Background: Dysphagia is frequent after hemorrhagic stroke, and some of the affected patients require prolonged enteral nutrition, most often via percutaneous endoscopic gastrostomy (PEG) tubes. The identification of patients at risk of prolonged dysphagia permits earlier tube placement and helps guide clinicians in the decision-making process. Methods: This retrospective study included all patients with spontaneous ICH admitted to a tertiary university hospital from 2007 until 2009 (n = 208). Fifty-one patients received PEG tubes. PEG tube placement was conducted in ventilated patients within 30 days and in spontaneously breathing patients if swallowing did not improve within 14 days. Results: Twenty-five percent of patients received PEG tubes. Those patients had larger lobar hemorrhages, intraventricular hemorrhage and occlusive hydrocephalus and higher ICH scores. Furthermore, patients with PEG scored worse on Glasgow Coma Scale (GCS), National Institute of Health Stroke Scale (NIHSS) and Acute Physiology And Chronic Health Evaluation (APACHE II), more frequently needed mechanical ventilation, and had more inflammatory and renal complications. A multivariate regression analysis identified GCS, occlusive hydrocephalus, mechanical ventilation, and systemic sepsis as independent risk factors for PEG tube placement. Conclusion: Disease severity and neurocritical care complications represent the major influencing parameters for PEG tube placement in spontaneous ICH patients.

Keywords:
Neurocritical care, Intracranial hemorrhage, Percutaneous endoscopic gastrostomy
1.
Barer DH: The natural history and functional consequences of dysphagia after hemispheric stroke. J Neurol Neurosurg Psychiatry 1989;52:236–241.
2.
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.
3.
Meng NH, Wang TG, Lien IN: Dysphagia in patients with brainstem stroke: Incidence and outcome. Am J Phys Med Rehabil 2000;79:170–175.
4.
Axelsson K, Asplund K, Norberg A, Alafuzoff I: Nutritional status in patients with acute stroke. Acta Med Scand 1988;224:217–224.
5.
Choi-Kwon S, Yang YH, Kim EK, Jeon MY, Kim JS: Nutritional status in acute stroke: undernutrition versus overnutrition in different stroke subtypes. Acta Neurol Scand 1998;98:187–192.
6.
Dennis M: Nutrition after stroke. Br Med Bull 2000;56:466–475.
7.
Davalos A, Ricart W, Gonzalez-Huix F, Soler S, Marrugat J, Molins A, Suner R, Genis D: Effect of malnutrition after acute stroke on clinical outcome. Stroke 1996;27:1028–1032.
8.
Gariballa SE, Parker SG, Taub N, Castleden CM: Influence of nutritional status on clinical outcome after acute stroke. Am J Clin Nutr 1998;68:275–281.
9.
Gariballa SE, Parker SG, Taub N, Castleden M: Nutritional status of hospitalized acute stroke patients. Br J Nutr 1998;79:481–487.
10.
Unosson M, Ek AC, Bjurulf P, von Schenck H, Larsson J: Feeding dependence and nutritional status after acute stroke. Stroke 1994;25:366–371.
11.
Chandra RK: Graying of the immune system: can nutrient supplements improve immunity in the elderly? JAMA 1997;277:1398–1399.
12.
Fiatarone MA, Evans WJ: The etiology and reversibility of muscle dysfunction in the aged. J Gerontol 1993;48:77–83.
13.
Davenport RJ, Dennis MS, Wellwood I, Warlow CP: Complications after acute stroke. Stroke 1996;27:415–420.
14.
Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the food trial. Stroke 2003;34:1450–1456.
15.
Finestone HM, Greene-Finestone LS, Wilson ES, Teasell RW: Malnutrition in stroke patients on the rehabilitation service and at follow-up: prevalence and predictors. Arch Phys Med Rehabil 1995;76:310–316.
16.
Gordon C, Hewer RL, Wade DT: Dysphagia in acute stroke. Br Med J 1987;295:411–414.
17.
