Introduction: In patients with stroke, poststroke dysphagia (PSD) is a common complication that plays an important role in morbidity and mortality. The aim of this paper was to assess the prevalence and risk factors of PSD using a systemic review and meta-analysis. Methods: PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched for potentially eligible studies published until September 2023. Further, the pooled incidence and risk factors for PSD were determined using a random-effects model. Overall, 58 studies involving 37,404 patients with acute stroke were selected for the meta-analysis. Results: The pooled incidence of PSD in patients with acute stroke was 42% (95% confidence interval [CI]: 36–48%), which is the highest in South America (47%) and lowest in Asia (37%). Notably, older age (odds ratio [OR]: 2.13; 95% CI: 1.53–2.97; p < 0.001), hypertension (OR: 1.23; 95% CI: 1.06–1.44; p = 0.007), diabetes mellitus (OR: 1.22; 95% CI: 1.04–1.44; p = 0.014), stroke history (OR: 1.26; 95% CI: 1.04–1.53; p = 0.019), and atrial fibrillation (OR: 1.58; 95% CI: 1.02–2.44; p = 0.039) were found to be associated with an increased risk of PSD. Conversely, sex differences, smoking, alcoholism, obesity, hyperlipidemia, ischemic heart disease, stroke type, and the hemisphere affected were not associated with the risk of PSD. Conclusion: The abstract reports the prevalence of PSD in patients with acute stroke and identified potential risk factors for PSD, including older age, hypertension, diabetes mellitus, stroke history, and atrial fibrillation.

Poststroke dysphagia (PSD) is one of the most common complications of stroke, with an estimated frequency of 30–80% [1‒4]. A previous study reported that spontaneous recovery occurs during the first few weeks after stroke, although approximately 50% of stroke survivors still present with swallowing abnormalities 6 months after stroke [5]. It has been reported that PSD is associated with an increased risk of various life-threatening complications, including aspiration pneumonia, malnutrition, and dehydration, which is associated with longer hospital stays [6‒8]. Thus, the prevalence and risk factors for PSD should be determined to screen high-risk patients for preventing the progression of PSD and reducing its socioeconomic burden.

Previous studies have focused on impairments in swallowing related to the location and size of lesions or on the prognosis of patients with PSD [9‒13]. They have reported that swallowing function is regulated by the medulla oblongata, and pharyngeal residue, vocal cord paralysis, dysarthria, and abnormal laryngeal elevation could be caused by pathological changes in the medulla oblongata [14, 15]. Furthermore, swallowing function has been reported to be regulated by the cortical and subcortical regions of the brain, and the recovery of this function could be affected by the superior corona radiata [13, 16]. However, patient-specific factors involved in the progression of PSD remain poorly explored.

Given that patient-specific factors are significantly associated with health outcomes at multiple levels, understanding the underlying conditions and biological and socioeconomic risk factors for PSD could allow screening of high-risk patients and provision of preventive care to improve the severity and prognosis of stroke [17, 18]. Thus, this systematic review and meta-analysis aimed to identify the prevalence and potential risk factors for PSD, which could help determine patients at high risk of PSD and improve stroke management in clinical practice to prevent the progression of swallowing disorders.

Data Sources, Search Strategy, and Selection Criteria

This study was conducted and reported in accordance with the Meta-analysis of Observational Studies in Epidemiology guidelines [19]. Epidemiology studies that investigated the prevalence or risk factors for PSD were considered eligible for meta-analysis, regardless of the publication language. PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched for studies published until September 2023, and the key search terms were as follows: dysphagia AND stroke AND (“prevalence” OR “incidence” OR “epidemiology” OR “risk factor” OR “predictor”) (online suppl. Material 1; for all online suppl. material, see https://doi.org/10.1159/000538218). Further, the reference lists of the relevant articles were manually reviewed to identify any new eligible studies.

Two reviewers independently conducted a literature search and study screening, and any conflicts between them were resolved through a mutual discussion by reviewing the full-text of the articles. Studies including patients with acute stroke, regardless of the type of stroke, and those reporting the prevalence or risk factors of PSD were considered eligible for this study. Notably, all included studies were epidemiological, including cross-sectional, case-control, retrospective cohort, or prospective cohort studies. Meanwhile, case reports, case series, and review articles were excluded.

Data Extraction and Quality Assessment

Data including authors’ name, publication year, study design, country, sample size, mean age, proportion of males, stroke type and phase, diagnostic methods, number of PSDs, time of PSDs, and reported outcomes were independently extracted by two reviewers. The Newcastle-Ottawa scale (NOS) was used to assess the methodological quality of each study in the meta-analysis; notably, the scale included three domains with eight items, and NOS scores for each study ranged from 0 to 9 [20]. Studies scoring 7–9 were considered to have high quality, and those scoring 4–6 were considered to have moderate quality. Two reviewers conducted the quality assessment for each study, and any disagreement between them was resolved by a third reviewer by referring to the original article.

Statistical Analysis

The number of patients with both PSD and stroke was calculated to assess the prevalence of PSD in patients with stroke, and the pooled incidence of PSD was calculated using a random-effect model with a logit transformation [21]. The restricted maximum likelihood estimation was used to fit all models with a classic continuity correction of 0.5 for zero cells and sample sizes [21]. Furthermore, the pooled risk factors for PSD were calculated using the random-effects model, considering the underlying differences among studies [21]. Heterogeneity was evaluated using the I2 and Cochran’s Q statistics, and significant heterogeneity was defined by I2 > 50.0% or p < 0.10 [22, 23]. The stability of the pooled results was assessed using a sensitivity analysis by sequential removal of individual studies [24]. The prevalence of PSD was stratified by country, and subgroup analyses were performed for risk factors for PSD according to the study design and country. Furthermore, differences between subgroups were assessed using the interaction t test, assuming that the data met the normal distribution [25]. Publication bias for the investigated outcomes was assessed using funnel plots, Egger test, and Begg test [26, 27]. All reported p values for the pooled results were two-sided, and the inspection level was 0.05. STATA software was used for all statistical analyses (version 12.0; Stata Corporation, College Station, TX, USA).

Literature Search and Study Selection

The search of electronic databases yielded 2,946 records, and 2,174 articles remained after the removal of duplicates. Further, 1,923 articles were excluded during the review of the titles and abstracts, and the remaining 251 studies were retrieved for full-text evaluations. After a detailed evaluation, 193 studies were removed because of the following reasons: they were not considered epidemiology studies (n = 112), they had insufficient data (n = 65), and they were review articles (n = 16). Further, a review of the reference lists yielded 13 potential studies for inclusion, and all studies with duplicate articles were removed. Finally, the remaining 58 studies were selected for meta-analysis (Fig. 1) [28‒85].

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart for literature search and study selection.

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart for literature search and study selection.

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Study Characteristics

The characteristics of the included studies and patients are summarized in Table 1. In total, 37,404 patients with acute stroke were included, and the sample size ranged from 30 to 12,276. Overall, 37, 17, and 4 studies with prospective cohort, retrospective cohort, and cross-sectional designs were included, respectively. Notably, 32 studies included both patients with ischemic and those with hemorrhagic stroke, 22 studies included patients with ischemic stroke, and the remaining 4 studies included patients with hemorrhagic stroke. The methodological quality of the included studies was assessed using NOS as follows: 6 studies scored 9, 11 studies scored 8, 29 studies scored 7, 8 studies scored 6, and the remaining 4 studies scored 5.

