National Institutes of Health Stroke Scale Assists in Predicting the Need for Percutaneous Endoscopic Gastrostomy Tube Placement in Acute Ischemic Stroke

Neurological Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio 44106-5040, USA.
Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association (Impact Factor: 1.67). 09/2010; 19(5):347-52. DOI: 10.1016/j.jstrokecerebrovasdis.2009.07.014
Source: PubMed


Percutaneous endoscopic gastrostomy (PEG) tubes are commonly needed for early nutrition in patients with acute ischemic stroke. We evaluated the relationship between the NIH Stroke Scale (NIHSS) score and the need for PEG tube placement. Patients with acute ischemic stroke were included in this study. We collected information on patient demographics, stroke severity as indicated by the NIHSS, and risk factors for vascular disease. We ascertained the swallowing evaluation and PEG tube placement during the same hospitalization. A hierarchical optimal classification tree was determined for the best predictors. A total of 187 patients (mean age, 67.2 years) were included, only 33 (17.6%) of whom had a PEG tube placed during the course of hospitalization. Those who had the PEG were slightly older (73.8 vs 65.8 years), had severe stroke (median NIHSS score, 18 vs 4), and a longer hospital stay (median 12 vs 4 days). Independent predictors for PEG placement included bulbar symptoms at onset, higher NIHSS score, stroke in the middle cerebral artery distribution, and aspiration pneumonia. Hierarchical analysis showed that patients with aspiration pneumonia and NIHSS score >or=12 had the highest likelihood (relative risk [RR] = 4.67; P < .0001) of requiring a PEG tube. In the absence of pneumonia, NIHSS score >or=16 yielded a moderate likelihood of requiring PEG (RR = 1.80; P < .0001). Our findings indicate that the presence of pneumonia and high NIHSS score are the best predictors for requiring PEG tube insertion in patients with ischemic stroke. These findings may have benefits in terms of early decision making, shorter hospitalization, and possible cost savings.