Robbins J, Levine RL, Maser A, Rosenbek JC, Kempster GB: Swallowing after unilateral stroke of the cerebral cortex. Arch Phys Med Rehabil 1993;74:1295–1300.
18.
Mann G, Hankey GJ, Cameron D: Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke 1999;30:744–748.
19.
Smithard DG, O’Neill PA, England RE, Park CL, Wyatt R, Martin DF, Morris J: The natural history of dysphagia following a stroke. Dysphagia 1997;12:188–193.
20.
Gencosmanoglu R: Percutaneous endoscopic gastrostomy: a safe and effective bridge for enteral nutrition in neurological or non-neurological conditions. Neurocrit Care 2004;1:309–317.
21.
van Gijn J, Hijdra A, Wijdicks EF, Vermeulen M, van Crevel H: Acute hydrocephalus after aneurysmal subarachnoid hemorrhage. J Neurosurg 1985;63:355–362.
22.
Huttner HB, Staykov D, Bardutzky J, Nimsky C, Richter G, Doerfler A, Schwab S: Treatment of intraventricular hemorrhage and hydrocephalus. Nervenarzt 2008;79:1369–1370, 1372–1364, 1376.
23.
Tejerina E, Esteban A, Fernandez-Segoviano P, Frutos-Vivar F, Aramburu J, Ballesteros D, Rodriguez-Barbero JM: Accuracy of clinical definitions of ventilator-associated pneumonia: comparison with autopsy findings. J Crit Care 2009;25:62–68.
24.
Muckart DJ, Bhagwanjee S: American College of Chest Physicians/Society of Critical Care Medicine consensus conference definitions of the systemic inflammatory response syndrome and allied disorders in relation to critically injured patients. Crit Care Med 1997;25:1789–1795.
25.
Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M, Khoury J: The ABCs of measuring intracerebral hemorrhage volumes. Stroke 1996;27:1304–1305.
26.
Graeb DA, Robertson WD, Lapointe JS, Nugent RA, Harrison PB: Computed tomographic diagnosis of intraventricular hemorrhage: etiology and prognosis. Radiology 1982;143:91–96.
27.
Brott T, Broderick J, Kothari R, Barsan W, Tomsick T, Sauerbeck L, Spilker J, Duldner J, Khoury J: Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke 1997;28:1–5.
28.
Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M, Morgenstern L, Ogilvy CS, Vespa P, Zuccarello M: Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality Of Care and Outcomes in Research Interdisciplinary Working Group. Circulation 2007;116:e391–e413.
29.
Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM Jr, Musher DM, Niederman MS, Torres A, Whitney CG: Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(suppl 2):S27–S72.
30.
Reinhart K, Brunkhorst FM, Bone HG, et al: Prevention, diagnosis, treatment, and follow-up care of sepsis: first revision of the S2K guidelines of the German Sepsis Society (DSG) and the German Interdisciplinary Association for Intensive and Emergency Care Medicine (DIVI)]. Anaesthesist 2010;59:347–370.
31.
American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992;20:864–874.
32.
Dellinger RP, Levy MM, Carlet JM, et al: Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296–327.
33.
Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P: Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: 2nd International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) group. Crit Care 2004;8:R204–R212.
34.
Ronco C, Levin A, Warnock DG, Mehta R, Kellum JA, Shah S, Molitoris BA: Improving outcomes from acute kidney injury (AKI): report on an initiative. Int J Artif Organs 2007;30:373–376.
35.
Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, Nitenberg G, van den Berghe G, Wernerman J, Ebner C, Hartl W, Heymann C, Spies C: Espen guidelines on enteral nutrition: Intensive care. Clin Nutr 2006;25:210–223.
36.
Volkert D, Berner YN, Berry E, et al: Espen guidelines on enteral nutrition: geriatrics. Clin Nutr 2006;25:330–360.
37.
Martin CM, Doig GS, Heyland DK, Morrison T, Sibbald WJ: Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ 2004;170:197–204.
38.
Taylor SJ, Fettes SB, Jewkes C, Nelson RJ: Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med 1999;27:2525–2531.