Table 1.

The baseline characteristics of identified studies and involved patients

Author, yearsStudy designCountrySample sizeMean age, yearsMale, %Type and phase of strokeDiagnostic methodsNumber of PSDTimepoint of PSD assessNOS
Gordon et al. [28], 1987 Prospective Italy 91 70 41.8 Type: IS and HS; phase: acute WST 41 Within 48 h 
Barer [29], 1989 Prospective UK 357 70 52.9 Type: IS and HS; phase: acute WST 105 Within 48 h 
Odderson et al. [30], 1995 Prospective USA 124 75 39.5 Type: IS; phase: acute WST 48 Within 24 h 
Gottlieb et al. [31], 1996 Prospective Israel 180 74 47.8 Type: IS and HS; phase: acute WST 51 Within 48 h 
Mann and Hankey [32], 2001 Prospective Australia 128 71 63.3 Type: IS and HS; phase: acute WST 82 Within 72 h 
Teasell et al. [33], 2002 Retrospective Canada 20 56 75.0 Type: IS and HS; phase: acute VFSS 11 Within 48 h 
Broadley et al. [34], 2003 Prospective Australia 149 72 59.1 Type: IS; phase: acute WST 74 Within 72 h 
Paciaroni et al. [35], 2004 Prospective Italy 406 73 54.7 Type: IS and HS; phase: acute WST 141 Within 24 h 
Schelp et al. [36], 2004 Prospective Brazil 102 62 64.7 Type: IS and HS; phase: acute WST 78 Within 72 h 
Crary et al. [37], 2006 Prospective USA 76 66 47.4 Type: IS; phase: acute MASA 40 Within 72 h 
Hamidon et al. [38], 2006 Prospective Malaysia 134 64 50.0 Type: IS; phase: acute WST 55 Within 7 days 
Kwon et al. [39], 2006 Prospective Korea 286 63 67.1 Type: IS and HS; phase: acute WST 96 Within 5 days 
Smithard et al. [40], 2007 Prospective UK 1,188 70 47.7 Type: IS and HS; phase: acute WST 567 Within 7 days 
Huang et al. [41], 2007 Retrospective China 563 22–95 58.3 Type: IS; phase: acute SDCSS 75 Within 24 h 
Sundar et al. [42], 2008 Prospective India 50 65 46.0 Type: IS; phase: acute SSA 21 Within 48 h 
Guyomard et al. [43], 2009 Retrospective UK 2,983 78 44.7 Type: IS and HS; phase: acute WST 1506 Within 48 h 
Turner-Lawrence et al. [44], 2009 Prospective USA 84 62 56.0 Type: IS and HS; phase: acute WST 48 Within 24 h 
Hasan et al. [45], 2010 Prospective Iraq 72 61 55.6 Type: IS and HS; phase: acute MASA 41 Within 7 days 
Remesso et al. [46], 2011 Retrospective Brazil 596 65 50.5 Type: IS; phase: acute NODAS 117 Within 14 days 
Suntrup et al. [48], 2012 Prospective Germany 30 71 53.3 Type: HS; phase: acute FEES 23 Within 72 h 
Zhang et al. [49], 2012 Prospective China 106 71 NA Type: IS; phase: acute WST 20 Within 48 h 
Cong et al. [47], 2012 Retrospective China 496 65 49.4 Type: IS; phase: acute WST 103 At admission 
Crary et al. [50], 2013 Prospective USA 67 66 43.3 Type: IS; phase: acute MASA 25 Within 48 h 
Shibazaki et al. [51], 2014 Prospective Japan 97 68 56.7 Type: HS; phase: acute V-VST 57 Within 24 h 
Suntrup et al. [52], 2015 Prospective Germany 200 74 50.5 Type: IS and HS; phase: acute FEES 165 Within 96 h 
Toscano et al. [53], 2015 Prospective Italy 275 73 50.2 Type: IS and HS; phase: acute WST 121 Within 48 h 
Zhang et al. [54], 2015 Prospective China 760 65 51.8 Type: IS and HS; phase: acute WST 482 Within 48 h 
Al-Khaled et al. [55], 2016 Prospective Germany 12,276 73 51.0 Type: IS; phase: acute WST 3,083 Within 3 h 
Flowers et al. [57], 2017 Retrospective Canada 160 66.7 56.9 Type: IS; phase: acute CWDS 76 Within 14 days 
Lapa et al. [59], 2017 Prospective Germany 59 68 54.2 Type: IS; phase: acute FEES 14 Within 24 h 
Abubakar et al. [56], 2017 Prospective Nigeria 94 56 56.4 Type: IS and HS; phase: acute WST 32 Within 72 h 
Henke et al. [58], 2017 Prospective Germany 1,646 70 55.5 Type: IS; phase: acute WST 413 Within 7 days 
Nam et al. [61], 2017 Retrospective Korea 308 68 62.3 Type: IS; phase: acute WST 58 Within 48 h 
Lendinez-Mesa et al. [60], 2017 Cross-sectional Spain 124 57 71.0 Type: IS and HS; phase: acute V-VST 58 Within 24 h 
Si et al. [62], 2017 Cross-sectional China 130 63 60.8 Type: IS and HS; phase: acute SSA 83 Within 24 h 
Yang et al. [65], 2018 Retrospective Korea 262 72 50.0 Type: IS; phase: acute VFSS 15 After admission 
Rofes et al. [64], 2018 Prospective Brazil 395 73 53.4 Type: IS and HS; phase: acute V-VST 178 Within 24 h 
Hao et al. [63], 2018 Retrospective China 177 70 65.5 Type: IS; phase: acute SSA 87 Within 24 h 
Beharry et al. [66], 2019 Retrospective New Zealand 340 76 54.1 Type: IS; phase: acute BDST 81 Within 24 h 
Braun et al. [67], 2019 Prospective Germany 152 73 61.8 Type: IS and HS; phase: acute FEES 110 After admission 
Carnaby et al. [68], 2019 Prospective USA 96 63 60.4 Type: IS and HS; phase: acute MASA 41 Within 24 h 
Ding et al. [69], 2019 Retrospective China 414 72 63.8 Type: IS and HS; phase: acute WST 72 Within 48 h 
Fernandez-Pombo et al. [70], 2019 Prospective Spain 106 72 54.7 Type: IS and HS; phase: acute V-VST 60 Within 72 h 
Gandolfo et al. [71], 2019 Prospective Italy 249 74 50.6 Type: IS and HS; phase: acute WST 94 Within 7 days 
Hernandez-Bello et al. [72], 2019 Prospective Spain 81 73 65.4 Type: IS and HS; phase: acute V-VST 10 Within 24 h 
De Cock et al. [73], 2020 Prospective Belgium 151 67 55.6 Type: IS and HS; phase: acute WST 35 Within 72 h 
Li et al. [74], 2020 Retrospective China 1,211 64 66.1 Type: IS; phase: acute WST 209 Within 24 h 
Diendere et al. [76], 2021 Prospective Burkina Faso 222 61 54.5 Type: IS and HS; phase: acute WST 83 Within 24 h 
Khedr et al. [78], 2021 Cross-sectional Egypt 250 55 46.4 Type: IS and HS; phase: acute WST 98 Within 72 h 
Cao et al. [75], 2021 Prospective China 542 60 71.0 Type: IS; phase: acute WST 202 Within 48 h 
Hess et al. [77], 2021 Retrospective Germany 132 72 59.1 Type: HS; phase: acute WST 84 Within 48 h 
Wu et al. [81], 2022 Retrospective China 4,877 59 41.5 Type: HS; phase: acute SDCSS 3,527 After admission 
Thu Hien et al. [80], 2022 Cross-sectional Vietnam 951 65 64.4 Type: IS; phase: acute GUSS 681 After admission 
Ghoreyshi et al. [79], 2022 Prospective Iran 100 63 56.0 Type: IS and HS; phase: acute MASA 36 After admission 
Mattavelli et al. [84], 2023 Retrospective Italy 228 76 52.0 Type: IS; phase: acute FOIS 126 After admission 
Huang et al. [82], 2023 Retrospective China 1,651 74 63.5 Type: IS and HS; phase: acute VFSS/FEES 189 After admission 
Silva et al. [85], 2023 Retrospective Portugal 250 76 55.2 Type: IS and HS; phase: acute GUSS 102 Within 48 h 
Londhe et al. [83], 2023 Prospective India 150 55 68.0 Type: IS and HS; phase: acute GUSS 64 Within 7 days 
