Solver settings

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Table 6 shows classification of cerebral infarct based on Oxfordshire Community Stroke Project (OCSP) classification. Four of dysphagic (11.4%) and two of non-dysphagic (3.1%) had TACI.

This was not statistically significant (p= 0.393). 55 of non-dysphagic (84.6%) and 26 of dysphagic (74.3%) had PACI and this difference was statistically significant (p= 0.001). Four of dysphagic (11.4%) and two of non-dysphagic (3.1%) had POCI (p=0.092). 2.9% of dysphagic and 9.2% of non-dysphagic had lacunar syndrome (p= 0.620)

Table 6: Distribution of vascular territories involved in dysphagic and non-dysphagic ischaemic strokes.

Variable Cases (%) (35)

Controls (%) (65)

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Table 7 shows sites of stroke lesion in dysphagic and non-dysphagic stroke patients. Fifty-one of dysphagic stroke patients (49.5%) and fifty-two of non-dysphagic stroke patients (50.5%) had cortical lesions. This difference was not statistically significant (p =1.00). Subcortical involvement of stroke was more in dysphagic stroke than in non-dysphagic stroke patients.

Sixty-four of dysphagic stroke patients (57.1%) and 48 of non-dysphagic stroke patients (42.9%) had lesion at subcortical regions. This difference was statistically significant (p =0.015). Six of dysphagic stroke patients and three of non-dysphagic stroke had stroke lesion at

brainstem/cerebellar sites. This difference was not statistically significant (p=0.29).

Sixteen of dysphagic stroke and 2 of non dysphagic stroke patients had both cortical and sub-cortical lesions

TABLE 7: Stroke lesion sites in study participants.

Lesion site Dysphagic Non-dysphagic P- value

Dominant hemisphere 53 (53.5%)

52 (51.5%) 0.775 Non-dominant hemisphere 46 (46.5%)

49 (48.5%) 0.839

Total 99 101

Cortical n=103(%) 51(49.5%) 52(50.5%) 1.00

Sub-cortical n=112(%)* 64(57.1%) 48(42.9%) 0.015 Brainstem/Cerebellum n=9(%) 6(66.7%) 3(33.3%) 0.29

16 cases and 2 controls had both cortical and sub-cortical lesions

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.Table 8 below shows complications observed in dysphagic and non-dysphagic stroke patients.

The commonest complication observed in the dysphagic was aspiration pneumonia. Sixty two of the dysphagic (62.63%) and one of the non-dysphagic (0.99%) had aspiration pneumonia. Same number of dysphagic and non-dysphagic had urinary tract infection (UTI). UTI was the commonest complication observed in the non-dysphagic. Eight of the controls (7.92%) and ten of the dysphagic (10.10%) had biochemical features of renal impairment. However, the difference was not statistically significant (p=0.590). Three of the non-dysphagic (2.97%) and two of the dysphagic (2.04%) had deep venous thrombosis. The difference was not statistically significant (p= 0.327). One of the dysphagic (1.02%) and three of the non-dysphagic (2.97%) had pulmonary thromboembolism. This was not statistically significant (p=0.675). None of the dysphagic had myocardial infarction as complication while one of the non-dysphagic (0.99%) had it.

TABLE 8: Frequency of complications observed in study participants.

Variable Dysphagic (%) Non-dysphagic (%) P-value

Urinary tract infection 20 (20.20%) 20 (19.80%) 0.944

Acute kidney injury 10 (10.10%) 8 (7.92%) 0.590

Pulmonary thromboembolism 1 (1.02%) 3 (2.97%) 0.675

Deep venous thrombosis 2 (2.04%) 3 (2.97%) 0.327

Myocardial infarction 0 (0.00%) 1 (0.99%) 0.321

Aspiration Pneumonia 62 (62.63%) 1 (0.99%) <0.001*

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Table 9 below shows patients’ outcome in dysphagic and non-dysphagic. Seventy nine of dysphagic (79.80%) and sixteen of non-dysphagic (15.84%) died on admission. The difference was statistically significant (p< 0.001). The average survival days for the non-dysphagic were 24.56 days and for dysphagic were 12.21 days. The difference was also statistically significant (p< 0.001).

TABLE 9: Outcome of dysphagic and non-dysphagic stroke patients.

Variable Dysphagic Non-dysphagic P-value

Died On Admission 79 (79.80%) 16 (15.84%) <0.001 Survival Time (Days) 12.21 (±1.15) 24.56 (±1.19 ) <0.001

.

