Stent-Graft Repair of a Large Cervical Internal Carotid Artery Pseudoaneurysm Causing Dysphagia

Pseudoaneurysms of the cervical internal carotid artery (ICA) are rare and most frequently result from trauma, infection, or sometimes spontaneously. They have the potential to cause life-threatening hemorrhage; thus, their immediate management is necessary. Endovascular treatment by stent graft placement in the affected artery appears to be a safe and effective treatment option. We present a case of a child who presented with neck swelling and dysphagia caused by a ruptured cervical ICA pseudoaneurysm which was managed by stent graft placement.     

Anatomical changes in the pharyngeal constrictors after chemo-irradiation of head and neck cancer and their dose-effect relationships: MRI-based study

Purpose

Dysfunction of pharyngeal constrictors (PCs) after chemo-irradiation of head and neck (HN) cancer has been proposed as major cause of dysphagia. We conducted prospective MRI study to evaluate anatomical changes in the PCs after chemo-irradiation, to gain insight of the mechanism of their dysfunction and their dose-effect relationships. The PCs were compared to the sternocleidomastoid muscles (SCMs), which receive high doses but do not relate to swallowing.

Patients and methods

Twelve patients with stage III-IV HN cancer underwent MRI before and 3 months after completing chemo-irradiation. T1- and T2-weighted signals and muscle thickness were evaluated for PCs (superior, middle, and inferior), and SCMs. Mean muscle doses were determined after registration with the planning CT.

Results

T1-weighted signals decreased in both PCs and SCMs receiving >50 Gy (p < 0.03), but not in muscles receiving lower doses. T2-weighted signals in the PCs increased significantly as the dose increased (R² = 0.34, p = 0.01). The T2 signal changes in the PCs were significantly higher than the T2 changes in the SCMs (p < 0.001). Increased thickness was noted in all PCs, with muscles receiving >50 Gy gaining significantly more thickness than PCs receiving lesser doses (p = 0.02). In contrast, the SCM thickness decreased post-therapy (p = 0.002).

Conclusions

These MRI-based findings, notably the differences between PCs and SCMs, suggest that underlying causes of PC dysfunction are inflammation and edema, likely consequential to acute mucositis affecting the submucosa-lying PCs. These results support reducing mean PC doses to ?50 Gy, as well as reducing acute mucositis, to improve long-term dysphagia.     

脑卒中后吞咽障碍与医院获得性肺炎的关系

目的观察脑卒中后吞咽障碍与医院获得性肺炎发生的关系及对预后的影响。方法对356例脑卒中住院患者进行床边误吸试验,由此分为吞咽障碍组(A组)与无吞咽障碍组(B组),观察两组医院获得性肺炎发生与死亡情况。结果A组医院获得性肺炎发生率达23.5%,B组医院获得性肺炎发生率4.6%,两组差异有统计学意义(2χ=25.8,P<0.01),A组死亡率10.4%,B组死亡率4.0%,差异有统计学意义(χ2=5.3,P<0.05)。结论脑卒中后吞咽障碍是医院获得性肺炎的重要危险因素,显著影响预后,应予以高度重视。     

