National Institutes of Health Stroke Scale Assists in Predicting
the Need for Percutaneous Endoscopic Gastrostomy Tube
Placement in Acute Ischemic Stroke
Amer Alshekhlee, MD, MSc, Nishant Ranawat, MD, Tanvir U. Syed, MD, MPH,
Devon Conway, MD, Saef A. Ahmad, MD, and Osama O. Zaidat, MD, MSc
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 infor-
mation 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 classi-
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
tion, and aspiration pneumonia. Hierarchical analysis showed that patients with as-
piration pneumonia and NIHSS score $12 had the highest likelihood (relative risk
findings indicate that the presence of pneumonia and high NIHSS score are the best
predictors for requiring PEG tube insertion in patients with ischemic stroke. These
and possible cost savings. Key Words: NIH stroke scale—PEG—pneumonia.
? 2010 by National Stroke Association
Dysphagia is prominent symptom, occurring in more
than half of hospitalized patients with acute ischemic
stroke.1Poststroke dysphagia can lead to dehydration,
malnutrition, and decreased functional independence.2,3
Furthermore, pharyngeal aspiration leading to aspiration
pneumonia is the most important acute complication of
dysphagia, affecting up to one-thirdof patients with acute
ischemic stroke. For this reason, dysphagia significantly
affects outcome, especially in the elderly population.4
The use of a nasogastric tube or percutaneous endoscopic
gastrostomy (PEG) are both effective for early nutrition;
the latter method is associated with fewer tube failures
and perhaps a lower risk of aspiration pneumonia.
Studies comparing stroke outcomes in patients treated
with nasogastric tube versus PEG tubes favored the latter,
due to fewer tube misplacements and replacements and
better nutritional status.5,6This was not corroborated by
the FOOD Trial Collaboration, however; that large Euro-
pean trial found essentially similar outcomes in both
Center, Case Western Reserve University, Cleveland, Ohio and De-
partment of Neurology, Froedtert Hospital, Medical College of Wis-
consin, Milwaukee, Wisconsin.
Received June 21, 2009; revision received July 19, 2009; accepted
July 31, 2009.
Address correspondence to Amer Alshekhlee, MD, MSc, Depart-
ment of Neurology, University Hospitals Case Medical Center, Case
Western Reserve University, 11100 Euclid Avenue, Cleveland, OH
44106-5040. E-mail: email@example.com.
1052-3057/$ - see front matter
? 2010 by National Stroke Association
Journal of Stroke and Cerebrovascular Diseases, Vol. 19, No. 5 (September–October), 2010: pp 347-352
especially in the acute phase. Swallowing problems fol-
lowing acute stroke may persist or recur in some patients,
or develop later in the course of the illness.24We did not
collect information about the timing of PEG placement
from onset of stroke; however, the FOOD Trial Collabora-
tion suggested a lack of benefit in early nutrition (within 7
days of stroke onset).7Second, the impact of the stroke in-
terventions may rapidly influence outcomes, including
NIHSS score as well as the need for long-term PEG nutri-
tion. Although more patients in the PEG group received
interventions in our cohort, the impact of those interven-
tional therapies on the need for PEG was not clearly
shown, perhaps due to the small sample size. Third, infer-
ence of an association between aspiration pneumonia and
PEG placement can be difficult to determine; thus, we
attempted to avoid the circular thinking by including a
patient who developed hospital complications (including
aspiration pneumonia) before PEG placement. Clinicians
regarding PEG placement. Finally, although our study
was inclusive for all acute ischemic stroke syndromes, is-
chemic strokes in the anterior circulation constituted the
majority of the cases. An exclusive analysis of patients
with ischemic syndrome of the posterior cerebral circula-
tion may establish similar NIHSS predictability.
In conclusion, there is significant practice variation in
the use of PEG tube feeding for dysphagic stroke patients,
and definitive clinical guidelines governing the place-
ment of PEG tubes are not yet available. With this kept
in mind, an NIHSS score of 16 without evidence of aspi-
ration pneumonia and an NIHSS score of 12 with evi-
dence of aspiration pneumonia may assist in early
decision making for PEG tube insertion in patients with
acute ischemic stroke. Our study is retrospective, and se-
lection bias is a possibility; thus, larger prospective stud-
ies to validate these cutoff points are needed.
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