Interventions for dysphagia in acute stroke (Review)

Background It is unclear how dysphagic patients should be fed and treated after acute stroke. Objectives The objective of this review was to assess the effect of different management strategies for dysphagic stroke patients, in particular how and when to feed, whether to supplement nutritional intake, and how and whether to treat dysphagia. Search strategy We searched the Cochrane Stroke Group trials register, Medline, Embase, ISI, and existing review articles.We contacted researchers in the field and equipment manufacturers. Date of the most recent searches: March 1999. Selection criteria Unconfounded truly or quasi randomised controlled trials in dysphagic patients with acute/subacute (within 3 months) stroke. Data collection and analysis Three reviewers independently applied the trial inclusion criteria. Two reviewers assessed trial quality and extracted the data. Main results Percutaneous endoscopic gastrostomy (PEG) versus nasogastric tube (NGT) feeding: two trials (49 patients) suggest that PEG reduces end-of-trial case fatality (Peto Odds Ratio, OR 0.28, 95% CI 0.09 to 0.89) and treatment failures (OR 0.10, 95% CI 0.02 to 0.52), and improves nutritional status, assessed as weight (Weighted Men Difference, WMD +4.1 kg, 95% CI -4.3 to +12.5), mid-arm circumference (WMD +2.2 cm, 95% CI -0.5 to +4.9) or serum albumin (WMD + 7.0 g/l, 95% CI +4.9 to +9.1) as compared with NGT feeding; two larger studies are ongoing. Timing of feeding: no completed trials; one large study is ongoing. Swallowing therapy for dysphagia: two trials (85 patients) suggest that formal swallowing therapy does not significantly reduce end-of-trial dysphagia rates (OR 0.55, 95%CI 0.18 to 1.66). Drug therapy for dysphagia: one trial (17 patients); nifedipine did not alter end-of-trial case fatality or the frequency of dysphagia. Nutritional supplementation: one trial (42 patients) found a non-significant trend to a lower case fatality, and significantly increased energy and protein intake; one large trial is ongoing and data is awaited from two other studies. Fluid supplementation: one trial (20 patients) found that supplementation did not alter the time to resolution of dysphagia. Authors’ conclusions Too few studies have been performed, and these have involved too few patients. PEG feeding may improve outcome and nutrition as compared with NGT feeding. Further research is required to assess how and when patients are fed, and the effect of swallowing or drug therapy on dysphagia.

Compression stockings and the prevention of symptomatic venous thromboembolism: data from the Tinzaparin in Acute Ischaemic Stroke Trial

Background: Venous thromboembolism (VTE) is a well recognised and preventable complication of acute stroke. While graduated compression stockings reduce the risk of VTE in surgical patients their benefit in acute stroke remains uncertain. Methods: The relationship between symptomatic VTE and use of stockings using observational data from the ‘Tinzaparin in Acute Ischaemic Stroke Trial’, which compared 10 days of treatment with tinzaparin (175 IU.kg-1 or 100 IU.kg-1) with, aspirin (300 mg od), was assessed using logistic regression adjusted for known VTE risk factors and treatment. Results: Symptomatic VTE occurred in 28 patients (1.9%, DVT 18, PE 13) within 15 days of enrolment in 1,479 patients. Patients wearing one or two stockings for any period of time during the first 10 days (n=803) had a non-significant increase (odds ratio, OR 2.45, 95% confidence interval, CI 0.95 - 6.32) in the risk of symptomatic VTE. In contrast, those wearing bilateral stockings for 10 days (n=374) had a non-significant reduction in the odds of symptomatic VTE as compared to those who wore no stockings or wore them for less than 10 days (OR 0.65, 95% CI 0.26-1.65). Mild stroke and treatment with tinzaparin were associated with a reduced risk of VTE. Conclusions: Bilateral graduated compression stockings may reduce the incidence of VTE by one-third in patients with acute ischaemic stroke. However, the uncertainty in this finding, low frequency of symptomatic VTE, potential for stockings to cause harm, and cost of stockings highlight the need for a large randomised-controlled trial to examine the safety and efficacy of stockings in acute stroke.

A randomised controlled trial of triple antiplatelet therapy (Aspirin, Clopidogrel and Dipyridamole) in the secondary prevention of stroke: safety, tolerability and feasibility

Background: Aspirin, dipyridamole and clopidogrel are effective in secondary vascular prevention. Combination therapy with three antiplatelet agents might maximise the benefit of antiplatelet treatment in the secondary prevention of ischaemic stroke. Methodology/Principal Findings: A randomised, parallel group, observer-blinded phase II trial compared the combination of aspirin, clopidogrel and dipyridamole with aspirin alone. Adult patients with ischaemic stroke or transient ischaemic attack (TIA) within 5 years were included. The primary outcome was tolerability to treatment assessed as the number of patients completing randomised treatment. Recruitment was halted prematurely after publication of the ESPRIT trial (which confirmed that combined aspirin and dipyridamole is more effective than aspirin alone). 17 patients were enrolled: male 12 (71%), mean age 62 (SD 13) years, lacunar stroke syndrome 12 (71%), median stroke/TIA onset to randomisation 8 months. Treatment was discontinued in 4 of 9 (44%) patients receiving triple therapy vs. none of 8 taking aspirin (p = 0.08). One recurrent stroke occurred in a patient in the triple group who was noncompliant of all antiplatelet medications. The number of patients with adverse events and bleeding complications, and their severity, were significantly greater in the triple therapy group (p,0.01). Conclusions/Significance: Long term triple antiplatelet therapy was asociated with a significant increase in adverse events and bleeding rates, and their severity, and a trend to increased discontinuations. However, the patients had a low risk of recurrence and future trials should focus on short term therapy in high risk patients characterised by a very recent event or failure of dual antiplatelet therapy.