Dysphagia is prevalent among individuals with acute stroke. Studies suggest that dysphagia occurs in >42% of patients with acute stroke within a median of 3 days from stroke diagnosis. Dysphagia contributes significantly to stroke patients' overall morbidity and mortality; many of these patients regain functional swallowing spontaneously over time, but in some, the disability is long-term [1,2]. The temporal profile of swallowing recovery in patients with hemispheric infarcts remains poorly delineated. Variables that influence the recovery of swallowing function have not been well established. Bihemispheric infarcts, right hemisphere infarcts, dysarthria, intubation, the National Institute of Health Stroke Scale (NIHSS) ≥12, aspiration during videofluoroscopic swallowing study, and age greater than 52 years were significant predictors of persistent dysphagia [3,4,5,6].

Patients with persistent dysphagia require a long-term treatment modality for nutrition and hydration in order to be discharged home to inpatient rehabilitation (IPR) or to long-term care facilities. Gastrostomy (percutaneous endoscopic gastrostomy [PEG]) placement has become a preferred method for long-term feeding in patients with dysphagia incurred from stroke. Compared with nasogastric tube (NGT) feeding, PEG reduced intervention failures (e.g., feeding interruption, blocking or leakage of the tube, non-adherence to treatment and gastrointestinal bleeding), and had higher feed delivery and albumin concentration [7,8].

Previous studies have shown that early PEG placement (within 2 weeks) is effective to support nutritional and hydration needs as many patients with dysphagia have protracted oral feeding difficulties [9]. Despite the high mortality seen in the first few months after PEG insertion, some of the stroke patients that survive long-term have been able to attain a reasonable level of function in their daily activities [9]. Improvement in swallow function and eating often leads to PEG tube removal. Previous research has shown that up to one-third of the PEG tubes were removed before the patients were discharged from rehabilitation and 75% were removed by 1 year [10,11].

Prediction of recovery of functional swallowing may allow setting expectations for patients and family members when PEG is recommended, and deferral of PEG in cases where recovery is likely within the subacute phase of stroke rehabilitation. We sought to determine the predictors of early recovery of functional swallowing among stroke patients discharged to IPR centers. We have provided additional evidence that younger age, left sided strokes, and hemorrhagic strokes are associated with more functional swallowing recovery and have explored additional predictive factors in our patient population.

We retrospectively reviewed consecutive patients with acute stroke presenting at our medical center from July 2008 to August 2012. Upon hospital admission, all patients received a dysphagia screen administered by the intensive care unit nursing staff. Within 24 hours of the admission, a bedside clinical swallow assessment by a speech and language therapist was performed, unless the patient was unable to participate. The second screening method was videofluoroscopic swallowing assessment, referred to as modified barium swallow study or MBSS; this was administered unless the patient was unable to participate or a diet was recommended based on lack of aspiration predictors on the bedside clinical swallow assessment. The decision for PEG insertion was individualized to each patient through the interdisciplinary evaluations that indicated enteral tube feeding was necessary to avoid further loss of body weight, to correct significant nutritional deficiencies, to rehydrate the patient, and to stop the related deterioration in the quality of life of the patient due to inadequate or unsafe oral nutritional intake. The interdisciplinary evaluations included sequential neurological assessments of the patient's ability/inability to participate in swallow assessments; sequential assessments of swallow function on clinical/bedside and/or MBSS with the speech-language pathologist; sequential adequacy of nutritional assessments with a dietician; and gastroenterology consult and/or general surgery consult to assess for patient's surgical candidacy for PEG insertion.

We identified patients who had PEG placement and the discharge disposition of these patients. We reviewed the discharge summaries from the IPR admission for all the patients who went to IPR with a PEG tube and identified patients who regained functional swallowing and patients who remained PEG dependent.

We collected information about age, gender, race, exposure to thrombolytic therapy, intubation, type of stroke (ischemic and hemorrhagic), localization of the stroke (right, left, bilateral, cortical, subcortical), length of hospitalization, antidepressant and neurostimulant treatment and stroke-related complications, including urinary tract infection and pneumonia. We compared demographics, stroke risk factors and characteristics, NIHSS scores on admission and at discharge, stroke admission events and discharge medications in patients who remained PEG-dependent after IPR with those who recovered functional swallowing. All NIHSS examinations were performed by NIHSS-certified healthcare providers. We also compared IPR length of stay and disposition after IPR in those who remained PEG-dependent after IPR with those who recovered functional swallowing.

We identified several potential predictors of early recovery of functional swallow, including younger age, left-sided stroke, and exposure to antidepressant medication. Our finding of younger age predicting swallow recovery is in keeping with another study (n=77) [6].