Author, yearsStudy designCountrySample sizeMean age, yearsMale, %Type and phase of strokeDiagnostic methodsNumber of PSDTimepoint of PSD assessNOS
Gordon et al. [28], 1987 Prospective Italy 91 70 41.8 Type: IS and HS; phase: acute WST 41 Within 48 h 
Barer [29], 1989 Prospective UK 357 70 52.9 Type: IS and HS; phase: acute WST 105 Within 48 h 
Odderson et al. [30], 1995 Prospective USA 124 75 39.5 Type: IS; phase: acute WST 48 Within 24 h 
Gottlieb et al. [31], 1996 Prospective Israel 180 74 47.8 Type: IS and HS; phase: acute WST 51 Within 48 h 
Mann and Hankey [32], 2001 Prospective Australia 128 71 63.3 Type: IS and HS; phase: acute WST 82 Within 72 h 
Teasell et al. [33], 2002 Retrospective Canada 20 56 75.0 Type: IS and HS; phase: acute VFSS 11 Within 48 h 
Broadley et al. [34], 2003 Prospective Australia 149 72 59.1 Type: IS; phase: acute WST 74 Within 72 h 
Paciaroni et al. [35], 2004 Prospective Italy 406 73 54.7 Type: IS and HS; phase: acute WST 141 Within 24 h 
Schelp et al. [36], 2004 Prospective Brazil 102 62 64.7 Type: IS and HS; phase: acute WST 78 Within 72 h 
Crary et al. [37], 2006 Prospective USA 76 66 47.4 Type: IS; phase: acute MASA 40 Within 72 h 
Hamidon et al. [38], 2006 Prospective Malaysia 134 64 50.0 Type: IS; phase: acute WST 55 Within 7 days 
Kwon et al. [39], 2006 Prospective Korea 286 63 67.1 Type: IS and HS; phase: acute WST 96 Within 5 days 
Smithard et al. [40], 2007 Prospective UK 1,188 70 47.7 Type: IS and HS; phase: acute WST 567 Within 7 days 
Huang et al. [41], 2007 Retrospective China 563 22–95 58.3 Type: IS; phase: acute SDCSS 75 Within 24 h 
Sundar et al. [42], 2008 Prospective India 50 65 46.0 Type: IS; phase: acute SSA 21 Within 48 h 
Guyomard et al. [43], 2009 Retrospective UK 2,983 78 44.7 Type: IS and HS; phase: acute WST 1506 Within 48 h 
Turner-Lawrence et al. [44], 2009 Prospective USA 84 62 56.0 Type: IS and HS; phase: acute WST 48 Within 24 h 
Hasan et al. [45], 2010 Prospective Iraq 72 61 55.6 Type: IS and HS; phase: acute MASA 41 Within 7 days 
Remesso et al. [46], 2011 Retrospective Brazil 596 65 50.5 Type: IS; phase: acute NODAS 117 Within 14 days 
Suntrup et al. [48], 2012 Prospective Germany 30 71 53.3 Type: HS; phase: acute FEES 23 Within 72 h 
Zhang et al. [49], 2012 Prospective China 106 71 NA Type: IS; phase: acute WST 20 Within 48 h 
Cong et al. [47], 2012 Retrospective China 496 65 49.4 Type: IS; phase: acute WST 103 At admission 
Crary et al. [50], 2013 Prospective USA 67 66 43.3 Type: IS; phase: acute MASA 25 Within 48 h 
Shibazaki et al. [51], 2014 Prospective Japan 97 68 56.7 Type: HS; phase: acute V-VST 57 Within 24 h 
Suntrup et al. [52], 2015 Prospective Germany 200 74 50.5 Type: IS and HS; phase: acute FEES 165 Within 96 h 
Toscano et al. [53], 2015 Prospective Italy 275 73 50.2 Type: IS and HS; phase: acute WST 121 Within 48 h 
Zhang et al. [54], 2015 Prospective China 760 65 51.8 Type: IS and HS; phase: acute WST 482 Within 48 h 
Al-Khaled et al. [55], 2016 Prospective Germany 12,276 73 51.0 Type: IS; phase: acute WST 3,083 Within 3 h 
Flowers et al. [57], 2017 Retrospective Canada 160 66.7 56.9 Type: IS; phase: acute CWDS 76 Within 14 days 
Lapa et al. [59], 2017 Prospective Germany 59 68 54.2 Type: IS; phase: acute FEES 14 Within 24 h 
Abubakar et al. [56], 2017 Prospective Nigeria 94 56 56.4 Type: IS and HS; phase: acute WST 32 Within 72 h 
Henke et al. [58], 2017 Prospective Germany 1,646 70 55.5 Type: IS; phase: acute WST 413 Within 7 days 
Nam et al. [61], 2017 Retrospective Korea 308 68 62.3 Type: IS; phase: acute WST 58 Within 48 h 
Lendinez-Mesa et al. [60], 2017 Cross-sectional Spain 124 57 71.0 Type: IS and HS; phase: acute V-VST 58 Within 24 h 
Si et al. [62], 2017 Cross-sectional China 130 63 60.8 Type: IS and HS; phase: acute SSA 83 Within 24 h 
Yang et al. [65], 2018 Retrospective Korea 262 72 50.0 Type: IS; phase: acute VFSS 15 After admission 
Rofes et al. [64], 2018 Prospective Brazil 395 73 53.4 Type: IS and HS; phase: acute V-VST 178 Within 24 h 
Hao et al. [63], 2018 Retrospective China 177 70 65.5 Type: IS; phase: acute SSA 87 Within 24 h 
Beharry et al. [66], 2019 Retrospective New Zealand 340 76 54.1 Type: IS; phase: acute BDST 81 Within 24 h 
Braun et al. [67], 2019 Prospective Germany 152 73 61.8 Type: IS and HS; phase: acute FEES 110 After admission 
Carnaby et al. [68], 2019 Prospective USA 96 63 60.4 Type: IS and HS; phase: acute MASA 41 Within 24 h 
Ding et al. [69], 2019 Retrospective China 414 72 63.8 Type: IS and HS; phase: acute WST 72 Within 48 h 
Fernandez-Pombo et al. [70], 2019 Prospective Spain 106 72 54.7 Type: IS and HS; phase: acute V-VST 60 Within 72 h 
Gandolfo et al. [71], 2019 Prospective Italy 249 74 50.6 Type: IS and HS; phase: acute WST 94 Within 7 days 
Hernandez-Bello et al. [72], 2019 Prospective Spain 81 73 65.4 Type: IS and HS; phase: acute V-VST 10 Within 24 h 
De Cock et al. [73], 2020 Prospective Belgium 151 67 55.6 Type: IS and HS; phase: acute WST 35 Within 72 h 
Li et al. [74], 2020 Retrospective China 1,211 64 66.1 Type: IS; phase: acute WST 209 Within 24 h 
Diendere et al. [76], 2021 Prospective Burkina Faso 222 61 54.5 Type: IS and HS; phase: acute WST 83 Within 24 h 
Khedr et al. [78], 2021 Cross-sectional Egypt 250 55 46.4 Type: IS and HS; phase: acute WST 98 Within 72 h 
Cao et al. [75], 2021 Prospective China 542 60 71.0 Type: IS; phase: acute WST 202 Within 48 h 
Hess et al. [77], 2021 Retrospective Germany 132 72 59.1 Type: HS; phase: acute WST 84 Within 48 h 
Wu et al. [81], 2022 Retrospective China 4,877 59 41.5 Type: HS; phase: acute SDCSS 3,527 After admission 
Thu Hien et al. [80], 2022 Cross-sectional Vietnam 951 65 64.4 Type: IS; phase: acute GUSS 681 After admission 
Ghoreyshi et al. [79], 2022 Prospective Iran 100 63 56.0 Type: IS and HS; phase: acute MASA 36 After admission 
Mattavelli et al. [84], 2023 Retrospective Italy 228 76 52.0 Type: IS; phase: acute FOIS 126 After admission 
Huang et al. [82], 2023 Retrospective China 1,651 74 63.5 Type: IS and HS; phase: acute VFSS/FEES 189 After admission 
Silva et al. [85], 2023 Retrospective Portugal 250 76 55.2 Type: IS and HS; phase: acute GUSS 102 Within 48 h 
Londhe et al. [83], 2023 Prospective India 150 55 68.0 Type: IS and HS; phase: acute GUSS 64 Within 7 days 