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Kaplan Meier survival curve in figure 2 below clearly depicts percentage cumulative survival in the dysphagic and non-dysphagic. Those with dysphagia were on admission for a longer period in the hospital and some of them died.

Figure 2: Kaplan-Meier survival curve for cases and control.

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Table 10 below compares outcome of patients that had dysphagia alone with patients that had dysphagia complicated by aspiration pneumonia. The outcome was worse with the dysphagic that had aspiration pneumonia. 55 of patients (69.6%) that had dysphagia complicated by aspiration pneumonia died on admission. 24 of the patients (30.4%) that had dysphagia without aspiration died on admission. The difference was statistically significant (p= 0.004). 30-day case fatality rate for patient with dysphagia alone was 24.2%. 30-day case fatality rate for dysphagic stroke patients complicated with aspiration pneumonia was 55.6%. The average survival days in the patients with dysphagia alone was shorter in dysphagic complicated by aspiration pneumonia (p= 0.023) than in non-dysphagic.

TABLE 10: Outcome of patients with dysphagia alone and patients with dysphagia and aspiration pneumonia.

Variable Dysphagia Alone Dysphagia with Aspiration P-value

Died On Admission 24 (30.4%) 55 (69.6%) 0.004

Survival Time (Days) 14.97 (±4.08) 9.53 (±0.88) 0.023

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Kaplan Meier survival curve in figure 5 clearly depicts percentage cumulative survival in the dysphagic without aspiration and those with aspiration. The survival drastically reduced in those patients that had aspiration pneumonia.

Figure 3: Kaplan-Meier survival curve for patient with dysphagia without aspiration and those with aspiration

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Table 11 below shows outcome in dysphagic and non-dysphagic using Modified Rankin Scale (MRS). The mean MRS of the dysphagic stroke patients at 4^th week post stroke was 3.83 (SD±

1.029). The mean MRS of non-dysphagic stroke patients at 4^th week was 2.55 (SD± 1.34). This difference was statistically significant. (p< 0.001). The mean BI of dysphagic stroke patients at 4th week post stroke was 28.04 (SD± 32.15) while the mean BI of non-dysphagic stroke patients was 65.52 (SD± 30.33). This difference was also statistically significant.(p< 0.001).

TABLE 11: Outcome of dysphagic and non-dysphagic stroke patients using Modified Rankin Scale (MRS) and Barthel Index (BI)

Variable Dysphagic Non-dysphagic P-value

MRS at 4^th week ±SD 3.83 ± 1.029 2.55 ± 1.34 <0.001 BI at 4th week ±SD 28.04± 32.15 65.52 ± 30.33 <0.001

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Table 12 below compares MRS at 4^th week in stroke patients that had dysphagia complicated by aspiration pneumonia to those that had dysphagia alone. The mean MRS of dysphagic stroke patents that had aspiration pneumonia at 4^th week was 4.38 (SD± 0.52) while the mean MRS of dysphagic stroke patients without aspiration pneumonia at 4^th week was 3.53 (SD± 1.13). This difference was not statistically significant (p=0.142). The mean BI of dysphagic stroke patients that had aspiration pneumonia at 4th week post stroke was 18.75 (SD± 24.31) while the mean BI of dysphagic stroke patients without aspiration pneumonia at 4th week post stroke was 33.00 (SD± 35.39). This difference was not statistically significant. (p=0.209).

TABLE 12: comparison of outcome of stroke patients with dysphagia alone and outcome of stroke patients with dysphagia complicated by aspiration pneumonia using Modified Rankin Scale (MRS) and Barthel Index (BI)

Variable Dysphagia with aspiration Dysphagia alone P-value MRS at 4th weeks ±SD 4.38 ± 0.52 3.53 ± 1.13 0.142 BI at 4^th week ±SD 18.75 ± 24.31 33.00±35.39 0.209

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Table 13 shows univariate and multivariate logistic regression analysis to assess determinants of 30-day case fatality in this study. Determinants of 30-day case fatality with statistical significance were dysphagia (p <0.001), aspiration pneumonia (p <0.001), sepsis (p <0.001), severe NIHSS (p <0.001), haemorrhagic stroke subtype (p <0.001), and mean arterial pressure (MAP) >145mmHg (p =0.041). With multivariate analysis, the most significant determinant of 30-day case fatality in this study was dysphagia (p= 0.005). This was followed by aspiration pneumonia (p =0.024), haemorrhagic stroke (p= 0.043) and severe NIHSS (0.049).

