The incidence, co-occurrence, and predictors of dysphagia, dysarthria, and aphasia after first-ever acute ischemic stroke
Introduction
Survivors of acute stroke often experience co-occurring impairments, such as dysphagia, dysarthria and/or aphasia (Martin and Corlew, 1990, Trapl et al., 2004). Second to hemiparesis, these impairments are the most frequent neurological deficits in patients with first-ever acute ischemic stroke (Lubart et al., 2005). The incidence of dysphagia after stroke approximates 55% in the acute stage (Guyomard et al., 2009, Martino et al., 2005), while the incidence of dysarthria ranges between 25% (Lubart et al., 2005) and 42% (Lawrence et al., 2001) after first-ever acute ischemic stroke. Similarly, incidence figures for aphasia range from 23% (Lubart et al., 2005) to 35% (Tsouli, Kyritsis, Tsagalis, Virvidaki, & Vemmos, 2009) after first-ever acute ischemic stroke. Few studies have reported the co-occurrence of these three impairments after acute stroke. Lapointe and McFarland (2004) documented that 79% of their acute stroke patients with dysphagia had concomitant communication impairments, such as dysarthria, aphasia, and voice and cognitive communication impairments. Trapl et al. (2004) reported that 10% of their acute stroke patients had both dysarthria and aphasia. Given the paucity of literature addressing the incidence of dysphagia and of these co-occurring impairments after first-ever acute ischemic stroke, further investigation is warranted to estimate their incidence.
Previous studies have documented clinical predictors of dysphagia including previous stroke with physical disability (Guyomard et al., 2009), advancing age (Guyomard et al., 2009), and atrial fibrillation (Gattellari, Goumas, Aitken, & Worthington, 2011). Likewise, previous studies have demonstrated that stroke with disability (Guyomard et al., 2009) and advancing age (Bersano et al., 2009, Engelter et al., 2006, Guyomard et al., 2009, Inatomi et al., 2008, Tsouli et al., 2009) predict aphasia. Additional previously reported predictors of aphasia include stroke severity (Inatomi et al., 2008), female gender (Bersano et al., 2009), atrial fibrillation (Bersano et al., 2009, Engelter et al., 2006, Inatomi et al., 2008, Tsouli et al., 2009), cardioembolism (Engelter et al., 2006), and the presence of multiple etiologies for ischemic stroke (Engelter et al., 2006). To the best of our knowledge, there are no known clinical predictors of dysarthria (Kumral, Çelebisoy, Çelebisoy, Canbaz, & Çalli, 2007) or of these three co-occurring impairments after acute stroke. Only two of the studies reporting predictors for dysphagia (Gattellari et al., 2011) and aphasia (Engelter et al., 2006) provided results for first-ever acute ischemic stroke samples. Consequently, clinically driven predictive models of these impairments are still needed within homogeneous samples of first-ever acute ischemic stroke patients.
Oropharyngeal dysphagia can lead to malnutrition (Crary et al., 2013), dehydration (Crary et al., 2013), aspiration pneumonia (Martino et al., 2005) and death (Altman, Yu, & Schaefer, 2010). The impact of dysarthria after stroke may include social and emotional disruptions and patient sentiments of stigmatization (Dickson, Barbour, Brady, Clark, & Paton, 2008). Aphasia is a major source of disability, incurring increased use of rehabilitation services (Dickey et al., 2010) and increased cost of care (Ellis, Simpson, Bonilha, Mauldin, & Simpson, 2012). It also has negative economic repercussions, such as decreased return to work (Dalemans et al., 2008, Ross Graham et al., 2011). Given these potentially detrimental outcomes, it is important to identify the incidence and precursors of dysphagia, dysarthria, and aphasia after stroke. Estimating their incidence, identifying risk factors that predict their presence, and describing clinical practice behaviors related to their assessment will aid in developing measures to improve management early in the acute stages of stroke.