BDST, Burke Dysphagia Screening Test; CWDS, speech language pathologists during clinical or instrumental assessment or documentation of enteral feeding tube insertion; FEES, flexible endoscopic evaluation of swallowing; FOIS, Functional Oral Intake Scale; GUSS, Gugging Swallow Screening; HS, hemorrhagic stroke; IS, ischemic stroke; MASA, Mann assessment of swallowing ability; NODAS, Neurogenic Oropharyngeal Dysphagia After Stroke; NOS, Newcastle-Ottawa scale; PSD, poststroke dysphagia; SDCSS, dysphagia clinical screening system; SSA, Standardized Bedside Swallowing Assessment; VFSS, videofluoroscopic swallowing study; V-VST, volume-viscosity swallow test; WST, Water Swallow Test.

SD Prevalence

After pooling all included studies, the pooled prevalence of PSD in patients with acute stroke was found to be 42% (95% confidence interval [CI]: 36–48%; Fig. 2), and there was significant heterogeneity among the included studies (I2 = 99.3%; p < 0.001). Sensitivity analysis revealed that the prevalence of PSD was stable and that the pooled incidence of PSD ranged from 41% to 42% (online suppl. Material 2). Meanwhile, subgroup analyses revealed that the prevalence of PSD in Europe, North America, the Middle East, Oceania, South America, Asia, and Africa was 44% (95% CI: 37–52%), 46% (95% CI: 41–52%), 40% (95% CI: 24–55%), 46% (95% CI: 20–71%), 47% (95% CI: 18–76%), 37% (95% CI: 23–50%), and 38% (95% CI: 34–42%), respectively. The results of the Egger test indicated no significant publication bias (p = 0.208), whereas those of the Begg test indicated a significant publication bias (p = 0.021) (online suppl. Material 3).

Fig. 2.

Pooled prevalence of PSD in patients with acute stroke.

Fig. 2.

Pooled prevalence of PSD in patients with acute stroke.

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Risk Factors for PSD

A total of 35 studies reported an association between sex and the risk of PSD in patients with acute stroke, and nonsignificant association in terms of sex difference for PSD (odds ratio [OR]: 0.93; 95% CI: 0.82–1.06; p = 0.278; Figure 3). Notably, significant heterogeneity was found among the included studies (I2 = 65.2%; p < 0.001). The sensitivity analysis revealed that the pooled conclusion was robust after sequentially removing single studies (online suppl. Material 2). Regarding the pooled studies from Europe, the subgroup analysis indicated that male sex was associated with a lower risk of PSD than female sex (Table 2). Furthermore, the association of sex with the risk of PSD could affect by study design (p < 0.001) and continent (p < 0.001). Although the Begg test indicated no significant publication bias (p = 0.989), the Egger test suggested a significant publication bias for sex difference in PSD (p = 0.001) (online suppl. Material 3).

Fig. 3.

Sex differences in the risk of PSD in patients with acute stroke.

Fig. 3.

Sex differences in the risk of PSD in patients with acute stroke.

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Table 2.