Table 13: Univariate and Multivariate Binary logistic regression analysis to assess the determinants of 30- day case fatality.

Variables

Analysis Univariate

OR(95% CI)

p-value Multivariate Β (95% CI)

p-value Dysphagia

Yes No

1(reference - death)

0.20 (0.13-0.32) <0.001 0.29(0.08-0.63) 0.005 Aspiration Pneumonia

Yes No

1(reference- death)

0.29(0.22-0.40) <0.001 0.28(0.09-0.84) 0.024 Sepsis

Yes No

1(reference- death)

0.23(0.11-0.50) <0.001 0.42(0.14-1.23) 0.112 NIHSS

Severe (21-42)

Mild-Moderate(0-20)

1(reference- death)

0.31(0.22-0.42) <0.001 0.36(0.13-1.00) 0.049 Gender

Male Female

1(reference-death)

0.79(0.56-1.06) 0.112 NA Stroke Subtype

Ischaemic Haemorrhagic

1(reference-death)

2.18(1.55-3.02) <0.001 2.34(1.03-5.31) 0.043 Post Stroke

Hyperglycaemia RBS > 140 RBS <140

1(reference-death) 0.76(0.55-1.04)

0.092

NA Mean Arterial Pressure

MAP> 145 MAP<145

1(reference-death)

0.72(0.54-0.97) 0.041 1.05(0.40-2.72) 0.923 NA- Not analysed

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Table 14 below shows Cox Proportional hazard model after controlling for the effect of sepsis in those patients that aspirated. Hazard ratio (HR) of aspiration among those without sepsis was 2.883 (p= 0.036) and this was statistically significant. Hazard ratio of aspiration complicated by sepsis was 1.525 and was not statistically significant (p= 0.335)

Table 14: COX Proportional Hazard Model for Patients with Dysphagia controlling for the effect of sepsis

Variable Beta SE p-value HR 95% CI

Aspiration without sepsis 1.059 0.509 0.036 2.883 1.070 – 7.767 Aspiration with Sepsis 0.422 0.438 0.335 1.525 0.646 – 3.600

*P-value <0.05- significant SE: Standard Error. HR: Hazard ratio. CI: Confidence Interval.

66 CHAPTER FIVE DISCUSSION

Dysphagia following acute stroke is a common and serious problem. It is being increasingly recognized now that unilateral hemispheric affectation can cause dysphagia.18, 62, 72, 141

Socio-demographic characteristic of the study population

The mean age of subjects at presentation was 60.8± 11.8 years. This finding is similar to reports by Danesi et al in urban Nigeria where the mean age at presentation was 58.5±13.5 years.⁴¹ Other studies done in Nigeria showed almost similar ages at presentation.40, 142, 143 However, these mean ages were found to be lower than the findings of Osuntokun where the ages at presentation were 8^th decade in male and 7^th decade in female.⁵ The difference in the peak ages at onset of stroke is probably due to increased incidence of cardiovascular risk factors for stroke among the middle aged group. Study by Owolabi et al¹⁴⁴ showed that stroke in the young adult was not as uncommon as was previously suggested. The cardiovascular risk factors identified in that study were hypertension, hypercholesterolemia, and diabetes mellitus.¹⁴⁴ The fact that middle aged group is now mostly affected by stroke will have significant economic, social and medical burden on low resource countries including Nigeria.

This study also showed male to female (M: F) ratio of 1.08: 1.0. This was similar to findings by Remesso, et al⁷⁴ in 2011 where the M: F was 1.02:1. Male to female ratios found by Danesi⁴¹ and

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Obiakor¹⁶ were 1.45:1 and 3.1:1 respectively. Desalu⁴⁰ and Onwuchewa¹⁴³ found a slightly higher female to male ratio. Findings from all these studies showed a clear departure from previous impression that stroke was much commoner in male. The role of risk factors unique to women such as the use of oral contraceptives, hormone replacement therapy, pregnancy, and insufficient treatment of conventional stroke risk factors in women have all been considered as probable explanations.¹⁴⁵

Clinical characteristics of study population

The commonest risk factor for stroke found in this study in both dysphagic and non-dysphagic stroke patients was hypertension. This finding was consistent with other findings in Nigeria^{5, 38,}

40, 42, 142, 146, 147 and in Sub-Saharan Africa.33, 34, 148, 149 Other risk factors identified were diabetes mellitus and dyslipidemia. Africa bears a heavy burden of stroke. In order to stem the surge of stroke and other vascular diseases in Nigeria and in Sub-Saharan Africa at large, a better coordinated community-based primary and secondary prevention programs needs to be instituted. This will help in curtailing these cardiovascular risk factors for stroke.

