Bengt Hindfelt

THE PROGNOSTIC SIGNIFICANCE of SUBFEBRILITY and FEVER IN ISCHAEMIC CEREBRAL INFARCTION

The prognostic influence of subfebrility and fever during the first week after an ischaemic cerebral stroke was analysed retrospectively in 110 patients with varying neurological disabilities. the results indicate that fever, and even subfebrility, carry a bad prognosis with respect to residual symptoms. It is concluded that fever and subfebrility, irrespective of their genesis, should be intensely combated during the early stages of an ischaemic stroke.

Dysphagia in Stroke: A Prospective Study of Quantitative Aspects of Swallowing in Dysphagic Patients

Abstract. This is a prospective study of 100 consecutive stroke patients. Within 24 h after stroke onset they were asked specifically about swallowing complaints and subjected to a clinical examination including neurologic examination, Mini-Mental test, and Barthel score. Dysphagic patients were examined with the repetitive oral suction swallow test (the ROSS test) for quantitative evaluation of oral and pharyngeal function at 24 h, after 1 week, and after 1 month. At 6 months, the patients were interviewed about persistent dysphagia. Seventy-two patients could respond reliably at 24 h after the stroke onset and 14 of these complained of dysphagia. Non-evaluable patients were either unconscious, aphasic, or demented. The presence of dysphagia was not influenced by age or other risk factors for stroke. Facial paresis, but no other clinical findings, were associated with dysphagia. Dysphagia 24 h after stroke increased the risk of pneumonia but did not influence the length of hospital stay, the manner of discharge from hospital, or the mortality. The initial ROSS test, during which the seated patient ingests water through a straw, was abnormal in all dysphagic stroke patients. One-third of the patients were unable to perform the test completely. Above all, dysfunction was disclosed during forced, repetitive swallow. All phases of the ingestion cycle were prolonged whereas the suction pressures, bolus volumes, and swallowing capacities were low. Abnormalities of quantitative swallowing variables decreased with time whereas the prevalences of swallowing incoordination and abnormal feeding-respiratory pattern became more frequent. After 6 months, 7 patients had persistent dysphagia. Five of these were initially non-evaluable because of unconsciousness, aphasia, or dementia.

Quantitative aspects of swallowing in an elderly nondysphagic population

The prevalence of swallowing impairment increases with age and is a major health care problem in the elderly. It has been assumed that age-related changes in nerves and muscles hamper muscle strength and coordination of swallowing. However, it is unclear what impairment is related to primary aging and what is the consequence of diseases prevalent in the elderly (secondary aging). In order to quantify swallowing in nondysphagic elderly we used the noninvasive ROSS (Repetitive Oral Suction Swallow) test. A total of 53 individuals aged 76±5 years (mean±SD) were examined. We found that the nondysphagic elderly demonstrated significant differences compared with young individuals in 10 of 17 measured variables, i.e., decreased peak suction pressure, increased frequency of multiple swallows after one ingestion, increased frequency of polyphasic laryngeal movements, increased frequency of inspiration after swallowing, and increased frequency of coughing during or after swallowing. Therefore, primary aging mainly seems to influence coordination of swallowing, but oral and pharyngeal swallow per se seem to be unaffected.

BRAIN INFARCTION IN YOUNG ADULTS

Sixty‐four young adults (aged 16 to 40 years) with ischemic stroke were analyzed in retrospect with regard to possible pathogenetic mechanisms. In older patients various predisposing factors emerge (arterial hypertension, hyperlipidemia etc.) which are rare among younger age groups. In patients lacking predisposing causes the stroke incidence exhibits a seasonal variation. It is suggested that infection may be important for the development of ischemic stroke.

Quantitative assessment of oral and pharyngeal function in Parkinson's disease

Oral and pharyngeal dysfunction is common in Parkinsons disease. To reveal the frequency of swallowing dysfunction and correlate swallowing dysfunction with locomotor disturbances, we studied 75 patients with Parkinsons disease staged I–IV according to the Hoehn and Yahr score. We assessed oral and pharyngeal swallow during optimal medication by a quantitative test of swallowing (the ROSS test) measuring the suction pressure, bolus volume, swallowing capacity, and time for important events in the swallowing cycle. We found abnormal results in 7/12 patients (58%) in stage 1 of the Hoehn and Yahr score, in 13/14 patients (93%) in stage 2, in 29/32 patients (91%) in stage 3, and in 16/17 patients (94%) in stage 4. Abnormal test results in stages, 1, 2, and 3 were seldom related to swallowing difficulties noticed by the patients. In advanced disease (Hoehn and Yahr stage 4), the abnormal results were often considerable, with swallowing difficulties obvious to the patient. Two of 17 patients coughed during or immediately after the test and 3/17 patients were unable to complete the test. The degree of swallowing disturbance increased during stress (forced, repetitive swallow). The Hoehn and Yahr score and the results in the ROSS test did not correlate, indicating that swallowing disturbances are due to nondopaminergic degeneration. Silent swallowing impairment may interfere with the nutrition and quality of life in Parkinsons disease, thus it is of interest to monitor this in clinical practice.

