Introduction
In stroke patients, dysphagia is associated with poor long term outcome, aspiration pneumonia and high mortality. However, it is still difficult to evaluate the prognosis for dysphagia, aspiration pneumonia and death after stroke. The object of this study was to investigate the risk factors of swallowing recovery, aspiration pneumonia and all-cause mortality in patients with stroke.
Material and method
Participant - all acute ischemic stroke patients admitted to Kangbuk Samsung Hospital from 2011 to 2019. Inclusion criteria - (1) first acute ischemic stroke, confirmed by MRI (2) abnormal swallowing ability by a video fluoroscopic swallowing study (VFSS).
Exclusion criteria - 1) other cause of dysphagia such as neurodegerative disease, motor neuron disease, GBS etc. 2) recurrent ischemic stroke within 1 year after 1st ischemic stroke, 3) pre-existent dysphagia 4) VFSS done after 1month after onset.
Main outcome - Swallowing recovery (last DOSS level > 5), incidence of aspiration pneumonia, all-cause mortality. DOSS (Dysphagia outcome and severity scale) is assessment tool for swallowing function based on measures from VFSS (DOSS 1 & 2, non-oral feeding; DOSS 3~5 modified diet; DOSS 6 & 7, normal diet).
Statistics - Three separate Cox regression were used to evaluate prognostic factors of dysphagia, aspiration pneumonia and all-cause mortality. The variables were collected including sex, age at onset, initial and last DOSS, lesion of infarcts, baseline NIHSS. In addition, hypertension, diabetes mellitus, dyslipidemia, coronary artery disease, and atrial fibrillation were collected. We used the Kaplan-Meier method to identify log-rank test and generate a curves for the proportion of patients with recovery, aspiration pneumonia and mortality
Results
We enrolled 113 participants. In the multivariate analysis, only initial DOSS has statistically significant factor of swallowing recovery (13 % of non-oral feeding vs 36 % of modified diet). Last DOSS was significantly associated with occurrence of aspiration pneumonia in multivariate analysis (63 % of non-oral feeding; 36% of modified diet; 0 % of normal diet). Last DOSS and age were significant factors associated with all-cause mortality (85 % of non-oral feeding; 21 % of modified diet; 4% of normal diet& 9% of younger than 70 years old vs 33% of older than 70 years old).
Conclusion
Initial swallowing status is strongly associated with swallowing recovery in post-ischemic stroke patients. Persistant dysphagia can also affect aspiration pneumonia and all-cause mortality in these patients. Old age can be also prognostic factor of all-cause mortality. In other words, we can prevent aspiration pneumonia and death in post ischemic stroke dysphagia through well modified diet and management of swallowing function.
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