspectos clínicos: comorbidades, número de AVC, queixas relacionadas às fases da deglutição, grau de severidade da disfagia (SD), funcionalidade da deglutição por meio da Functional Oral IntakeScale (FOIS) e, aspectos da avaliação videoendoscópica da deglutição (presença de estases, penetrações e aspirações laríngeas). Os sujeitos foram atendidos no ambulatório de Otorrinolaringologia /Disfagia do Hospital das Clínicas da Universidade Estadual de Campinas. Dentre os 38 sujeitos, 24, eram do gênero masculino, com mediana de idade de 63 anos e 14 do gênero feminino, com mediana de idade de 63 anos. Destes, 31 eram hipertensos e 14 diabéticos. O número de pacientes com AVC, se único ou múltiplo, foi respectivamente 26 e 12. O tempo de avaliação pós AVC foi de 1 a 12 meses. No estudo foi observado maior número de queixas de fase oral (FO) do que de fase faríngea (FF) (p=0,015). Na avaliação da deglutição, os sujeitos apresentaram FOIS nos níveis 1 (7,89%), 5 (84,21%) e 7 (7,89%). O grau da disfagia foi ausente em 15,78%, leve em 39,47%, moderado em 31,57% e grave em 13,15%. Foram observadas penetrações laríngeas de alimento em 34,21% e aspirações laríngeas em 7,89% por meio das videoendoscopias da deglutição (VEDs) realizadas. Houve correlação estatística positiva entre presença de estase e presença de clareamento, em todas as consistências analisadas. Também foi observada correlação positiva entre SD e penetração (p=<0,0001). Conclui-se que, 84% dos sujeitos após AVC, apresentaram algum grau de disfagia, no presente estudo. Não foram observadas correlações entre os parâmetros da deglutição estudados com os aspectos clínicos, porém evidenciou-se tendência dos sujeitos com maior tempo de AVC apresentarem maior severidade da disfagia (p=0,0501). Há a necessidade de avaliações da deglutição, a longo prazo, de todos os sujeitos pós-AVC, em virtude da manutenção da disfagia e do comprometimento na funcionalidade da ingestão oral. Também, concluí-se que a metodologia de avaliação da deglutição nos pacientes após AVC deve incluir necessariamente o teste de todas as consistências alimentares, por meio de exame objetivo, principalmente das consistências sólidas, pastosas e líquidas.


Disfagia no acidente vascular cerebral agudo: um estudo transversal

Alvares-da-Silva, Mário Reis; Alvares-Da-Silva, Alexandre Ulrich; Saafeld, Vitor; Silvério, Américo de Oliveira.

GED gastroenterol. endosc. dig; 12(3): 83-7, jul.-set. 1993.


A presença de disfagia em acidente vascular cerebral agudo (AVC) ven sendo relatada como sinal de mau prognóstico. Com o objetivo de determinar a prevalência de disfagia em AVC agudo e correlacioná-la com infecçao respiratória, estado de hidrataçao e evoluçao clínica, realizamos um estudo transversal em 23 pacientes admitidos à Sala de Observaçao da Emergência de nosso hospital. Encontramos disfagia em 17,4 por cento dos pacientes. Nao houve relaçao entre a presença de disfagia e infecçao respiratória, hidrataçao e evoluçao clínica.

Adaptações alimentares em adultos pós AVCI sem queixa de disfagia

Menezes, Fernanda Teixeira; Gonçalves, Maria Inês Rebelo; Chiari, Brasília Maria.

Fono atual; 8(34): 14-24, set.-dez. 2005.