颈前路减压零切迹椎间植骨融合内固定系统治疗颈椎病的早期疗效分析

目的:分析颈前路减压零切迹椎间植骨融合内固定系统(Zero-P)治疗颈椎病的早期疗效。方法 :2010年6月~10月39例颈椎病患者接受颈前路减压Zero-P植骨内固定手术,患者年龄33~71岁,平均50.3岁。神经根型颈椎病8例,脊髓型31例;单间隙14例,2个间隙18例,3个间隙7例。共置入Zero-P 71枚,C3/4、C4/5、C5/6、C6/7椎间隙置入Zero-P分别为8、19、30、14枚。术前、术后2个月及12个月对神经根型颈椎病患者行VAS评分、脊髓型颈椎病患者行JOA评分,在颈椎中立侧位X线片上测量颈椎Cobb角(C2和C7椎体后缘切线的夹角),观察术后吞咽不适的发生率以及症状持续时间。根据术后伸屈侧位X线片观察手术间隙有无异常活动。结果:手术时间48~130min,平均86min;术中出血量40~310ml,平均110ml。14例患者术后1周内出现吞咽不适,其中13例术后2个月内症状消失,1例(2.6%)症状持续至术后4个月消失。随访12~16个月,平均14.6个月。神经根型颈椎病患者术后2个月、12个月时的VAS评分分别为1.5±0.8分、1.3±0.9分,均低于术前的7.3±1.3分(P<0.05)。脊髓型颈椎病患者术后2个月、12个月时的JOA评分分别为14.6±1.1分、15.0±1.2分,均高于术前的9.7±1.7分(P<0.05)。术后2个月及12个月颈椎Cobb角分别为18.4°±9.6°、17.8°±9.2°,大于术前的9.0°±10.0°(P<0.05)。术后12个月时的VAS评分、JOA评分和颈椎Cobb角与术后2个月比较无显著性差异(P>0.05)。随访期间手术间隙无异常活动,内置物无移位。结论:颈前路减压Zero-P植骨内固定治疗颈椎病的早期疗效满意,稳定性可靠,可重建颈椎曲度,术后慢性吞咽不适发生率低。     

六泉穴解惑刺法治疗脑卒中后吞咽障碍的临床研究

目的:观察六泉穴解惑刺法对于脑卒中后吞咽障碍患者吞咽功能的影响。方法:将89例患者随机分为治疗组45例和对照组44例。治疗组采用六泉穴解惑刺法,对照组采用神经内科常规治疗联合吞咽康复训练。2组进行标准吞咽功能评估量表、改良的Barthel量表、吞咽困难生活质量量表评估。结果:2组治疗前各量表评分比较差异无统计学意义(P0.05);2组治疗后各量表评分组间比较差异均具有统计学意义(P0.05);治疗组和对照组总有效率分别是93.33%和79.55%。结论:治疗组在改善患者吞咽功能,提高生活质量、日常生活活动能力方面改善程度更大,证明六泉穴解惑刺法疗效更优。     

Nutritional Management in Adult Patients With Dysphagia: Position Paper From Japanese Working Group on Integrated Nutrition for Dysphagic People

This position paper prepared by the Japanese Working Group on Integrated Nutrition for Dysphagic People (JWIND) aims to summarize the need for nutritional management in adult patients with dysphagia, the issues that nutrition professionals should address, and the promising approaches as well as to propose a vision for the future of nutritional care for adult patients with dysphagia. JWIND is a joint certification system recognized by the Japan Dietetic Association and the Japanese Society of Dysphagia Rehabilitation; its members are mostly experts known as “Certified Specialist of Registered Dietitian for Dysphagia Rehabilitation.” Malnutrition and dysphagia are associated with each other. Therefore, malnutrition detection and intervention are essential for patients with dysphagia. However, evidence on the usefulness nutritional assessment and intervention to ensure appropriate nutritional care remains insufficient. Here, we present current knowledge of the relationship between primary diseases causing dysphagia and malnutrition, the indicators used for nutritional assessment, and nutritional interventions such as texture-modified diet (TMD) quality improvement, oral nutritional supplementation, and comprehensive intervention. We also discuss the current status and issues in nutritional care for adult patients with dysphagia. Furthermore, we have proposed measures that nutrition professionals should consider based on 3 perspectives: nutritional assessment, TMD, and nutritional intervention. Individualized and specialized nutritional management by registered dietitians (RDs) through appropriate assessment of the nutritional status of adult patients with dysphagia is needed. To maintain and improve swallowing function and nutritional status, RDs should intervene from the state of risk or early dysphagia onset, providing individualized care per their expertise as part of a multidisciplinary team. However, systematic clinical practice and research regarding the association of nutrition with dysphagia are currently insufficient. Therefore, further clinical practice and evidence building, including the verification of the efficacy on nutritional support through intervention research, are needed.     

