Background: For the early detection of post-stroke dysphagia (PSD), valid screening parameters are crucial as part of a step-wise diagnostic procedure. This study examines the role of the National Institute of Health Stroke Scale (NIH-SS) as a potential low-threshold screening parameter. Methods: During a ten-year period, 687 newly admitted patients at University Hospital Muenster were included in a retrospective analysis, if they had ischemic or haemorrhagic stroke confirmed by neuroimaging and had received NIH-SS scoring and endoscopic swallowing evaluation upon admission. The NIH-SS score was correlated with dysphagia severity as measured by the validated 6-point fiberoptic endoscopic dysphagia severity score (FEDSS), and the ideal cut-off score to predict PSD, defined as FEDSS > 1, was calculated. Supra- and infratentorial strokes were analysed separately due to their differing role in the pathophysiology of neurogenic dysphagia. Results: NIH-SS and dysphagia severity show a significant positive correlation in the whole study population (R2 = 0.745) as well as in both analysed subgroups (R2 = 0.494 for supra- and R2 = 0.646 for infratentorial strokes, p < 0.0005, respectively). For supratentorial strokes, the ideal NIH-SS cut-off is > 9 (sensitivity 68.3%, specificity 61.5%, positive predictive value 89.7%, negative predictive value 28.4%). For infratentorial strokes, a lower ideal cut-off > 5 was calculated (sensitivity 67.4%, specificity 85.0%, positive predictive value 95.1%, negative predictive value 37.8%). Conclusions: NIH-SS may be used as an adjunct to predict dysphagia in acute stroke patients with moderate sensitivity and specificity. Differentiation between supra- and infratentorial regions is essential not to miss dysphagia in infratentorial stroke.

Keywords:
Acute stroke management, Dysphagia, Dysphagia screening, National Institute of Health Stroke Scale, Post stroke dysphagia
1.
Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R: Dysphagia after stroke: Incidence, diagnosis, and pulmonary complications. Stroke 2005; 36: 2756–2763.
2.
Smithard DG, Smeeton NC, Wolfe CD: Long-term outcome after stroke: does dysphagia matter? Age ageing 2007; 36: 90–94.
3.
Teasell R, Foley N, Fisher J, Finestone H: The incidence, management, and complications of dysphagia in patients with medullary strokes admitted to a rehabilitation unit. Dysphagia 2002; 17: 115–120.
4.
Joundi RA, Martino R, Saposnik G, Giannakeas V, Fang J, Kapral MK: Predictors and outcomes of dysphagia screening after acute ischemic stroke. Stroke 2017; 48: 900–906.
5.
Grube MM, Koennecke HC, Walter G, Meisel A, Sobesky J, Nolte CH, Wellwood I, Heuschmann PU: Influence of acute complications on outcome 3 months after ischemic stroke. PLoS One 2013; 8:e75719.
6.
Suntrup-Krueger S, Minnerup J, Muhle P, Claus I, Schröder JB, Marian T, Warnecke T, Kalic M, Berger K, Dziewas R: The effect of improved dysphagia care on outcome in patients with acute stroke: trends from 8-year data of a large stroke register. Cerebrovasc Dis 2018; 45: 101–108.
7.
Bray BD, Smith CJ, Cloud GC, Enderby P, James M, Paley L, Tyrrell PJ, Wolfe CD, Rudd AG: The association between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated pneumonia. J Neurol Neurosurg Psychiatry 2017; 88: 25–30.
8.
Rofes L, Vilardell N, Clavé P: Post-stroke dysphagia: progress at last. Neurogastroenterol Motil 2013; 25: 278–282.
9.
Dziewas R, Beck AM, Clave P, Hamdy S, Heppner HJ, Langmore SE, Leischker A, Martino R, Pluschinski P, Roesler A, Shaker R, Warnecke T, Sieber CC, Volkert D, Wirth R: Recognizing the importance of dysphagia: stumbling blocks and stepping stones in the twenty-first century. Dysphagia 2017; 32: 78–82.
10.
Etges CL, Scheeren B, Gomes E, Barbosa Lde R: Screening tools for dysphagia: a systematic review. Codas 2014; 26: 343–349.
11.
Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S: Formal dysphagia screening protocols prevent pneumonia. Stroke 2005; 36: 1972–1976.
12.
Leder SB, Espinosa JF: Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia 2002; 17: 214–218.
13.
Young FB, Weir CJ, Lees KR: Comparison of the National Institutes of Health Stroke Scale with disability outcome measures in acute stroke trials. Stroke 2005; 36: 2187–2192.
14.
Jeyaseelan RD, Vargo MM, Chae J: National Institutes of Health Stroke Scale (NIHSS) as an early predictor of poststroke dysphagia. PM R 2015; 7: 593–598.
15.
Toscano M, Cecconi E, Capiluppi E, Viganò A, Bertora P, Campiglio L, Mariani C, Petolicchio B, Sasso D'Elia T, Verzina A, Vicenzini E, Fiorelli M, Cislaghi G, Di Piero V: Neuroanatomical, clinical and cognitive correlates of post-stroke dysphagia. Eur Neurol 2015; 74: 171–177.