THE PROGNOSIS OF ISCHEMIC STROKE IN YOUNG ADULTS

The report provides prognostic information on 60 patients (aged 16 to 40 years) with ischemic stroke. Immediate mortality from stroke is low and long‐term mortality is due to other causes than cerehrovascular disease. The recovery from neurological deficits is good except for patients with occlusions of the internal carotic artery or the proximal part of the middle cerebral artery. Reinfarction is rare (about 0.5 per cent annually) and other late neurological complications do not seriously affect long‐term prognosis. More than 80 per cent of the patients will be able to resume work on a full or part‐time basis.

Quantitative assessment of swallowing in healthy adults

Swallowing has hitherto been evaluated during physical examination, radiologic barium studies, manometry, and cervical auscultation. Radiography principally demonstrates qualitative aspects of oral and pharyngeal function, whereas quantitative aspects have primarily been documented by manometry. To evaluate swallowing quantitatively, without using invasive methods or radiation, we have applied a combined test of water drinking, i.e., the Repetitive Oral Suction Swallow test (ROSS). The test provides reliable measurements of suction pressure, bolus volume, timing of important events in oral and pharyngeal swallow, and respiration. The test is described and results from 292 healthy, nondysphagic subjects are presented. We found a mean bolus volume of 25.6±8.5 ml during single swallow and 21.1±8.2 ml during stress (forced, repetitive swallow). During forced, repetitive swallow, the bolus volume was more strongly associated with suction time (r2=0.55) than with peak suction pressure (r2=0.04), indicating that suction time is more important than suction pressure in determining the bolus volume. The oral-pharyngeal transit time decreased: single swallow 0.56±0.36 sec, forced repetitive swallow 0.23±0.11 sec, as did the coefficient of variation (48% and 64%, respectively) indicating a more automatic neural process for pharyngeal function in forced, repetitive swallow. The postswallow respiration started with inspiration in 10% of studied individuals, but did not correlate with deviations in other variables in the test. Thus, postswallow inspiration must be considered as normal. The ROSS test offers a rapid and easy quantitative assessment of swallowing.

Assessment of respiration during video fluoroscopy of dysphagic patients

RATIONALE AND OBJECTIVES The authors evaluated the coordination of swallowing and respiration in dysphagic patients. MATERIALS AND METHODS Video fluoroscopy and respirometry were performed simultaneously during 98 swallows in 33 patients (18 women, 15 men) with a median age of 70 years (interquartile range, 52-78 years). Pharyngeal transit time, deglutition apnea, and the ratio between the two (swallowing safety index) were calculated. Presence of a misdirected swallow (aspiration or penetration) was indicated. RESULTS Pharyngeal transit time was not associated with deglutition apnea. Misdirected swallow was associated with a slightly prolonged pharyngeal transit time, a slightly shorter deglutition apnea, and a significantly lower swallowing safety index (1.8 [1.0-4.2] vs 4.5 [2.4-6.7]; P < .001) compared with normally directed swallow. The association between misdirected swallow and lower swallowing safety index was independent of pharyngeal transit time. CONCLUSION Assessment of respiration is important in the evaluation of dysphagia. Aspiration, especially in elderly dysphagic patients, may be a consequence of primarily disturbed respiration. A low swallowing safety index may indicate risk of misdirected swallow.

Clinical and cerebrospinal fluid findings in lymphocytic meningo‐radiculitis (Bannwarth's syndrome)

11 patients with lymphocytic meningo‐radiculitis (Bannwarths syndrome) are described. The disease is characterized by intensive pain, often radiating and migrating, and neurological deficits, i.e. peripheral facial palsies, as well as disseminated radiculopathies. In 4 patients the onset was preceeded by an arthropode bite, close to which 3 patients exhibited an erythema chronicum migrans.

Brain proteins in hepatic encephalopathy.

Brain proteins were analyzed in supra‐ and infratentorial structures of 6 patients dying from liver failure. An equal number of patients, lacking any evidence of liver disease or neurological disorder, served as controls. The results were related to regional light microscopic findings. Hepatic coma was associated with a marked reduction of soluble brain proteins, particularly in areas of grey matter. The protein loss is probably neuronal and may be secondary to abnormalities in glial function. Implications for the pathogenesis of hepatic encephalopathy are discussed.