Arquivo da tag: stroke

Correlation between brain injury and dysphagia in adult patients with stroke

Nunes, Maria Cristina 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.


INTRODUCTION: In the literature, the incidence of oropharyngeal dysphagia in patients with cerebrovascular accident (AVE) ranges 20–90%. Some studies correlate the location of a stroke with dysphagia, while others do not.
OBJECTIVE: To correlate brain injury with dysphagia in patients with stroke in relation to the type and location of stroke.
METHOD: A prospective study conducted at the Hospital de Clinicas with 30 stroke patients: 18 women and 12 men. All patients underwent clinical evaluation and swallowing nasolaryngofibroscopy (FEES®), and were divided based on the location of the injury: cerebral cortex, cerebellar cortex, subcortical areas, and type: hemorrhagic or transient ischemic.
RESULTS: Of the 30 patients, 18 had ischemic stroke, 10 had hemorrhagic stroke, and 2 had transient stroke. Regarding the location, 10 lesions were in the cerebral cortex, 3 were in the cerebral and cerebellar cortices, 3 were in the cerebral cortex and subcortical areas, and 3 were in the cerebral and cerebellar cortices and subcortical areas. Cerebral cortex and subcortical area ischemic strokes predominated in the clinical evaluation of dysphagia. In FEES®, decreased laryngeal sensitivity persisted following cerebral cortex and ischemic strokes. Waste in the pharyngeal recesses associated with epiglottic valleculae predominated in the piriform cortex in all lesion areas and in ischemic stroke. A patient with damage to the cerebral and cerebellar cortices from an ischemic stroke exhibited laryngeal penetration and tracheal aspiration of liquid and honey.
CONCLUSION: Dysphagia was prevalent when a lesion was located in the cerebral cortex and was of the ischemic type.


Evaluation of Dysphagia in Early Stroke Patients by Bedside, Endoscopic, and Electrophysiological Methods

Umay EK, Unlu E, Saylam GK, Cakci A, Korkmaz H.

Dysphagia. 2013 Feb 5


We aimed in this study to evaluate dysphagia in early stroke patients using a bedside screening test and flexible fiberoptic endoscopic evaluation of swallowing (FFEES) and electrophysiological evaluation (EE) methods and to compare the effectiveness of these methods. Twenty-four patients who were hospitalized in our clinic within the first 3 months after stroke were included in this study. Patients were evaluated using a bedside screening test [including bedside dysphagia score (BDS), neurological examination dysphagia score (NEDS), and total dysphagia score (TDS)] and FFEES and EE methods. Patients were divided into normal-swallowing and dysphagia groups according to the results of the evaluation methods. Patients with dysphagia as determined by any of these methods were compared to the patients with normal swallowing based on the results of the other two methods. Based on the results of our study, a high BDS was positively correlated with dysphagia identified by FFEES and EE methods. Moreover, the FFEES and EE methods were positively correlated. There was no significant correlation between NEDS and TDS levels and either EE or FFEES method. Bedside screening tests should be used mainly as an initial screening test; then FFEES and EE methods should be combined in patients who show risks. This diagnostic algorithm may provide a practical and fast solution for selected stroke patients.


The influence of laterality of pharyngeal bolus passage on Dysphagia in hemiplegic stroke patients

Kim MS, Lee SJ, Kim TU, Seo DH, Hyun JK, Kim JI.

Ann Rehabil Med. 2012 Oct;36(5):696-701



To investigate swallowing laterality in hemiplegic patients with stroke and recovery of dysphagia according to the laterality.


The sample was comprised of 46 dysphagic patients with hemiplegia after their first stroke. The sample’s videofluoroscopic swallowing study (VFSS) was reviewed. Swallowing laterality was determined by the anterior-posterior view of VFSS. We measured width difference of barium sulfate liquid flow in the pharyngoesophageal segment. If there was double or more the width of that from the opposite width in the pharyngoesophageal segment more than twice on three trials of swallowing, then it was judged as having laterality. Subjects were assigned to no laterality (NL), laterality that is ipsilateral to hemiplegic side (LI), and laterality that is contralateral to hemiplegic side (LC) groups. We measured the following: prevalence of aspiration, the 8-point penetration-aspiration scale, and the functional dysphagia scale of the subjects at baseline and follow up.


Laterality was observed in 45.7% of all patients. Among them, 52.4% were in the hemiplegic direction. There was no significant difference between groups at baseline in all measurements. When we compared the changes in all measurements on follow-up study, there were no significant differences between groups.


Through this study, we found that there was no significant relation between swallowing laterality and the severity or prognosis of swallowing difficulty. More studies for swallowing laterality on stroke patients will be needed.

