Stroke is regularly accompanied by dysphagia and other factors associated with decreased nutritional intake. Dysphagia with aspiration pneumonia and insufficient nutritional intake lead to worse outcome after stroke.

Objective: Introduction and validation of a phenotypic classification of neurogenic dysphagia based on flexible endoscopic evaluation of swallowing (FEES). Methods: A systematic literature review was conducted, searching MEDLINE from inception to 05/2020 for FEES findings in neurological diseases of interest. Based on a retrospective analysis of FEES-videos in neurological diseases and considering the results from the review, a classification of neurogenic dysphagia was developed distinguishing different phenotypes. The classification was validated using 1012 randomly selected FEES-videos of patients with various neurological disorders. Chi-square-tests were used to compare the distribution of dysphagia phenotypes between the underlying neurological disorders. Results: 159 articles were identified of which 59 were included in the qualitative synthesis. Seven dysphagia phenotypes were identified: (1) “Premature bolus spillage” and (2) “delayed swallowing reflex” occurred mainly in stroke patients, (3) “predominance of residue in the valleculae” was most common in Parkinson9s disease, (4) “predominance of residue in the piriform sinus” occurred only in myositis, motoneuron disease and brainstem stroke patients, (5) “pharyngolaryngeal movement disorder” was found in atypical Parkinsonian syndromes and stroke patients, (6) “fatigable swallowing weakness” was common in patients with myasthenia gravis, and (7) “complex disorder” with a heterogeneous dysphagia pattern was the leading mechanism in amyotrophic later sclerosis. The interrater reliability showed a strong agreement (kappa = 0.84). Conclusion: Neurogenic dysphagia is not a mere symptom, but a multi-etiological syndrome with different phenotypic patterns depending on the underlying disease. Dysphagia phenotypes can facilitate differential diagnosis in patients with dysphagia of unclear etiology.

Background: Parkinson's disease (PD) is a common neurodegenerative disorder. The contribution of the immune system to its pathogenesis remains incompletely understood. Methods: In this study, we performed comprehensive immune cell profiling in the cerebrospinal fluid (CSF) and peripheral blood (PB) of PD patients. Ten PD patients were diagnosed according to brain bank criteria and underwent detailed clinical examination, magnetic resonance imaging, PB and CSF immune cell profiling by multiparameter flow cytometry, and cytokine and chemokine measurements by bead-based arrays. Thirteen healthy elderly volunteers served as control population. Results: The proportions of activated T-lymphocytes and non-classical monocytes in the CSF were increased in patients with PD compared to the control group. In accordance, we found increased levels of the pro-inflammatory cytokines IL-2, IL-6 and TNFα and of the monocyte chemoattractant protein 1 (MCP-1) in the CSF of the included PD patients. Conclusions: Our data provide novel evidence for a response of the innate and adaptive immune system in the central nervous system of patients with PD.

Background and Purpose: Fiberoptic endoscopic evaluation of swallowing (FEES) is a suitable method for dysphagia assessment after acute stroke. Recently, we developed the fiberoptic endoscopic dysphagia severity scale (FEDSS) for acute stroke patients, grading dysphagia into 6 severity codes (1 to 6; 1 being best). The purpose of this study was to investigate the impact of the FEDSS as a predictor of outcomes at 3 months and intermediate complications during acute treatment. Methods: A total of 153 consecutive first-ever acute stroke patients were enrolled. Dysphagia was classified according to the FEDSS, assessed within 24 h after admission. Intermediate outcomes were pneumonia and endotracheal intubation. Functional outcome was measured by the modified Rankin Scale (mRS) at 3 months. Multivariate regression analysis was used to identify whether the FEDSS was an independent predictor of outcome and intercurrent complications. Analyses were adjusted for sex, age and National Institutes of Health Stroke Scale (NIH-SS) on admission. Results: The FEDSS was found to predict the mRS at 3 months as well as but independent from the NIH-SS. For each additional point on the FEDSS, the likelihood of dependency at 3 months (mRS ≥ 3) raised by ∼50%. Each increase of 1 point on the FEDSS conferred a more than 2-fold increased chance of developing pneumonia. The odds for the necessity of endotracheal intubation raised by a factor of nearly 2.5 with each additional point on the FEDSS. Conclusions: The FEDSS strongly and independently predicts outcome and intercurrent complications after acute stroke. Thus, a baseline FEES examination provides valuable prognostic information for the treatment of acute stroke patients.

Objectives: Decisions regarding tracheostomy tube removal after mechanical ventilation often depend on the physician’s individual experience because evidence-based practice guidelines are still scarce, especially for critically ill neurologic patients. In these patients, the prevalence of aspiration is high and regarded as an important contributor to decannulation failure. The presence of severe neurological deficits may, however, give clinicians the subjective impression that a tracheostomy tube is still necessary although decannulation may actually be safe. It is therefore crucial to test swallowing function reliably prior to decannulation in this patient population. Design: Prospective observational study. Setting: University hospital, neurological ICU. Patients: One hundred tracheostomized patients with acute neurologic disease completely weaned from mechanical ventilation. Interventions: An endoscopic protocol evaluating readiness for decannulation and a conventional clinical swallowing examination were carried out by separate, experienced practitioners blinded to each other’s decisions. Patient management always followed the decision made with endoscopy. Measurements and Main Results: Practitioners’ decannulation decisions (yes/no) reached with both assessments were compared. Decannulated patients were monitored throughout their stay for complications related to tube removal. Endoscopy was performed successfully in all subjects without any complications. Following the protocol, the tracheostomy tube was successfully removed in 54 patients, whereas according to the clinical swallowing examination, only 29 patients would have been decannulated at that point. Only one patient needed recannulation due to respiratory problems, resulting in a failure rate of 1.9%. Conclusions: In neurologic patients, speech-language pathologists’ impressions about the patient’s state when clinically assessing indirect variables of swallowing function often lead to the unnecessary prolongation of cannulation time. Endoscopic evaluation has the advantage of objectively visualizing the patient’s ability to manage secretions directly and allows for faster but, nonetheless, safe decannulation. The endoscopic protocol proposed here is a safe, efficient, and objective bedside tool to guide decannulation decisions.