Objetivo: Associar as alterações da cavidade oral (diminuição de força, mobilidade e sensibilidade de lábios, língua e bochechas; xerostomia), presença de próteses dentárias e/ou ausência de dentes e mastigação com as adaptações alimentares, em pacientes que sofreram acidente vascular cerebral isquêmico (AVCI). Métodos: A pesquisa foi realizada no Ambulatório de Distúrbios Adquiridos de Fala e Linguagem da Disciplina de Distúrbios da Comunicação Humana (DCH) da UNIFESP-EPM. Foram avaliados 12 pacientes que sofreram AVCI, sem queixas relacionadas à deglutição, na faixa etária entre 38 e 78 anos de idade, de ambos os sexos, sendo 8 homens e 4 mulheres. Os pacientes foram submetidos à anamnese específica da alimentação e à avaliação clínica fonoaudiológica da deglutição. Resultados: As adaptações alimentares encontradas neste estudo, em ordem decrescente de ocorrência, foram: deglutição de alimentos mais moles (41, 67 por cento); alimentos amassados (16,67 por cento); intercalar sólidos e líquidos (16,67 por cento) e multiplas deglutições (8,33 por cento). Conclusão: 1) alterações de força, mobilidade e sensibilidade de lábios, língua e bochechas estiveram associadas à ingestão de alimentos moles, ao amassamento de alimentos, à diminuição da quantidade de alimento e à necessidade de múltiplas deglutições por bolo; 2) a presença de prótese dentária e/ou ausência de dentes esteve associada à ingestão de alimentos moles e ao amassamento dos alimentos; 3) as adaptações alimentares mais associadas à mastigação foram a ingestão de alimentos mais moles e o amassmaento dos alimentos; 4) a xerostomia esteve associada à ingestão de alimentos moles e à manobra de intercalar sólidos e líquidos.

Dysphagia in stroke patients

Singh S; Hamdy S.

Postgrad Med J; 82(968): 383-91, 2006


Swallowing musculature is asymmetrically represented in both motor cortices. Stroke affecting the hemisphere with the dominant swallowing projection results in dysphagia and clinical recovery has been correlated with compensatory changes in the previously non-dominant, unaffected hemisphere. This asymmetric bilaterality may explain why up to half of stroke patients are dysphagic and why many will regain a safe swallow over a comparatively short period. Despite this propensity for recovery, dysphagia carries a sevenfold increased risk of aspiration pneumonia and is an independent predictor of mortality. The identification, clinical course, pathophysiology, and treatment of dysphagia after stroke are discussed in this review.


Transtornos de Deglutição/etiologia Acidente Cerebral Vascular/complicações Doenças do Sistema Nervoso Central/complicaçõesDoenças do Sistema Nervoso Central/fisiopatologia Deglutição/fisiologia Transtornos de Deglutição/diagnóstico Transtornos de Deglutição/terapia Endoscopia do Sistema Digestório/métodos Terapia por Exercício Fluoroscopia/métodos Humanos Sistemas Automatizados de Assistência Junto ao Leito Prognóstico Acidente Cerebral Vascular/reabilitação


Comparação entre queixas de deglutição e achados videofluoroscópicos no paciente pós acidente vascular encefálico

Gatto , Ana Rita; Rehder, Maria Inês Beltrati Cornacchioni.

Rev. CEFAC; 8(3): 320-327, jul.-set. 2006.


Objetivo: comparar queixas referidas de alterações na deglutição com achados do exame objetivo dadeglutição em pacientes pós acidente vascular encefálico. Métodos: foram avaliados, neste estudo,20 sujeitos idosos, de ambos os gêneros, pós Acidente Vascular Encefálico (AVE), do Hospital dasClínicas da Universidade Estadual Paulista û Unesp/Botucatu, internados na Enfermaria de Neurologiaou Pronto Socorro. Resultados: 30% dos pacientes queixavam-se de dificuldades de deglutição,quando a pergunta era geral; os demais pacientes somente referiam dificuldades quando minuciosamenteinterrogados; 90% dos pacientes apresentavam disfagia orofaríngea, sendo que 40% destas eramdisfagia grave. Destes 40%(6), somente 50%(3) apresentavam queixas. Dos pacientes sem queixas,com alteração na dinâmica da deglutição, constatou-se que 16(84,21%) dos pacientes, sem queixasde dificuldades com alimentos pastosos, apresentavam quadro de disfagia orofaríngea e 11(57,89%)alteração do controle oral, 13(86,67%) dos pacientes, sem queixas de dificuldades com líquidos,tinham disfagia e 8(53,33), alteração no controle oral. Conclusão: concluiu-se que as queixas dospacientes não corresponderam e apresentaram-se aquém dos achados da videofluoroscopia dadeglutição. Desta forma, é sempre necessária uma avaliação cuidadosa da deglutição nos pacientespós-acidente vascular encefálico.


Estudo Comparativo Humanos Masculino Feminino Meia-Idade Idoso Acidente Cerebral Vascular/complicações Transtornos de Deglutição/radiografia Fluoroscopia/métodos Acidente Cerebral Vascular/fisiopatologia Transtornos de Deglutição/etiologiaOrofaringe/fisiopatologia Distribuição de Qui-Quadrado Gravação de Videoteipe Questionários Anamnese Transtornos de Deglutição/fisiopatologia