National institute health stroke scale (NIHSS) score of study participants was significantly higher at presentation in dysphagic stroke patients than in non-dysphagic. The average NIHSS of the dysphagic was in severe category and this also affected the outcome of the dysphagic stroke patients as it contributed significantly to the 30-day case fatality. Dawodu,¹⁵⁰ Adams et al,¹⁵¹ and Fonarow et al¹⁵² showed that initial NIHSS score predicted mortality risk in stroke patients. The

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mean initial NIHSS score in stroke patients with complications was much higher than those without complication.

Frequency of dysphagia among stroke patients.

The frequency of dysphagia in this study was 46.47% with peripheral oxygen desaturation and 48.50% with 10mls water swallowing test. These findings were similar to results from other studies that used similar methods.72, 106, 116, 132, 153-155 The incidence of dysphagia in stroke patients ranged from 65% to 81% when Videofluoroscopy and FEES, the gold standards for detecting dysphagia, were used.76, 87, 156 Positive and negative predictive values of the bedside swallowing methods used in this study were not estimated as the gold standards for detecting dysphagia (Videofluoroscopy and FEES) were not available.

This study showed that checking for gag reflex is a useful method for screening for dysphagia in stroke patients. 49.50% of those patients screened were found to have absent gag reflex (95% CI:

43.19-54.58). This finding was consistent with other studies which showed that absent gag reflex is predictive of aspiration in stroke patients.^106-108 However, findings of some other studies showed that using gag reflex alone to screen for dysphagia in stroke patients had low sensitivity and specificity.110, 123, 157, 158 It was found in other studies that Peripheral Oxygen desaturation during swallowing of 10mls of water had high specificity.111, 114, 115 Studies have shown that combination of both water swallowing test (WST) and peripheral oxygen desaturation method increased sensitivity and specificity of detecting dysphagia in stroke patients.20, 115, 116, 157 These findings from this study underscored the importance of checking for swallowing difficulty in all stroke patients.

69 Brain lesion and occurrence of dysphagia

It was observed in this study that 64.65% of patients with dysphagia had hemorrhagic stroke (p<0.001) while the predominant stroke type in those patients without dysphagia was ischemic (64.36%) (p< 0.001). These findings were statistically significant. These findings are similar to the findings of Paciaroni et al¹⁵⁹, Sundar et al¹⁴¹ and El-Sheikh W. M¹⁵⁵ where it was noted that dysphagia was more frequent in patients with hemorrhagic stroke. Remesso et al⁶⁴ also noted that severity of dysphagia was worse in patients with hemorrhagic stroke. Although hemorrhagic stroke is less common than ischemic stroke, presence of hemorrhagic stroke may be predictive of swallowing dysfunction.

This study also showed that the laterality of neurological deficit appeared not to influence the development of dysphagia. All the controls and almost all the cases were right-handed, inferring left hemispheric dominance. 53.5% of patients with dominant hemispheric lesion and 46.5% of patients with non-dominant hemispheric lesion developed dysphagia. In those patients without swallowing dysfunction, 51.5% had dominant hemispheric lesion while 48.5% had

non-dominant hemispheric lesion. These differences were not statistically significant. These findings were comparable to findings in other studies.141, 155, 159, 160 It is becoming increasingly evident that unilateral affectation of either lobe, dominant or non-dominant, can result in dysphagia contrary to the earlier belief that only bi-hemispheric lesions, where supratentorial structures are concerned, could lead to dysphagia.^{62, 66} Studies by Hamdy et al^{63, 72} suggest that swallowing is represented bilaterally but asymmetrically with no clear right or left laterality and the size of the cortical area associated with swallowing in the unaffected cortex determines the presence or absence of dysphagia. We can therefore infer that there is the possibility of unilateral

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hemispheric dominance which varies between individuals.Further studies requiring serial imaging and transcranial magnetic stimulation to identify the swallow-dominant side can help determine whether there is a dominant hemisphere in each individual that, if affected, results in swallowing dysfunction or if the increased representation of swallowing in the unaffected hemisphere is a result of cortical reorganization and compensation.