Subgroup analyses for risk factors of PSD

FactorsFactorsSubgroupsStudies, nOR and 95% CIp valueHeterogeneity (I2)Q statisticp value between subgroups
Male versus female Study design Prospective 20 0.92 (0.77–1.09) 0.341 63.4 <0.001 <0.001 
Retrospective 12 0.89 (0.75–1.06) 0.204 47.2 0.035 
Cross-sectional 1.24 (0.94–1.64) 0.134 0.0 0.5548 
Continent Africa 0.91 (0.58–1.42) 0.663 0.0 0.965 <0.001 
Asia 0.97 (0.75–1.26) 0.840 62.5 0.009 
Europe 15 0.85 (0.72–1.00) 0.046 66.0 <0.001 
Middle East 1.06 (0.57–1.98) 0.849 0.0 0.344 
North America 1.42 (0.84–2.38) 0.188 16.5 0.309 
Oceania 1.43 (0.41–5.00) 0.574 87.0 0.006 
South America 0.82 (0.53–1.27) 0.385 57.8 0.124 
Older age versus younger Study design Prospective 1.88 (1.38–2.57) <0.001 14.0 0.323 0.075 
Retrospective 2.12 (1.12–4.03) 0.022 88.5 <0.001 
Cross-sectional 3.49 (1.43–8.53) 0.006 69.0 0.072 
Continent Africa 1.19 (0.48–2.95) 0.707 0.288 
Asia 2.60 (1.58–4.27) <0.001 83.9 <0.001 
Europe 1.88 (1.34–2.66) <0.001 0.0 0.402 
Middle East 1.42 (0.48–4.19) 0.525 
Oceania 1.74 (0.77–3.93) 0.183 
Smoking Study design Prospective 1.46 (1.08–1.96) 0.013 43.5 0.150 0.025 
Retrospective 1.10 (0.89–1.36) 0.376 39.6 0.127 
Cross-sectional 0.72 (0.37–1.40) 0.329 0.0 0.349 
Continent Africa 0.72 (0.37–1.40) 0.329 0.0 0.349 0.369 
Asia 1.14 (0.89–1.46) 0.316 47.6 0.126 
Europe 1.29 (0.75–2.23) 0.359 80.3 0.006 
North America 1.20 (0.55–2.64) 0.646 26.0 0.245 
Oceania 1.38 (0.76–2.52) 0.294 
South America 1.27 (0.84–1.92) 0.257 
Alcoholism Study design Prospective 1.51 (0.88–2.60) 0.135 9.1 0.333 0.331 
Retrospective 1.11 (0.85–1.46) 0.448 0.0 0.814 
Continent Asia 1.20 (0.92–1.57) 0.188 0.0 0.883 0.347 
Europe 1.99 (0.54–7.30) 0.299 
North America 6.20 (0.71–54.46) 0.100 
South America 0.99 (0.59–1.66) 0.970 
Obesity Study design Prospective 0.92 (0.20–4.23) 0.918 76.5 0.039 0.997 
Retrospective 1.09 (0.53–2.25) 0.816 
Cross-sectional 1.08 (0.72–1.61) 0.720 0.0 0.529 
Continent Africa 1.43 (0.75–2.72) 0.282 0.0 0.774 0.210 
Asia 0.90 (0.54–1.51) 0.688 
Europe 1.37 (0.79–2.39) 0.268 0.0 0.336 
North America 0.40 (0.12–1.33) 0.134 
Hypertension Study design Prospective 11 1.24 (1.05–1.46) 0.012 29.6 0.164 0.075 
Retrospective 1.39 (1.00–1.94) 0.049 75.2 <0.001 
Cross-sectional 0.83 (0.53–1.31) 0.424 31.4 0.233 
Continent Africa 0.69 (0.39–1.22) 0.203 0.0 0.368 0.322 
Asia 1.48 (1.03–2.13) 0.032 81.2 <0.001 
Europe 1.09 (0.90–1.33) 0.364 37.9 0.140 
North America 1.57 (0.95–2.61) 0.080 0.0 0.418 
Oceania 1.42 (0.77–2.62) 0.262 
South America 1.25 (0.66–2.39) 0.495 69.8 0.069 
Diabetes mellitus Study design Prospective 11 1.25 (1.00–1.56) 0.048 51.5 0.024 0.789 
Retrospective 1.22 (0.90–1.68) 0.205 58.4 0.018 
Cross-sectional 1.19 (0.57–2.49) 0.652 72.3 0.027 
Continent Africa 1.20 (0.51–2.85) 0.680 60.2 0.081 0.721 
Asia 1.46 (0.97–2.19) 0.071 74.8 0.001 
Europe 1.08 (0.83–1.40) 0.576 52.2 0.051 
North America 1.09 (0.57–2.07) 0.794 30.4 0.238 
Oceania 0.98 (0.52–1.84) 0.950 
  South America 1.43 (0.94–2.17) 0.095 50.4 0.156  
Stroke history Study design Prospective 1.50 (1.09–2.05) 0.012 38.4 0.150 <0.001 
Retrospective 1.10 (0.85–1.41) 0.464 48.9 0.068 
Cross-sectional 1.50 (0.92–2.45) 0.105  
Continent Asia 1.21 (0.86–1.70) 0.264 67.9 0.025 <0.001 
Europe 1.47 (1.35–1.60) <0.001 0.0 0.494 
North America 0.69 (0.38–1.25) 0.223 0.0 0.342 
Oceania 0.72 (0.38–1.37) 0.318 
South America 1.61 (1.15–2.26) 0.006 0.0 0.710 
Hyperlipidemia Study design Prospective 1.05 (0.68–1.61) 0.821 76.9 0.002 0.016 
Retrospective 1.02 (0.76–1.36) 0.892 0.0 0.530 
Cross-sectional 1.85 (0.88–3.90) 0.105 0.0 0.648 
Continent Africa 1.85 (0.88–3.90) 0.105 0.0 0.648 0.121 
Asia 0.73 (0.23–2.33) 0.597 66.5 0.084 
Europe 1.15 (0.61–2.16) 0.676 87.5 <0.001 
North America 0.95 (0.59–1.53) 0.833 0.0 0.613 
Oceania 1.06 (0.58–1.95) 0.851 
South America 1.01 (0.68–1.51) 0.961 
Ischemic heart disease Study design Prospective 1.09 (0.73–1.62) 0.687 56.6 0.056 0.627 
Retrospective 1.56 (0.84–2.88) 0.156 
Cross-sectional 1.17 (0.24–5.81) 0.844 41.7 0.190 
Continent Africa 0.96 (0.25–3.71) 0.956 29.1 0.244 0.134 
Asia 1.56 (0.84–2.88) 0.156 
Europe 1.04 (0.71–1.50) 0.847 50.1 0.157 
North America 0.40 (0.11–1.50) 0.174 
  South America 1.78 (1.14–2.77) 0.011  
Atrial fibrillation Study design Prospective 1.38 (0.73–2.61) 0.323 92.5 <0.001 0.024 
Retrospective 1.46 (0.76–2.81) 0.260 70.8 0.033 
Cross-sectional 1.85 (0.06–54.21) 0.720 76.1 0.041 
Continent Africa 1.85 (0.06–54.21) 0.720 76.1 0.041 0.213 
Asia 1.17 (0.53–2.57) 0.696 
Europe 1.25 (0.68–2.30) 0.472 93.8 <0.001 
North America 1.60 (0.33–7.78) 0.560 
Oceania 2.56 (1.54–4.27) <0.001 
Stroke type (ischemic vs. hemorrhagic) Study design Prospective 0.66 (0.48–0.91) 0.010 0.0 0.522 0.238 
Retrospective 1.17 (0.59–2.31) 0.655 64.6 0.037 
Continent Asia 1.19 (0.57–2.50) 0.646 0.347 
Europe 0.81 (0.55–1.18) 0.268 47.3 0.077 
Middle East 0.43 (0.08–2.33) 0.327 0.0 0.979 
North America 0.56 (0.04–7.64) 0.664 
Oceania 2.31 (0.66–8.06) 0.189 
South America 0.55 (0.26–1.18) 0.123 
Hemisphere affected (left vs. right) Study design Prospective 1.23 (0.90–1.68) 0.188 49.5 0.054 0.048 
Retrospective 0.89 (0.68–1.17) 0.421 21.1 0.284 
Continent Asia 1.00 (0.62–1.61) 0.994 61.8 0.073 0.056 
Europe 1.07 (0.80–1.42) 0.661 32.2 0.207 
Middle East 2.57 (1.27–5.21) 0.009 17.5 0.271 
Oceania 0.98 (0.47–2.05) 0.957 