Swallowing screens after acute stroke: a systematic review

Schepp SK; Tirschwell DL; Miller RM; Longstreth WT
Stroke; 43(3): 869-71, 2012 Mar.
BACKGROUND AND PURPOSE: Swallowing screens after acute stroke identify those patients who do not need a formal swallowing evaluation and who can safely take food and medications by mouth. We conducted a systematic review to identify swallowing screening protocols that met basic requirements for reliability, validity, and feasibility.
METHODS: We searched MEDLINE and supplemented results with references identified through other databases, journal tables of contents, and bibliographies. All relevant references were reviewed and evaluated with specific criteria.
RESULTS: Of 35 protocols identified, 4 met basic quality criteria. These 4 had high sensitivities of ≥87% and high negative predictive values of ≥91% when a formal swallowing evaluation was used as the gold standard. Two protocols had greater sample sizes and more extensive reliability testing than the others.
CONCLUSIONS: We identified only 4 swallowing screening protocols for patients with acute stroke that met basic criteria. Cost-effectiveness of screening, including costs associated with false-positive results and impact of screening on morbidity, mortality, and length of hospital stay, requires elucidation.

Dysphagia in Stroke: A New Solution

Claire Langdon and David Blacker

Stroke Research and Treatment, Volume 2010 (2010), Article ID 57040



Dysphagia is extremely common following stroke, affecting 13%–94% of acute stroke sufferers.  It is associated with respiratory complications, increased risk of aspiration pneumonia, nutritional compromise and dehydration, and detracts from quality of life.  While many stroke survivors experience a rapid return to normal swallowing function, this does not always happen.  Current dysphagia treatment in Australia focuses upon prevention of aspiration via diet and fluid modifications, compensatory manoeuvres and positional changes, and exercises to rehabilitate paretic muscles.  This article discusses a newer adjunctive treatment modality, neuromuscular electrical stimulation (NMES), and reviews the available literature on its efficacy as a therapy for dysphagia with particular emphasis on its use as a treatment for dysphagia in stroke.
There is a good theoretical basis to support the use of NMES as an adjunctive therapy in dysphagia and there would appear to be a great need for further well-designed studies to accurately determine the safety and efficacy of this technique.


A review of the relationship between dysphagia and malnutrition following stroke

Norine C. Foley, Ruth E. Martin, Katherine L. Salter, Robert W. Teasell

J Rehabil Med 2009; 41: 707–713


Objective: To clarify the relationship between malnutrition and dysphagia following stroke.

Design: Systematic review.

Methods: All published trials that had examined both the swallowing ability and nutritional status of subjects following stroke were identified. Pooled analyses were performed to establish whether the odds of being malnourished were increased given the presence of dysphagia.

Results: Eight studies were identified. The presence of malnutrition and dysphagia ranged from 8.2% to 49.0% and 24.3% to 52.6%, respectively. Five of the included trials were conducted within the first 7 days following stroke, while 3 were conducted during the rehabilitation phase. The overall odds of being malnourished were higher among subjects who were dysphagic compared with subjects with intact swallowing (odds ratio: 2.425; 95% confidence interval: 1.264–4.649, p < 0.008). In subgroup analysis, the odds of malnutrition were significantly increased during the rehabilitation stage (odds ratio: 2.445; 95% confidence interval: 1.009–5.925, p < 0.048), but not during the first 7 days of hospital admission (odds ratio: 2.401; 95% confidence interval: 0.918–6.277, p < 0.074).

Conclusion: In a systematic review including the results from 8 studies, the odds of being malnourished were increased given the presence of dysphagia following stroke.



Andrea Santamato, Francesco Panza, Vincenzo Solfrizzi, Anna Russo, Vincenza Frisardi, Marisa Megna, Maurizio Ranieri, Pietro Fiore

J Rehabil Med 2009; 41: 639–645

Objective: To perform acoustic analysis of swallowing sounds, using a microphone and a notebook computer system, in healthy subjects and patients with dysphagia affected by neurological diseases, testing the positive/negative predictive value of a pathological pattern of swallowing sounds for penetration/aspiration.

Design: Diagnostic test study, prospective, not blinded, with the penetration/aspiration evaluated by fibreoptic endoscopy of swallowing as criterion standard.

Subjects: Data from a previously recorded database of normal swallowing sounds for 60 healthy subjects according to gender, age, and bolus consistency was compared with those of 15 patients with dysphagia from a university hospital referral centre who were affected by various neurological diseases.

Methods: Mean duration of the swallowing sounds and post-swallowing apnoea were recorded. Penetration/aspiration was verified by fibreoptic endoscopy of swallowing in all patients with dysphagia.

Results: The mean duration of swallowing sounds for a liquid bolus of 10 ml water was significantly different between patients with dysphagia and healthy patients. We also described patterns of swallowing sounds and tested the negative/positive predictive values of post-swallowing apnoea for penetration/aspiration verified by fibreoptic endoscopy of swallowing (sensitivity 0.67 (95% confidence interval 0.24–0.94); specificity 1.00 (95% confidence interval 0.56–1.00)).

Conclusion: The proposed technique for recording and measuring swallowing sounds could be incorporated into the bedside evaluation, but it should not replace the use of more diagnostic and valuable measures.


. Predictive factors for removal of percutaneous endoscopic gastrostomy tube in post-stroke dysphagia

Yi Y, Yang EJ, Kim J, Kim WJ, Min Y, Paik NJ.

J Rehabil Med. 2012 Nov 5;44(11):922-5. doi: 10.2340/16501977-1050.