冰盐水喷洒口腔黏膜缓解吞咽功能障碍患者口渴的效果分析

目的　探讨冰盐水喷洒口腔黏膜缓解吞咽功能障碍患者口渴的应用效果。方法　本研究为试验性研究,选取2020年11月至2021年8月内蒙古自治区人民医院神经内科重症监护室吞咽功能障碍的患者70例,采用随机数字表法分为对照组和冰盐水组各35例。对照组男性患者23例,女性患者12例,年龄（68.11±10.16）岁;冰盐水组男性患者19例,女性患者16例,年龄（67.69±13.54）岁。对照组采用神经内科常规护理,即无菌棉签蘸生理盐水湿润口唇及舌面,冰盐水组将2～6 ℃的冰盐水装入象鼻喷壶,直喷喷洒口腔黏膜。采用口渴主观评价指标和客观评价指标对患者口渴程度、口腔唾液pH值等进行评价和统计学分析,比较两种方法缓解患者的口渴程度,采用Spearman相关性分析分析口渴程度与口腔唾液pH值的相关性。计量资料采用独立样本t检验,计数资料采用χ²检验,等级资料比较采用秩和检验。结果　干预后,对照组口渴数字等级评分（Numeric Rating Scale,NRS）为（8.51±0.85）分,冰盐水组NRS为（1.26±1.12）分,差异有统计学意义（t=30.487,P<0.001）;对照组口腔唾液pH值为（6.01±0.19）,冰盐水组口腔唾液pH值为（6.94±0.24）,差异有统计学意义（t=-17.890,P<0.001）。Spearman相关性分析显示NRS与口腔唾液pH值之间为负相关（r_s<0,P<0.05）。结论　冰盐水喷洒口腔黏膜可以缓解患者口渴的程度,患者的口渴程度与口腔唾液pH值之间呈中度负相关,口渴程度越严重,口腔唾液pH值越小,通过口腔唾液pH值可以判断患者口渴的严重程度。     

Effects of Neurostimulation on Poststroke Dysphagia: A Synthesis of Current Evidence From Randomized Controlled Trials

ObjectivesTo evaluate the effects of neurostimulation, including repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS) and pharyngeal electrical stimulation (PES), for poststroke dysphagia based on evidence from randomized controlled trials (RCTs).Materials and MethodsElectronic databases were systematically searched between January 1985 and June 2020 and studies were included based on prespecified selection criteria. The quality of studies was evaluated and data were extracted and synthesized by two independent reviewers. The primary outcome measure was change in (any) relevant clinical swallowing-related characteristic. Subgroup analysis were conducted based on follow-up period and stimulation parameters.ResultsData from 852 stroke patients were collected from 26 RCTs studies. Active neurostimulation treatments demonstrated a significant and moderate effect size compared to control treatment (0.69 [95% CI = 0.50, 0.89]; p < 0.001). The effect size of rTMS was the largest (0.73 [95% CI = 0.49, 0.98]; p < 0.001), followed by PES (0.68 [95% CI = 0.22, 1.14]; p = 0.004) and tDCS (0.65 [95% CI = 0.25, 1.04]; p = 0.001). All treatments showed comparable effect sizes within the first two weeks. Between three weeks and two months, tDCS demonstrated the largest effects (1.02 [95% CI = 0.45, 1.59]; p < 0.001) among the three treatments. No significant treatment effects were reported beyond three months. The combined effect size was large when applied in acute (<14 days) stroke (0.8 [95% CI = 0.34, 1.26]; p < 0.001). For noninvasive brain stimulation (NIBS), bihemispheric stimulation demonstrated the strongest effect size (0.93 [95% CI = 0.53, 1.33]; p < 0.001). In contrast, unilateral rTMS using ipsilesional high-frequency stimulation had a combined effect size of 0.83 (95% CI = 0.14, 1.52; p = 0.02). For tDCS, a significant effect size was found only with anodal stimulation applied over the contralesional hemisphere (1.04 [95% CI = 0.54, 1.53]; p < 0.001).ConclusionsThe results show that neurostimulation can benefit patients with poststroke dysphagia. The treatment effects were the strongest in acute stroke patients and within the first two months of application. For NIBS, bihemispheric stimulation appeared to be most effective. The most beneficial hemisphere for unilateral stimulation differed between rTMS and tDCS. These findings provide a platform for future studies and clinical practice.