16.
Okubo PCMI, Fábio SRC, Domenis DR, Takayanagui OM: Using the National Institute of Health Stroke Scale to predict dysphagia in acute ischemic stroke. Cerebrovasc Dis 2012; 33: 501–507.
17.
Bravata DM, Daggett VS, Woodward-Hagg H, Damush T, Plue L, Russell S, Allen G, Williams LS, Harezlak J, Chumbler NR: Comparison of two approaches to screen for dysphagia among acute ischemic stroke patients: nursing admission screening tool versus National Institutes of Health stroke scale. J Rehabil Res Dev 2009; 46: 1127–1134.
18.
Henke C, Foerch C, Lapa S: Early screening parameters for dysphagia in acute ischemic stroke. Cerebrovasc Dis 2017; 44: 285–290.
19.
Ribeiro PW, Cola PC, Gatto AR, da Silva RG, Luvizutto GJ, Braga GP, Schelp AO, de Arruda Henry MA de, Bazan R: Relationship between Dysphagia, National Institutes of Health Stroke Scale Score, and predictors of pneumonia after ischemics. J Stroke Cerebrovasc Dis 2015; 24: 2088–2094.
20.
Suntrup S, Meisel A, Dziewas R, Ende F, Reichmann H, Heuschmann P, Ickenstein GW: Dysphagiediagnostik und -therapie des akuten Schlaganfalls: Eine bundesweite Erhebung auf zertifizierten stroke-units. Der Nervenarzt 2012; 83: 1619–1624.
21.
Flader CM, Rosendahl C, Günther T: Leitlinienkonforme Dysphagiediagnostik: Eine repräsentative Befragung von Logopäden an zertifizierten stroke-units. Der Nervenarzt 2017; 88: 1168–1176.
22.
Linfante I, Llinas RH, Schlaug G, Chaves C, Warach S, Caplan LR: Diffusion-weighted imaging and National Institutes of Health Stroke Scale in the acute phase of posterior-circulation stroke. Arch Neurol 2001; 58: 621–628.
23.
Flowers HL, Skoretz SA, Streiner DL, Silver FL, Martino R: MRI-based neuroanatomical predictors of dysphagia after acute ischemic stroke: a systematic review and meta-analysis. Cerebrovasc Dis 2011; 32: 1–10.
24.
Prosiegel M, Riecker A, Weinert M, Dziewas R, Lindner-Pfleghar B, Stanschus S, Warnecke T: Dysphagiemanagement in der akuten Schlaganfallphase. Der Nervenarzt 2012; 83: 1590–1599.
25.
Perry L: Screening swallowing function of patients with acute stroke. Part one: identification, implementation and initial evaluation of a screening tool for use by nurses. J Clin Nurs 2001; 10: 463–473.
26.
Falsetti P, Acciai C, Palilla R, Bosi M, Carpinteri F, Zingarelli A, Pedace C, Lenzi L: Oropharyngeal dysphagia after stroke: Incidence, diagnosis, and clinical predictors in patients admitted to a neurorehabilitation unit. J Stroke Cerebrovasc Dis 2009; 18: 329–335.
27.
Dziewas R, Warnecke T, Olenberg S, Teismann I, Zimmermann J, Kramer C, Ritter M, Ringelstein EB, Schabitz WR: Towards a basic endoscopic assessment of swallowing in acute stroke – development and evaluation of a simple dysphagia score. Cerebrovasc Dis 2008; 26: 41–47.
28.
Warnecke T, Ritter MA, Kroger B, Oelenberg S, Teismann I, Heuschmann PU, Ringelstein EB, Nabavi DG, Dziewas R: Fiberoptic endoscopic dysphagia severity scale predicts outcome after acute stroke. Cerebrovasc Dis 2009; 28: 283–289.
29.
Dziewas R, Sörös P, Ishii R, Chau W, Henningsen H, Ringelstein EB, Knecht S, Pantev C: Neuroimaging evidence for cortical involvement in the preparation and in the act of swallowing. Neuroimage 2003; 20: 135–144.
30.
Lang IM: Brain stem control of the phases of swallowing. Dysphagia 2009; 24: 333–348.
31.
Walter U, Knoblich R, Steinhagen V, Donat M, Benecke R, Kloth A: Predictors of pneumonia in acute stroke patients admitted to a neurological intensive care unit. J Neurol 2007; 254: 1323–1329.
32.
Brogan E, Langdon C, Brookes K, Budgeon C, Blacker D: Dysphagia and factors associated with respiratory infections in the first week post stroke. Neuroepidemiology 2014; 43: 140–144.
33.
Flowers HL, Silver FL, Fang J, Rochon E, Martino R: The incidence, co-occurrence, and predictors of dysphagia, dysarthria, and aphasia after first-ever acute ischemic stroke. J Commun Disord 2013; 46: 238–248.
© 2018 S. Karger AG, Basel
2018
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.