South America 0.87 (0.55–1.37) 0.547 
FactorsFactorsSubgroupsStudies, nOR and 95% CIp valueHeterogeneity (I2)Q statisticp value between subgroups
Male versus female Study design Prospective 20 0.92 (0.77–1.09) 0.341 63.4 <0.001 <0.001 
Retrospective 12 0.89 (0.75–1.06) 0.204 47.2 0.035 
Cross-sectional 1.24 (0.94–1.64) 0.134 0.0 0.5548 
Continent Africa 0.91 (0.58–1.42) 0.663 0.0 0.965 <0.001 
Asia 0.97 (0.75–1.26) 0.840 62.5 0.009 
Europe 15 0.85 (0.72–1.00) 0.046 66.0 <0.001 
Middle East 1.06 (0.57–1.98) 0.849 0.0 0.344 
North America 1.42 (0.84–2.38) 0.188 16.5 0.309 
Oceania 1.43 (0.41–5.00) 0.574 87.0 0.006 
South America 0.82 (0.53–1.27) 0.385 57.8 0.124 
Older age versus younger Study design Prospective 1.88 (1.38–2.57) <0.001 14.0 0.323 0.075 
Retrospective 2.12 (1.12–4.03) 0.022 88.5 <0.001 
Cross-sectional 3.49 (1.43–8.53) 0.006 69.0 0.072 
Continent Africa 1.19 (0.48–2.95) 0.707 0.288 
Asia 2.60 (1.58–4.27) <0.001 83.9 <0.001 
Europe 1.88 (1.34–2.66) <0.001 0.0 0.402 
Middle East 1.42 (0.48–4.19) 0.525 
Oceania 1.74 (0.77–3.93) 0.183 
Smoking Study design Prospective 1.46 (1.08–1.96) 0.013 43.5 0.150 0.025 
Retrospective 1.10 (0.89–1.36) 0.376 39.6 0.127 
Cross-sectional 0.72 (0.37–1.40) 0.329 0.0 0.349 
Continent Africa 0.72 (0.37–1.40) 0.329 0.0 0.349 0.369 
Asia 1.14 (0.89–1.46) 0.316 47.6 0.126 
Europe 1.29 (0.75–2.23) 0.359 80.3 0.006 
North America 1.20 (0.55–2.64) 0.646 26.0 0.245 
Oceania 1.38 (0.76–2.52) 0.294 
South America 1.27 (0.84–1.92) 0.257 
Alcoholism Study design Prospective 1.51 (0.88–2.60) 0.135 9.1 0.333 0.331 
Retrospective 1.11 (0.85–1.46) 0.448 0.0 0.814 
Continent Asia 1.20 (0.92–1.57) 0.188 0.0 0.883 0.347 
Europe 1.99 (0.54–7.30) 0.299 
North America 6.20 (0.71–54.46) 0.100 
South America 0.99 (0.59–1.66) 0.970 
Obesity Study design Prospective 0.92 (0.20–4.23) 0.918 76.5 0.039 0.997 
Retrospective 1.09 (0.53–2.25) 0.816 
Cross-sectional 1.08 (0.72–1.61) 0.720 0.0 0.529 
Continent Africa 1.43 (0.75–2.72) 0.282 0.0 0.774 0.210 
Asia 0.90 (0.54–1.51) 0.688 
Europe 1.37 (0.79–2.39) 0.268 0.0 0.336 
North America 0.40 (0.12–1.33) 0.134 
Hypertension Study design Prospective 11 1.24 (1.05–1.46) 0.012 29.6 0.164 0.075 
Retrospective 1.39 (1.00–1.94) 0.049 75.2 <0.001 
Cross-sectional 0.83 (0.53–1.31) 0.424 31.4 0.233 
Continent Africa 0.69 (0.39–1.22) 0.203 0.0 0.368 0.322 
Asia 1.48 (1.03–2.13) 0.032 81.2 <0.001 
Europe 1.09 (0.90–1.33) 0.364 37.9 0.140 
North America 1.57 (0.95–2.61) 0.080 0.0 0.418 
Oceania 1.42 (0.77–2.62) 0.262 
South America 1.25 (0.66–2.39) 0.495 69.8 0.069 
Diabetes mellitus Study design Prospective 11 1.25 (1.00–1.56) 0.048 51.5 0.024 0.789 
Retrospective 1.22 (0.90–1.68) 0.205 58.4 0.018 
Cross-sectional 1.19 (0.57–2.49) 0.652 72.3 0.027 
Continent Africa 1.20 (0.51–2.85) 0.680 60.2 0.081 0.721 
Asia 1.46 (0.97–2.19) 0.071 74.8 0.001 
Europe 1.08 (0.83–1.40) 0.576 52.2 0.051 
North America 1.09 (0.57–2.07) 0.794 30.4 0.238 
Oceania 0.98 (0.52–1.84) 0.950 
  South America 1.43 (0.94–2.17) 0.095 50.4 0.156  
Stroke history Study design Prospective 1.50 (1.09–2.05) 0.012 38.4 0.150 <0.001 
Retrospective 1.10 (0.85–1.41) 0.464 48.9 0.068 
Cross-sectional 1.50 (0.92–2.45) 0.105  
Continent Asia 1.21 (0.86–1.70) 0.264 67.9 0.025 <0.001 
Europe 1.47 (1.35–1.60) <0.001 0.0 0.494 
North America 0.69 (0.38–1.25) 0.223 0.0 0.342 
Oceania 0.72 (0.38–1.37) 0.318 
South America 1.61 (1.15–2.26) 0.006 0.0 0.710 
Hyperlipidemia Study design Prospective 1.05 (0.68–1.61) 0.821 76.9 0.002 0.016 
Retrospective 1.02 (0.76–1.36) 0.892 0.0 0.530 
Cross-sectional 1.85 (0.88–3.90) 0.105 0.0 0.648 
Continent Africa 1.85 (0.88–3.90) 0.105 0.0 0.648 0.121 
Asia 0.73 (0.23–2.33) 0.597 66.5 0.084 
Europe 1.15 (0.61–2.16) 0.676 87.5 <0.001 
North America 0.95 (0.59–1.53) 0.833 0.0 0.613 
Oceania 1.06 (0.58–1.95) 0.851 
South America 1.01 (0.68–1.51) 0.961 
Ischemic heart disease Study design Prospective 1.09 (0.73–1.62) 0.687 56.6 0.056 0.627 
Retrospective 1.56 (0.84–2.88) 0.156 
Cross-sectional 1.17 (0.24–5.81) 0.844 41.7 0.190 
Continent Africa 0.96 (0.25–3.71) 0.956 29.1 0.244 0.134 
Asia 1.56 (0.84–2.88) 0.156 
Europe 1.04 (0.71–1.50) 0.847 50.1 0.157 
North America 0.40 (0.11–1.50) 0.174 
  South America 1.78 (1.14–2.77) 0.011  
Atrial fibrillation Study design Prospective 1.38 (0.73–2.61) 0.323 92.5 <0.001 0.024 
Retrospective 1.46 (0.76–2.81) 0.260 70.8 0.033 
Cross-sectional 1.85 (0.06–54.21) 0.720 76.1 0.041 
Continent Africa 1.85 (0.06–54.21) 0.720 76.1 0.041 0.213 
Asia 1.17 (0.53–2.57) 0.696 
Europe 1.25 (0.68–2.30) 0.472 93.8 <0.001 
North America 1.60 (0.33–7.78) 0.560 
Oceania 2.56 (1.54–4.27) <0.001 
Stroke type (ischemic vs. hemorrhagic) Study design Prospective 0.66 (0.48–0.91) 0.010 0.0 0.522 0.238 
Retrospective 1.17 (0.59–2.31) 0.655 64.6 0.037 
Continent Asia 1.19 (0.57–2.50) 0.646 0.347 
Europe 0.81 (0.55–1.18) 0.268 47.3 0.077 
Middle East 0.43 (0.08–2.33) 0.327 0.0 0.979 
North America 0.56 (0.04–7.64) 0.664 
Oceania 2.31 (0.66–8.06) 0.189 
South America 0.55 (0.26–1.18) 0.123 
Hemisphere affected (left vs. right) Study design Prospective 1.23 (0.90–1.68) 0.188 49.5 0.054 0.048 
Retrospective 0.89 (0.68–1.17) 0.421 21.1 0.284 
Continent Asia 1.00 (0.62–1.61) 0.994 61.8 0.073 0.056 
Europe 1.07 (0.80–1.42) 0.661 32.2 0.207 
Middle East 2.57 (1.27–5.21) 0.009 17.5 0.271 
Oceania 0.98 (0.47–2.05) 0.957 
South America 0.87 (0.55–1.37) 0.547 