Objective: To investigate predictive factors for percutaneous endoscopic gastrostomy (PEG) removal, thereby minimizing unnecessary PEG insertion in post-stroke dysphagia.

Design: Retrospective cohort study. Patients: A total of 49 patients who undertook PEG tube insertion for post-stroke dysphagia

Methods: Patients were divided into a removal group (n = 8) and a sustaining group (n = 41) depending on the presence of a PEG tube. Patients’ demographic data, nutritional status, Charlson’s Comorbidity Index (CCI), and video-fluoroscopic swallowing study findings at the time of PEG insertion were compared between the 2 groups.

Results: Eight out of 49 patients (16.3%) removed the PEG tube at a mean of 4.8 months after the insertion. Demographic data, nutritional status, and CCI were comparable between the 2 groups before tube insertion. Video-fluoroscopic swallowing study findings in the removal group showed a lower prevalence of premature bolus loss (50.0% vs 73.2%; p = 0.032), aspiration (37.5% vs 80.6%; p = 0.012) and pharyngeal trigger delay (12.5% vs 74.2%; p = 0.010) than those in the sustaining group.

Conclusion: The absence of aspiration or pharyngeal trigger delay in video-fluoroscopic swallowing study findings at the time of PEG insertion may be a predictive factor for eventual removal of PEG tubes. Identification of removal factors will assist in determining PEG insertion.


Interventions for dysphagia in acute stroke

Bath PM; Bath FJ; Smithard DG

Cochrane Database Syst Rev; (2): CD000323, 2000.

BACKGROUND: It is unclear how dysphagic patients should be fed and treated after acute stroke.

OBJECTIVES: The objective of this review was to assess the effect of different management strategies for dysphagic stroke patients, in particular how and when to feed, whether to supplement nutritional intake, and how and whether to treat dysphagia.

SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register, Medline, Embase, ISI, and existing review articles. We contacted researchers in the field and equipment manufacturers. Date of the most recent searches: March 1999.

SELECTION CRITERIA: Unconfounded truly or quasi randomised controlled trials in dysphagic patients with acute/subacute (within 3 months) stroke.

DATA COLLECTION AND ANALYSIS: Three reviewers independently applied the trial inclusion criteria. Two reviewers assessed trial quality and extracted the data.

MAIN RESULTS: Percutaneous endoscopic gastrostomy (PEG) versus nasogastric tube (NGT) feeding: two trials (49 patients) suggest that PEG reduces end-of-trial case fatality (Peto Odds Ratio, OR 0.28, 95% CI 0.09 to 0.89) and treatment failures (OR 0.10, 95% CI 0.02 to 0.52), and improves nutritional status, assessed as weight (Weighted Men Difference, WMD +4.1 kg, 95% CI -4.3 to +12.5), mid-arm circumference (WMD +2.2 cm, 95% CI -0.5 to +4.9) or serum albumin (WMD + 7.0 g/l, 95% CI +4.9 to +9.1) as compared with NGT feeding; two larger studies are ongoing. Timing of feeding: no completed trials; one large study is ongoing. Swallowing therapy for dysphagia: two trials (85 patients) suggest that formal swallowing therapy does not significantly reduce end-of-trial dysphagia rates (OR 0.55, 95% CI 0.18 to 1.66). Drug therapy for dysphagia: one trial (17 patients); nifedipine did not alter end-of-trial case fatality or the frequency of dysphagia. Nutritional supplementation: one trial (42 patients) found a non-significant trend to a lower case fatality, and significantly increased energy and protein intake; one large trial is ongoing and data is awaited from two other studies. Fluid supplementation: one trial (20 patients) found that supplementation did not alter the time to resolution of dysphagia.

REVIEWER’S CONCLUSIONS: Too few studies have been performed, and these have involved too few patients. PEG feeding may improve outcome and nutrition as compared with NGT feeding. Further research is required to assess how and when patients are fed, and the effect of swallowing or drug therapy on dysphagia.


Enteral nutrition in patients with dementia and stroke

Freeman C; Ricevuto A; DeLegge MH
Curr Opin Gastroenterol; 26(2): 156-9, 2010 Mar.
PURPOSE OF REVIEW: Patients suffering from dementia or significant cognitive impairment (SCI) due to neurologic injury routinely receive percutaneous endoscopic gastrostomy (PEG) due to swallowing difficulty or lack of appetite. This review discusses current data and opinion regarding the risks and benefits of PEG in these populations.
RECENT FINDINGS: The current data regarding PEG placement in patients with dementia or SCI due to neurologic injury do not confirm either improvement or worsening of survival. Significant risk factors for poor prognosis after PEG include sex, hypoalbuminemia, age, chronic heart failure, and subtotal gastrectomy. Complications associated with enteral nutrition are minor and easily controlled when managed by a nutritional team. Alternative options for feeding elderly demented patients are available for family members considering PEG.
SUMMARY: In contrast to previously published data regarding worse clinical outcomes in the dementia and SCI populations receiving PEG, recent data suggest that clinical outcomes in this population are no different than in other patient populations receiving PEG. A prospective, randomized study is needed to ascertain whether PEG is appropriate and beneficial in the dementia/SCI populations.