Only six study participants had TACI based on Oxfordshire Community Stroke Project (OCSP) classification of cerebral infarct. Four of the patients with TACI had dysphagia and the other two did not have it. Although this finding was not statistically significant (p= 0.393) probably due to the small number of patients that had TACI, Sundar et al¹⁴¹ in his study found that all the patients that had TACI had swallowing difficulty. Presence of dysphagia in TACI is probably dueto large area of hemispheric infarction involved. Only oneout of the seven patients in the study population that had lacunar syndrome had dysphagia. This finding is consistent with the findings of Sundar¹⁴¹ and Ellul et al.¹⁶¹ The fact that patients with lacunar stroke has lower incidence of dysphagia may probably be due to smaller infarct volume and better collateral circulation through the Circle of Willis.

Although supplementary motor area, represented in the superior and middle frontal gyri, is believed to be associated with planning of sequential movements, as occurs with swallowing⁸⁸ lesions in the cortical areas were not significantly associated with dysphagia in this study. This was similar to the findings of Gonzalez-Fernandez et al.⁹⁸ Findings from this study showed that sub-cortical lesions were associated with swallowing. This was similar to the findings in other studies.^{91, 98} The later stages of swallowing process are largely involuntary and are controlled by

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subcortical mechanisms which may be affected by basal ganglia, thalamic, large hemispheric or bi-hemispheric lesions.¹⁶² Subcortical lesions found to be associated with dysphagia in this study involved the internal capsule, thalamus and basal ganglia..

Brainstem/ cerebellar lesions were found more in dysphagic than in non-dysphagic stroke patients in this study. The difference was not statistically significant probably due to small numbers of patients with brainstem and cerebellar lesions. Lesions in brainstem were found in several other studies to be associated with dysphagia.64, 141, 155, 163, 164 Dysphagia is common in brain stem strokes probably due to lower motor involvement of bulbar swallowing mechanisms.

Lesions in the brainstem could affect the sensitivity of the oral cavity, tongue and cheeks, and could trigger swallowing disorders and laryngeal elevation_.^{60, 77}

.

Stroke severity and dysphagia

The initial mean National institute health stroke scale (NIHSS) score was higher in dysphagic stroke patients than in dysphagic stroke. The initial mean NIHSS of dysphagic and non-dysphagic stroke patients was 22.81±6.23 and 8.92±6.37 respectively. This difference was statistically significant. Jevaseelan et al¹⁶⁶ showed that NIHSS >9 was moderately predictive of clinically relevant dysphagia. Okubo et al¹⁶⁷ also showed that NIHSS is highly sensitive and specific in detecting dysphagia, with NIHSS score of 12 being suggested as a cutoff value.

Beside the fact that high NIHSS score contributed to the 30-day mortality in this study, it appears there is an association between initial NIHSS score and presence of dysphagia.

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Effect of dysphagia on the 30-day outcome in acute stroke patients.

This study clearly showed that swallowing difficulty contributed significantly to the morbidity and mortality of acute stroke patients. 79.8% of acute stroke patients with dysphagia died on admission while 16.8% of group of patients without dysphagia died. This study also showed that stroke patients without dysphagia survived significantly longer (25.56 days) than those with dysphagia (12.21days). 30-day case fatality rate for patient with dysphagia alone was 24.2%.

Modified Rankin Scale (MRS) and Barthel Index (BI) were used in this study to objectively measure the functional outcome of dysphagic stroke patients and non-dysphagic stroke patients.

The findings were statistically significant. Findings from this study showed that stroke patients with dysphagia had worse functional outcome at the end of 4th week based on the MRS and BI values. These findings were comparable to results of other studies.19, 52-54, 56, 128, 155, 169, 170 Study by Remesso et al showed that stroke patients who showed abnormalities of swallowing had higher mortality rates.⁶⁴ Smithard et al¹²⁴ concluded that the presence of dysphagia was associated with an increased risk of death, disability, length of hospital stay, and institutional care among stroke patients. Study by Paciaroni.et al¹⁵⁹ revealed that stroke mortality and disability were independently associated with dysphagia.

Apart from respiratory complication that is associated with dysphagia, dehydration and deterioration in nutritional status have also been found to be common complications of

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dysphagia.27, 59, 117, 126 Parameters for assessing dehydration and deterioration in nutritional status were not checked for in this study.

