Dysphagia assessment in ischemic stroke after mechanical thrombectomy: When and how?

Abstract

BackgroundDysphagia is a frequent symptom in acute ischemic stroke (AIS). Endovascular treatment (EVT) has become the standard of care for acute stroke secondary to large vessel occlusion. Although standardized guidelines for poststroke dysphagia (PSD) management exist, they do not account for this setting in which patients receive EVT under general anesthesia. Therefore, the aim of this study was to evaluate PSD prevalence and severity, as well as an appropriate time point for the PSD evaluation, in patients undergoing EVT under general anesthesia (GA).MethodsWe prospectively included 54 AIS patients undergoing EVT under GA. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) was performed within 24 h post-extubation in all patients. Patients presenting significant PSD received a second FEES-assessment to determine the course of dysphagia deficits over time. Dysphagia severity was rated according the Fiberoptic Dysphagia Severity Scale (FEDSS).ResultsAt first FEES (FEES 1) assessment, performed in the median 13 h (IQR 5–17) post-extubation, 49/54 patients (90.7%) with dysphagia were observed with a median FEDSS of 4 (IQR 3–6). Severe dysphagia requiring tube feeding was identified in 28/54 (51.9%) subjects, whereas in 21 (38.9%) patients early oral diet with certain food restrictions could be initiated. In the follow up FEES examination conducted in the median 72 h (IQR 70–97 h) after initial FEES 34/49 (69.4%) patients still presented PSD. Age (p = 0.030) and ventilation time (p = 0.035) were significantly associated with the presence of PSD at the second FEES evaluation. Significant improvement of dysphagia frequency (p = 0.006) and dysphagia severity (p = 0.001) could be detected between the first and second dysphagia assessment.ConclusionsPSD is a frequent finding both immediately within 24 h after extubation, as well as in the short-term course. In contrast to common clinical practice, to delay evaluation of swallowing for at least 24 h post-extubation, we recommend a timely assessment of swallowing function after extubation, as 50% of patients were safe to begin oral intake. Given the high amount of severe dysphagic symptoms, we strongly recommend application of instrumental swallowing diagnostics due to its higher sensitivity, when compared to clinical swallowing examination. Furthermore, advanced age, as well as prolonged intubation, were identified as significant predictors for delayed recovery of swallowing function.

Early flexible endoscopic evaluation of swallowing after mechanical thrombectomy in stroke patients

“…In these cohorts the prevalence of dysphagia varied between 61% and 93%. 8,[30][31][32] FEES-confirmed aspiration occurred in almost half of the patients in our study population, and it was found in 45%-81% of patients in previous studies. [30][31][32][33] There is, however, a significant selection bias in studies using instrumental assessment of swallowing in acute stroke patients, which can influence not only the prevalence of dysphagia and aspiration risk but also the specific findings of swallowing impairment.…”

“…There are relatively few studies which systematically assessed swallowing in acute ischaemic stroke patient cohorts using FEES. In these cohorts the prevalence of dysphagia varied between 61% and 93% 8,30–32 . FEES‐confirmed aspiration occurred in almost half of the patients in our study population, and it was found in 45%–81% of patients in previous studies 30–33 .…”

“…Mechanical thrombectomy (MT), with or without intravenous thrombolysis, has become the standard of care for acute stroke patients with large vessel occlusion in the last decade 7 . There are few studies addressing the frequency and characteristics of dysphagia and the performance of dysphagia screening tests in this group of patients, and there are still open questions related to the optimal strategy of swallowing assessment 8,9 . Current international guidelines for the diagnosis of post‐stroke dysphagia recommend a detailed dysphagia assessment for stroke patients who fail a dysphagia screen and for patients who present risk factors for post‐stroke dysphagia 10 .…”

“… 7 There are few studies addressing the frequency and characteristics of dysphagia and the performance of dysphagia screening tests in this group of patients, and there are still open questions related to the optimal strategy of swallowing assessment. 8 , 9 Current international guidelines for the diagnosis of post‐stroke dysphagia recommend a detailed dysphagia assessment for stroke patients who fail a dysphagia screen and for patients who present risk factors for post‐stroke dysphagia. 10 A detailed dysphagia assessment, including comprehensive clinical swallowing assessment and instrumental swallowing assessment, allows not only to identify the presence of dysphagia and the risk of aspiration, but is also able to further characterize the type and severity of dysphagia and to provide dietary recommendations.…”

Acute Dysphagia Following Reperfusion Therapies: A Prospective Pilot Cohort Study

“…Following this, a 2022 single-site German study investigated dysphagia post-EVT via Fiberoptic Endoscopic Evaluation of Swallowing (FEES). The study included patients who were identified as at risk of dysphagia (failure of a water swallowing test, moderate dysarthria/aphasia, facial palsy, and NIHSS score of five or greater) [ 11 ]. Of the patients who were identified as at risk, n = 54/89 underwent FEES within 24 h, with a second FEES conducted following 72 h for patients who presented with dysphagia in the initial FEES only ( n = 41) [ 11 ].…”