Overall, 12 studies reported an association between age and the risk of PSD in patients with acute stroke. Notably, older age was reported to be associated with an increased risk of PSD (OR: 2.13; 95% CI: 1.53–2.97; p < 0.001; Fig. 4), and significant heterogeneity was observed among the included studies (I2 = 74.1%; p < 0.001). Sensitivity analysis indicated that the pooled conclusion was robust and unaffected by sequential removal of individual studies (online suppl. Material 2). In the subgroup analyses, a significant association was found between age and PSD in most subgroups; however, in the pooled studies in Africa or Oceania, no significant association was found between age and PSD (Table 2). Moreover, there was no significant publication bias in PSD related to age (p value for Egger: 0.574; p value for Begg: 0.661; online suppl. Material 3).

Fig. 4.

Association between age and the risk of PSD in patients with acute stroke.

Fig. 4.

Association between age and the risk of PSD in patients with acute stroke.

Close modal

The associations of smoking, alcoholism, and obesity with the risk of PSD in patients with acute stroke were reported in 12, 6, and 5 studies, respectively (Fig. 5). Notably, current smoking status (OR: 1.18; 95% CI: 0.99–1.41; p = 0.068), alcoholism (OR: 1.19; 95% CI: 0.95–1.51; p = 0.137), and obesity (OR: 1.09; 95% CI: 0.78–1.53; p = 0.608) were not associated with the risk of PSD in patients with acute stroke. Among the included studies, significant heterogeneity was observed for smoking (I2 = 48.9%; p = 0.024), whereas no significant heterogeneity was observed for alcoholism (I2 = 0.0%; p = 0.615) or obesity (I2 = 9.7%; p = 0.354). In the sensitivity analysis, current smoking status was found to be associated with an increased risk of PSD, and there was a stable association between alcoholism and obesity and the risk of PSD (online suppl. Material 2). The subgroup analysis revealed that current smoking was associated with an increased risk of PSD in the pooled prospective studies (Table 2). Study design could affect the association of smoking with the risk of PSD (p = 0.025). No significant publication bias was found for PSD related to smoking status (p value for Egger: 0.829; p value for Begg: 0.855) and obesity (p value for Egger: 0.998; p value for Begg: 1.000). However, a significant potential publication bias was observed for PSD related to alcoholism (p value for Egger: 0.023; p value for Begg: 0.133) (online suppl. Material 3).

Fig. 5.

Association between smoking, alcoholism, and obesity and the risk of PSD in patients with acute stroke.

Fig. 5.

Association between smoking, alcoholism, and obesity and the risk of PSD in patients with acute stroke.

Close modal

Associations between hypertension and diabetes mellitus and the risk of PSD in patients with acute stroke were reported in 22 and 21 studies, respectively (Fig. 6). We found that hypertension (OR: 1.23; 95% CI: 1.06–1.44; p = 0.007) and diabetes mellitus (OR: 1.22; 95% CI: 1.04–1.44; p = 0.014) were associated with an increased risk of PSD in patients with acute stroke, and significant heterogeneity was found for PSD related to hypertension (I2 = 59.6%; p < 0.001) and diabetes mellitus (I2 = 53.5%; p = 0.002). In the sensitivity analyses, the pooled conclusions for PSD related to hypertension and diabetes mellitus were found to be stable by sequential removal of individual studies (online suppl. Material 2). In the pooled prospective or retrospective studies, the subgroup analysis revealed that hypertension was associated with an increased risk of PSD, whereas in the pooled prospective studies from Asia, diabetes mellitus was associated with an increased risk of PSD (Table 2). No significant publication bias was found for PSD related to hypertension (p value for Egger: 0.264; p value for Begg: 0.369) and diabetes mellitus (p value for Egger: 0.574; p value for Begg: 0.652) (online suppl. Material 3).

Fig. 6.

Association between hypertension and diabetes mellitus and the risk of PSD in patients with acute stroke.

Fig. 6.

Association between hypertension and diabetes mellitus and the risk of PSD in patients with acute stroke.

Close modal

Associations between history of stroke, hyperlipidemia, ischemic heart disease, and atrial fibrillation and the risk of PSD in patients with acute stroke were reported in 14, 11, 7, and 8 studies, respectively (Fig. 7). We observed that stroke history (OR: 1.26; 95% CI: 1.04–1.53; p = 0.019) and atrial fibrillation (OR: 1.58; 95% CI: 1.02–2.44; p = 0.039) were associated with an increased risk of PSD, whereas hyperlipidemia (OR: 1.07; 95% CI: 0.82–1.39; p = 0.627) and ischemic heart disease (OR: 1.19; 95% CI: 0.87–1.63; p = 0.267) were not associated with the risk of PSD in patients with acute stroke. Significant heterogeneity was found for PSD related to stroke history (I2 = 64.0%; p = 0.001), hyperlipidemia (I2 = 62.0%; p = 0.002), and atrial fibrillation (I2 = 86.3%; p < 0.001), whereas no significant heterogeneity was observed for PSD related to ischemic heart disease (I2 = 41.0%; p = 0.105). The pooled conclusions for PSD related to stroke history and atrial fibrillation were variable, but there was a stable association between hyperlipidemia and ischemic heart disease and the risk of PSD (online suppl. Material 2). In the pooled prospective studies, the subgroup analysis revealed that stroke history was associated with an increased risk of PSD among studies from Europe or South America; meanwhile, ischemic heart disease was associated with an increased risk of PSD in the pooled studies from South America. Additionally, atrial fibrillation was associated with an increased risk of PSD in the pooled studies from Oceania (Table 2). The association of history of stroke with the risk of PSD could affect by study design (p < 0.001) and continent (p < 0.001). Study design could affect the association of hyperlipidemia (p = 0.016), and atrial fibrillation (p = 0.024) with the risk of PSD. No significant publication bias was observed for PSD related to stroke history (p value for Egger: 0.492; p value for Begg: 0.743), ischemic heart disease (p value for Egger: 0.379; p value for Begg: 0.711), and atrial fibrillation (p value for Egger: 0.154; p value for Begg: 0.917), whereas a potential significant publication bias was found for hyperlipidemia (p value for Egger: 0.018; p value for Begg: 0.837) (online suppl. Material 3).