39.
Doig GS, Simpson F, Finfer S, Delaney A, Davies AR, Mitchell I, Dobb G: Effect of evidence-based feeding guidelines on mortality of critically ill adults: a cluster randomized controlled trial. JAMA 2008;300:2731–2741.
40.
Dennis MS, Lewis SC, Warlow C: Effect of timing and method of enteral tube feeding for dysphagic stroke patients (food): a multicentre randomised controlled trial. Lancet 2005;365:764–772.
41.
Schroder O, Hoepffner N, Stein J: Enteral nutrition by endoscopic means. 1. Techniques, indications, types of enteral feed. Z Gastroenterol 2004;42:1385–1392.
42.
DePippo KL, Holas MA, Reding MJ: Validation of the 3-oz water swallow test for aspiration following stroke. Arch Neurol 1992;49:1259–1261.
43.
DePippo KL, Holas MA, Reding MJ: The burke dysphagia screening test: validation of its use in patients with stroke. Arch Phys Med Rehabil 1994;75:1284–1286.
44.
Gottlieb D, Kipnis M, Sister E, Vardi Y, Brill S: Validation of the 50 ml3 drinking test for evaluation of post-stroke dysphagia. Disabil Rehabil 1996;18:529–532.
45.
Hinds NP, Wiles CM: Assessment of swallowing and referral to speech and language therapists in acute stroke. Q J Med 1998;91:829–835.
46.
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.
47.
Langmore SE: Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior? Curr Opin Otolaryngol Head Neck Surg 2003;11:485–489.
48.
Leder SB, Espinosa JF: Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia 2002;17:214–218.
49.
Lim SH, Lieu PK, Phua SY, Seshadri R, Venketasubramanian N, Lee SH, Choo PW: Accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) in determining the risk of aspiration in acute stroke patients. Dysphagia 2001;16:1–6.
50.
Warnecke T, Dziewas R, Oelenberg S, Ritter M, Dittrich R, Schabitz WR, Ringelstein EB, Nabavi DG: Serial fiberoptic endoscopic evaluation of swallowing in patients with acute stroke and dysphagia: case report and general considerations. J Stroke Cerebrovasc Dis 2006;15:172–175.
51.
Warnecke T, Teismann I, Oelenberg S, Hamacher C, Ringelstein EB, Schabitz WR, Dziewas R: The safety of fiberoptic endoscopic evaluation of swallowing in acute stroke patients. Stroke 2009;40:482–486.
52.
Bola KR: Use of percutaneous endoscopic gastrostomy in acute dysphagic stroke. Saudi J Gastroenterol 2001;7:59–61.
53.
Bath PMW, Bath FJ, Smithard DG: Interventions for dysphagia in acute stroke (Cochrane review). London, The Cochrane Library, 2002.
54.
Conway DS, Ranawat NS, Degeorgia M, Alshekhlee A: Predictors of peg tube placement in acute ischemic stroke. AAN Ann Meet, 2009, A158.
55.
Diringer MN, Edwards DF, Zazulia AR: Hydrocephalus: A previously unrecognized predictor of poor outcome from supratentorial intracerebral hemorrhage. Stroke 1998;29:1352–1357.
56.
Yokohama S, Aoshima M: Risk factors of early mortality after percutaneous endoscopic gastrostomy: a retrospective study. Nippon Shokakibyo Gakkai Zasshi 2009;106:1313–1320.
57.
Freeman C, Ricevuto A, Delegge MH: Enteral nutrition in patients with dementia and stroke. Curr Opin Gastroenterol 2010;26:156–159.
58.
Higaki F, Yokota O, Ohishi M: Factors predictive of survival after percutaneous endoscopic gastrostomy in the elderly: is dementia really a risk factor? Am J Gastroenterol 2008;103:1011–1016; quiz 1017.
59.
Nair S, Hertan H, Pitchumoni CS: Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia. Am J Gastroenterol 2000;95:133–136.
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