Frequency of aspiration pneumonia in acute stroke patients with dysphagia.

There is high incidence of dysphagia after stroke which is also associated with increased risk of aspiration pneumonia. Dysphagia is an independent risk factor for aspiration in patients with acute stroke.^{62, 168}

In this study, presence of aspiration pneumonia in stroke patients with dysphagia was diagnosed based on the presence of ≥3 of the following clinical variables: fever (>38°C), Abnormal

respiratory examination (Tachypnea (>22/min), Chest crackles and bronchial breathing), tachycardia, CXR abnormality, and Leucocytosis. These criteria were also used in other studies to diagnose aspiration pneumonia.132, 141, 155

The frequency of aspiration pneumonia in those patients with dysphagia in this study was 62.6%.

Aspiration pneumonia was also the commonest complication of acute stroke found in this study.

This was similar to findings of Obiako et al in 2011.¹⁶ Other studies also showed that aspiration pneumonia was the commonest complication in stroke patients that had swallowing

dysfunction.52, 55, 56, 128, 155

These findings further highlight the importance of screening for dysphagia in acute stroke patients in other to prevent complication of aspiration pneumonia which may increase morbidity and mortality in stroke.

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Effect of aspiration pneumonia on the 30-day outcome in acute stroke patients

This study showed that aspiration pneumonia contributed significantly to the morbidity and mortality of acute stroke patients. More patients with aspiration pneumonia died (69.4%) on admission compared to 30.4% of dysphagic patients without aspiration that died on admission.

Also, patients that had aspiration pneumonia survived for much shorter days (9.5 days) than those patients without aspiration (15 days). These findings were statistically significant. This study also showed that dysphagic stroke patients that had aspiration pneumonia had worse functional outcome based on the MRS and BI at 4th week post stroke than those without aspiration pneumonia. 30-day case fatality rate for dysphagic stroke patients complicated by aspiration pneumonia was 55.6%. These findings were comparable to results of other studies. In a large community-wide study of stroke outcomes by Katzan et al⁵⁵, pneumonia conferred a threefold increased risk of 30-day death. Aslanyan et al¹²⁸ showed that pneumonia was associated with poor outcome in acute stroke patients. Heuschmann et al⁵³ did a study on

predictors of in-hospital mortality and attributable risks of death after ischemic stroke. Aspiration pneumonia was the complication with the highest attributable proportion of death in the entire stroke population. Vermeij et al⁵⁶ concluded that stroke-associated infection, in particular pneumonia, was independently associated with poor functional outcome after stroke.

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Logistic regression was used to determine variables associated with 30-day stroke fatality in this study. Variables considered were dysphagia, aspiration pneumonia, baseline NIHSS, gender, sepsis, stroke subtype, post stroke hyperglycemia, and mean arterial pressure at presentation.

In the multivariable analysis, dysphagia, aspiration pneumonia, severe baseline NIHSS, and haemorrhagic stroke subtype were important determinants of 30-day case fatality.

When a regression analysis was done for the stroke patients with dysphagia, aspiration was found to be an independent predictor for death. On further analysis, after controlling for the effect of sepsis on those patients that aspirated, the Hazard Ratio (HR) of aspiration among those without sepsis was statistically significant.

76 CHAPTER SIX

CONCLUSION

The frequency of dysphagia in this study was 46.47% with peripheral oxygen desaturation and 48.50% with 10mls water swallowing test.

Haemorrhagic stroke type was associated with dysphagia in acute stroke patients in this study. . Stroke lesions in the subcortical regions were more associated with dysphagia than cortical lesions. There was an association between stroke severity and dysphagia. The size of stroke lesion was also associated with dysphagia. Stroke patients with large lesion sizes had increased propensity to develop dysphagia.

Dysphagia contributed significantly to the morbidity and mortality of acute stroke patients in this study. 78.9% of stroke patients with dysphagia died on admission with their average survival days shorter than those without swallowing difficulty. Dysphagic stroke patients had worse functional outcome at the end of 4th week based on the MRS and BI values. 30-day case fatality rate for patient with dysphagia alone was 24.2%.

The frequency of aspiration pneumonia in stroke patients with dysphagia in this study was 62.6%. Aspiration pneumonia contributed significantly to the morbidity and mortality of acute stroke patients in this study. 69.4% of patients with aspiration pneumonia died on admission with

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