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    • "Multiple studies conducted over the last three decades suggest that PEG is a safe and effective means of providing long-term enteral nutrition.1–6 A number of studies have demonstrated the effectiveness of enteral feeding using PEG tubes in in patients with CVD/hypoxia, dysphagia, head and neck cancer and head trauma20–30. Our data adds to this information in a Turkish population of hospitalized adults with CVD, cerebral hypoxia, cranial trauma, head and neck cancers, and MND. "
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    ABSTRACT: BACKGROUND / OBJECTIVES The aim of this study was to perform a retrospective analysis characterizing patients receiving tube feeding following percutaneous endoscopic gastrostomy ( PEG) tube placement between 2004 and 2012 at Erciyes University Hospital in Turkey. METHODS Patients above the age of 18 years, who required long term enteral tube feeding were studied. All PEGs were performed using the pull-through technique by one experienced endoscopist Demographic, clinical outcomes, and PEG-related complication data were collected. RESULTS Of the 128 subjects studied, 91 were male (71%) and 37 were female (29%). The mean age of this patient population was 54±19 years. The most common reason for PEG tube insertion was inability to consume oral diet due to complications of cerebrovascular disease (CVD; 27%), while cerebral hypoxia, occuring after non-neurological medical disorders, was the second most common indication (23%). A total of 70 patients (55%) had chronic comorbidities, with hypertension the most common (20%). The most common procedure related complication was insertion site bleeding, which occurred in 4 % of patients. Long term complications, during one year were insertion site cellulitis, gastric contents leakage, and peristomal ulceration occurred in 14%, 5%, and 0.5% of patients, respectively. There were no PEG insertion-related mortalities; one-year mortality was unrelated to the indication for PEG tube insertion. CONCLUSIONS PEG tube insertion was a safe method to provide enteral access for nutrition support in this hospitalized patient population.
    Full-text · Article · Feb 2014 · European journal of clinical nutrition
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    • "A randomization software (minim.exe, Department of Bioengineering , Salford Royal NHS Trust) was used for the process of minimization to evenly distribute patients of different age (above or below 80) and stroke severity (scoring <12 or !12 on the National Institute of Health stroke Severity Scale (NIHSS) [26] [27]). One independent researcher delivered the real or sham stimulation, while those researchers analyzing the data remained blinded to the procedure. "
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    ABSTRACT: Background Swallowing problems following stroke may result in increased risk of aspiration pneumonia, malnutrition, and dehydration. Objective/hypothesis Our hypothesis was that three neurostimulation techniques would produce beneficial effects on chronic dysphagia following stroke through a common brain mechanism that would predict behavioral response. Methods In 18 dysphagic stroke patients (mean age: 66 ± 3 years, 3 female, time-post-stroke: 63 ± 15 weeks [±SD]), pharyngeal electromyographic responses were recorded after single-pulse transcranial magnetic stimulation (TMS) over the pharyngeal motor cortex, to measure corticobulbar excitability before, immediately, and 30 min, after real and sham applications of neurostimulation. Patients were randomized to a single session of either: pharyngeal electrical stimulation (PES), paired associative stimulation (PAS) or repetitive TMS. Penetration-aspiration scores and bolus transfer timings were assessed before and after both real and sham interventions using videofluoroscopy. Results Corticobulbar excitability of pharyngeal motor cortex was beneficially modulated by PES, PAS and to a lesser extent by rTMS, with functionally relevant changes in the unaffected hemisphere. Following combining the results of real neurostimulation, an overall increase in corticobulbar excitability in the unaffected hemisphere (P = .005, F1,17 = 10.6, ANOVA) with an associated 15% reduction in aspiration (P = .005, z = −2.79) was observed compared to sham. Conclusions In this mechanistic study, an increase in corticobulbar excitability the unaffected projection was correlated with the improvement in swallowing safety (P = .001, rho = −.732), but modality-specific differences were observed. Paradigms providing peripheral input favored change in neurophysiological and behavioral outcome measures in chronic dysphagia patients. Further larger cohort studies of neurostimulation in chronic dysphagic stroke are imperative.
    Full-text · Article · Dec 2013 · Brain Stimulation
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    • "In previous studies, several clinical factors were found to have a relationship with dysphagia following stroke such as older age, stroke severity, disturbed consciousness, speech abnormalities, presence of cortical signs, absence of the gag reflex, large cortical or insular lesions, and bihemispheric lesions [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17]. However, relatively few studies identified the predictors for the long-term prognosis of swallowing function or PEG placement over several months [8] [9] [14] [18]. "
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    ABSTRACT: Objective: A single-center, observational study was performed to identify the predictors for oral intake 3 months after onset in stroke patients with severe dysphagia. Methods: Of 4972 consecutive acute stroke patients, 723 could not eat orally on day 10. Three months after onset, a questionnaire was sent to all patients. Those who survived and replied to the questionnaire were divided into 2 groups, and the clinical factors that predicted their acquisition of oral intake were analyzed. Results: Of the 586 dysphagic patients who responded, 141 (24.2%) achieved oral intake after 3 months. On logistic-regression model analysis, age ≤ 80 years, hyperlipidemia, non-cardioembolic stroke, modified Rankin Scale score 0 before onset, and National Institutes of Health Stroke Scale (NIHSS) score were independently related to oral intake 3 months after onset. From two different model analyses, NIHSS score ≤ 17 on day 10 (OR 3.58, 95% CI, 2.35-5.54) was found to be a stronger predictor for oral intake than NIHSS score ≤ 17 on admission (OR 2.17, 95% CI, 1.40-3.39). Conclusion: In severely dysphagic acute stroke patients, functional independence at baseline, younger age, absence of hyperlipidemia, non-cardioembolic stroke, and a milder NIHSS score on day 10 are useful predictors of the resumption of oral intake.
    Full-text · Article · Sep 2012 · Journal of the neurological sciences
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