Our study suggests that patients with right-sided strokes are less likely to recover swallowing than left sided strokes. Swallowing musculature is represented on the cortices of both hemispheres but displays interhemispheric asymmetry, independent of handedness, with larger representation on the right hemisphere for volitional swallowing [3,13,14,15,16,17]. Following stroke, dysphagia has been reported to be associated with a smaller pharyngeal representation on the intact hemisphere [15]. This finding may be related to the larger representation of swallow function on the right hemisphere and greater risk of silent laryngeal penetration and aspiration with right-sided strokes [5,16,18]. Patients who were on antidepressants at discharge to IPR had a significantly higher swallow recovery percentage than those not treated. Antidepressant exposure has been associated with better outcomes in ischemic stroke patients (n=49-118) although these results are controversial [19,20,21]. Studies using transcranial magnetic stimulation found an increased excitability of the affected areas in the brain after intake of a single dose of a serotonergic drug by stroke patients [22]. The influence on excitability of the motor cortices presumably modulates brain plasticity and thereby the relearning of motor function after stroke. Improvement in dysphagia in our sample could be due to overall improvement of patient functionality, in other words antidepressants increased brain plasticity, that's why these patients are more capable of relearning how to swallow. In our study, patient functionality could not be assessed given lack of randomization of antidepressant administration and prospective standardized documentation of modified Rankin Scale after discharge from IPR.

In our study, hemorrhagic stroke was associated with significantly higher odds of having PEG placed. While hemorrhagic stroke tends to be more severe than ischemic stroke [23,24], we found no relationship of baseline or discharge NIHSS with recovery of functional swallow. Interestingly, hemorrhagic strokes were more likely to recover functional swallowing than ischemic strokes. While our results failed to reach statistical significance, the difference in swallowing recovery in intracranial hemorrhage patients relative to acute ischemic stroke patients is clinically significant. Even though a previous retrospective study (n=65) reported that neglect, facial weakness and dysarthria were more frequent in patients with less swallowing recovery [25], our results showed no association of these symptoms with remaining PEG dependent. We were unable to compare recovery of swallow based on infratentorial vs. supratentorial stroke location, due to very small numbers of patients who were discharged to IPR with PEG placement after infratentorial stroke.

Similar proportions of patients completed MBSS or had impaired mental status that prevented complete assessment of dysphagia in the two groups. Due to low numbers of patients, we were unable to demonstrate that aspiration on MBSS predicted persistent dependence on PEG feeds. The impaired level of consciousness prevented performance of a MBSS and would have prevented adequate caloric consumption had a functional swallow been documented. Presence of cortical involvement of stroke was not associated with better or worse swallowing recovery.

Patients who recovered swallowing were more likely to be discharged home from IPR than patients who remained PEG dependent. Discharge home after stroke is associated with tremendous lifetime cost savings (almost 20% direct costs) compared with chronic custodial care [26].

Our study is one of the few limiting the analyses to patients who are discharged to IPR after PEG was placed, during the admission for new stroke. A similar study [6] had a much lower discontinuation rate for PEG use after a substantially longer IPR stay. Since our overall PEG rate was lower than in the previous study, it is unlikely that our center has a lower threshold for PEG placement. Worse stroke severity could account for the difference in discontinuation rate, but NIHSS scores were not included in the earlier report. Younger age, as in our study, was found to be predictive of PEG removal prior to discharge from IPR.

Our study is not without limitations. It is limited by its small sample size and retrospective nature. Due to small sample size constraints we were limited in what we could adjust for in the final models. We decided on the variables in the final models based on model fit statistics and clinical relevance. Despite its limitations, our study is one of the few studies that have investigated factors predicting early PEG removal. Our study contributes additional evidence for some of the factors already identified, age and side of stroke. Further, we observed antidepressant use and hemorrhagic strokes, a previously unreported factor, to be predictors of early PEG removal. We recommend these predicting factors to be taken into consideration when deciding whether to place PEG or not, in patients with potential for rapid swallow recovery. Due to the exploratory nature of this manuscript we intend to investigate these findings in the future with more generalizable population and a prospective study to prove the utility of these predicting factors and the benefit of deferring PEG placement in patients who meet certain criteria.

Although PEG represents a safer and more effective intervention to manage long-term dysphagia [27], the efficacy of its use in the acute phase of stroke recovery (<3 weeks) is disputable [28]. Further research is needed to assess the clinically effective timing of PEG placements to support functional recovery of activity participation (including oral nutrition and hydration) among patients with acute stroke. Identification of predictors of swallow recovery could aid in setting expectations for duration of PEG when discussing PEG placement, determining which patients may be able to defer PEG placement and the risks and expenses that ensue by opting for continuation of NGT feeds while anticipating recovery of swallow function. Predictors of swallow recovery could also allow for negotiating with IPR medical directors to accept patients with short term modalities of enteral feeding (e.g., NGTs).