Among stroke subtypes, ischemic etiology is the most frequent cause of stroke, followed by intracerebral hemorrhage and then subarachnoid hemorrhage (Broderick et al., 1993, Kumral et al., 1998). Recent advances in neuroimaging include routine magnetic resonance (MR) imaging in acute stroke (Keir and Wardlaw, 2000, Schaefer et al., 2000, Tan et al., 2006). Magnetic resonance imaging with diffusion-, T1-, and T2-weighted scans facilitates the diagnosis of stroke etiology and confirms the presence of an acute versus previous stroke. Specifically, diffusion weighted imaging (DWI) is most sensitive to acute ischemic stroke (Mullins et al., 2002, Prichard and Grossman, 1999), distinguishing an acute stroke from a previous stroke better than T2-wieghted MR (Fazekas et al., 2009, Van Everdingen et al., 1998) or computed tomography (Barber et al., 1999, Lansberg et al., 2000). Magnetic resonance with diffusion weighted imaging is currently the gold standard for diagnosing acute cerebral ischemia with a sensitivity of 88% and a specificity of 95% (Lovblad et al., 1998). Acute stroke protocols often include the acquisition of DWI scans along with standard T1 and T2 scans (Tan et al., 2006). Given the recent availability of MR scan techniques, researchers have begun to describe impairments such as dysphagia (Cola et al., 2010), dysarthria (Kumral et al., 2007), aphasia (Joinlambert et al., 2012), and apraxia of speech (Hillis et al., 2004, Richardson et al., 2012) following MR confirmed acute stroke. To extend and corroborate these preliminary studies, it is important to further document the incidence and co-occurrence of these frequent impairments in a homogeneous sample of first-ever acute ischemic stroke, confirmed by MR imaging.
Despite the growing body of literature reporting the incidence and clinical predictors of isolated impairments after stroke, many previous studies failed to delineate results according to stroke etiology and recurrence. Many also varied in their definitions of acute stroke, leading to differences in the timing of acute stage assessments. These methodological differences likely contributed to variations in the reported incidence of dysphagia, dysarthria, and aphasia. To address these gaps in the literature, we selected consecutive patients with acute ischemic stroke, confirmed by diffusion-weighted MR imaging.
Our purpose was to identify epidemiological attributes and risk factors for three frequent impairments: dysphagia, dysarthria and aphasia. On an exploratory basis, we also recorded the reported frequency of apraxia of speech (AOS), recognizing that its differential identification might be determined exclusively in patients seen by speech language pathologists (SLP) for treatment planning. Our primary objectives were two-fold. First, we sought to estimate the incidence and co-occurrence of dysphagia, dysarthria, and aphasia. Second, we proposed to identify their demographic and clinical predictors and to explore clinical practice behaviors related to their assessment.
Section snippets
Operational definitions
We defined dysphagia to be “oropharyngeal dysphagia”, characterized by abnormal swallowing physiology of the upper aerodigestive tract and detected by clinical examination, instrumental assessment (Martino et al., 2005), or insertion of enteral feeding. We defined aphasia to be an acquired language impairment, characterized by anomia (Helm-Estabrooks & Albert, 1991) and/or other language deficits (Chapey & Hallowell, 2001), evidenced in any language modality (Chapey & Hallowell, 2001) and
Results
From July 1, 2003 to March 31, 2008, there were 3162 consecutive patients with possible stroke, of whom 981 had sustained a first-ever ischemic stroke (Fig. 1). Demographic characteristics for these 981 patients included a mean age of 71 years and male gender for 53% (Table 1). Seven hundred and sixteen (73%) had an MRI scan. Comparisons of those with MRI scans (n = 716) to those without (n = 265) demonstrated significant differences for age [p < .0001], Canadian Neurological Scale (CNS) score [p <
Discussion
This study is the first to estimate the incidence and co-occurrence of dysphagia, dysarthria and aphasia in a homogenous sample of patients with first-ever acute ischemic stroke confirmed by diffusion weighted MR imaging. Close to half the patients in our sample had dysphagia or dysarthria, and almost one-third had aphasia. In addition, close to one-third of all patients had both dysphagia and dysarthria, while 1 in 10 patients had all three impairments. Our exploration of the reported
Conflict of Interest Statement
The authors of this article have not reported any financial or non-financial conflict of interest.
Acknowledgements
This article was approved by the publication board of the Registry of the Canadian Stroke Network (RCSN). The RCSN receives an operating grant from the Ontario Ministry of Health and Long-Term Care. Results and conclusions of the current study should be attributed to the authors and not to funding organizations. The authors exclusively designed and conducted the study and also collected, analyzed, and interpreted the data.
The first author received funding from the Heart and Stroke Foundation of
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