Prolonged impairment of deglutition in supratentorial ischaemic stroke: the predictive value of Parramatta Hospitals' Assessment of Dysphagia.

Abstract

Up to 50% of ischaemic stroke patients show initial dysphagia, which may persist for months. Guidelines recommend switching nasogastric (NG) to percutaneous endoscopic gastrostomy (PEG) tube feeding at the second week after the stroke if impaired deglutition is expected for another 4 weeks. Precise prognostic criteria are lacking. We hypothesised that the Parramatta Hospitals' Assessment of Dysphagia (PAHD) performed 8 to 10 days after the stroke predicts impaired deglutition for another 4 weeks. After a first dysphagia assessment (buccolingual motor function, liquid and semisolid swallow tests, "two-out-of-six" scale) within 48 hours of onset, patients with a first hemispheric stroke and risk of aspiration, defined as a two-out-of-six scale score of ≥2 (dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, cough / voice change after swallowing) were included and were assessed by a blinded rater using the PHAD. The same dysphagia assessments were repeated 8 to 10 days after the stroke (second assessment) and patients remained in the study if the two-out-of-six scale score remained ≥2. At a final evaluation by telephone after 4 weeks, impaired deglutition was assessed with the Bogenhausen dysphagia score (BODS-2). Exclusion criteria were infratentorial or recurrent stroke and pre-existing dysphagia. The primary objective was to define a threshold score and value of the PHAD at second assessment that predicted impaired deglutition as assessed with the BODS-2 (score ≥4) at the final evaluation. The secondary objective was to explore the value of the PHAD assessed within 48 hours to predict impaired deglutition (BODS-2 ≥4) at final evaluation. To evaluate the predictive value of the PHAD score assessed 8 to 10 days after stroke onset for impaired deglutition for another 4 weeks, we determined the area under the receiver operating curve (ROC AUC). Over a 1-year period, 29 out of 252 assessed patients remained at risk of aspiration after the second assessment. In these patients, ROC analysis of PHAD recorded 8 to 10 days after the stroke showed excellent accuracy with an AUC of 0.971 (cut-off 71.5) predicting a BODS-2 score of ≥4 at final evaluation. The accuracy of ROC analysis of the PHAD score assessed within 48 hours of stroke onset to predict prolonged impairment of deglutition was poor (AUC 0.685). In a selected population at risk of aspiration, the PHAD with a threshold of 70 assessed in the second week after stroke onset may be a valuable tool to predict prolonged impairment of deglutition for another 4 weeks and to guide the decision about switching from NG to PEG tube feeding after supratentorial ischaemic stroke.