Fig. 7.

Association between stroke history, hyperlipidemia, ischemic heart disease, and atrial fibrillation and the risk of PSD in patients with acute stroke.

Fig. 7.

Association between stroke history, hyperlipidemia, ischemic heart disease, and atrial fibrillation and the risk of PSD in patients with acute stroke.

Close modal

Associations between stroke type and the hemisphere affected and the risk of PSD in patients with acute stroke were reported in 13 and 12 studies, respectively (Fig. 8). We found that stroke type (OR: 0.82; 95% CI: 0.62–1.09; p = 0.166) and the hemisphere affected (OR: 1.09; 95% CI: 0.87–1.38; p = 0.444) were not associated with the risk of PSD in patients with acute stroke. No significant heterogeneity was found for PSD related to stroke type (I2 = 29.4%; p = 0.150), whereas a significant potential heterogeneity was noted for PSD related to the hemisphere affected (I2 = 49.0%; p = 0.028). Sensitivity analysis revealed that ischemic stroke might be associated with a lower risk of PSD than hemorrhagic stroke, and there was a stable association for PSD related to the hemisphere affected (online suppl. Material 2). Subgroup analysis revealed that in the pooled prospective studies, ischemic stroke was associated with a lower risk of PSD compared with hemorrhagic stroke, and in the pooled studies from the Middle East, affected left hemisphere was associated with a higher risk of PSD compared with affected right hemisphere (Table 2). The associations between the hemisphere affected and the risk of PSD could affected by study design (p = 0.048). No significant publication bias was found for PSD related to stroke type (p value for Egger: 0.541; p value for Begg: 0.583) and the hemisphere affected (p value for Egger: 0.235; p value for Begg: 0.150) (online suppl. Material 3).

Fig. 8.

Association between stroke type and the hemisphere affected and the risk of PSD in patients with acute stroke.

Fig. 8.

Association between stroke type and the hemisphere affected and the risk of PSD in patients with acute stroke.

Close modal

This meta-analysis was conducted to assess the prevalence of PSD in patients with acute stroke and identify the risk factors for PSD to screen high-risk patients. In total, 37,404 patients with acute stroke were identified from 58 studies, which included various patient characteristics. The present study found that the prevalence of PSD in patients with acute stroke was 42%, which was the highest in South America and lowest in Asia. Moreover, we found that the risk factors for PSD in patients with acute stroke were older age, hypertension, diabetes mellitus, stroke history, and atrial fibrillation. However, the risk of PSD in patients with acute stroke was not related to sex, smoking, alcoholism, obesity, hyperlipidemia, ischemic heart disease, stroke type, or the hemisphere affected. Finally, we found that the risk factors for PSD in patients with acute stroke may vary in terms of the study design and continent.

A previous meta-analysis investigated 42 studies with 26,366 patients and found that the prevalence of PSD was 42%. Moreover, it reported that the prevalence of PSD was highest in South America, whereas it was lowest in Asia [3]. These results are consistent with those of our study. However, the results should be interpreted with caution given that the prevalence of PSD could be affected by stroke type, diagnostic methods, and time of PSD assessment. Considering that the prevalence of PSD was relatively high in patients with acute stroke, the risk factors for PSD in patients with acute stroke should be identified to further prevent the risk of PSD.

Our study found that older age was associated with an increased risk of PSD in patients with acute stroke, which is consistent with another study, demonstrating that age is significantly associated with swallowing function [86]. In addition, it has been reported that aging can lead to a gradual weakening of body functions, which is highly associated with impairment of the patient’s oral and maxillomandibular system, thereby favoring the development of dysphagia [55, 87]. Similarly, degeneration of cranial nerve function and abnormal swallowing reflex in older patients could be additional risk factors for swallowing dysfunction [8, 88, 89].

The present study found that the risk of PSD was increased in patients with hypertension or diabetes mellitus. Notably, hypertension has been recognized as a risk factor for ischemic and hemorrhagic stroke, which could greatly affect the prognosis of acute stroke [90]. Moreover, the combined effect of hypertension and diabetes mellitus could negatively affect the overall function of patients with stroke, thereby significantly increasing the risk of PSD [91, 92]. Furthermore, we found that stroke history was associated with an increased risk of PSD and that stroke severity was commonly associated with recurrent cases. Finally, some studies have reported that atrial fibrillation is significantly associated with cognitive disorders that play a crucial role in the physiological process of dysphagia [93].

In the present study, we found that PSD was not affected by sex, smoking, alcoholism, obesity, hyperlipidemia, ischemic heart disease, stroke type, or the hemisphere affected. However, the sensitivity analysis revealed that smoking and stroke type may be associated with in the risk of PSD in patients with acute stroke. Cigarette smoking was considered an independent risk factor for acute stroke, but other traditional risk factors were not balanced between smokers and nonsmokers, which may affect the risk of PSD. In addition, we found that ischemic stroke might be associated with a lower risk of PSD. This could be explained by the fact that hemorrhagic stroke was associated with lesions in the internal capsule and thalamus, which are considered more severe and debilitating.

Based on the subgroup analyses performed according to continents, the risk factors for PSD were older age and hypertension; sex, older age, and stroke history; the hemisphere affected; atrial fibrillation; and stroke history and ischemic heart disease in Asia, Europe, the Middle East, Oceania, and South America, respectively. These results indicate that risk factors are different for different continents, and effective intervention should be employed for high-risk patients to improve the prognosis of stroke.

This study has some limitations. First, the results are prone to both selection and confounding biases because the analyses included various study designs (prospective cohort, retrospective cohort, and cross-sectional). Second, stroke subtypes, severity and previous treatments might affect the progression of PSD in patients with acute stroke, and the heterogeneity among the included trials was not fully assessed. Third, PSD determination differed among the included studies; thus, the effect estimates of the prevalence and risk factors for PSD could be affected. Finally, there are limitations inherent in the meta-analysis of published articles, including restricted detailed analyses and inevitable publication bias.

In this study, the prevalence of PSD in patients with acute stroke was 42%, which was the highest in South America and lowest in Asia. Moreover, older age, hypertension, diabetes mellitus, stroke history, and atrial fibrillation might associate with the risk of PSD in patients with acute stroke. Given that study results may be influenced by inter-study heterogeneity and that different study types may introduce uncontrollable study biases, further prospective cohort studies are warranted to verify the findings of this study and construct a prediction model for PSD in patients with acute stroke.

An ethics statement is not applicable because this study is based exclusively on published literature.

The authors have no conflicts of interest to declare.

This study was supported by Ningbo science and technology for the people project (Grant No. 2015C50037).

Haiyan Gu: concept, design, definition of intellectual content, and literature search; Dan Ren: data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, and manuscript review.

All data generated or analyzed during this study are included in this article and its supplementary information files.

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