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American Journal of  Medical 
Science and Innovation (AJMSI) 

Relationship between the Injury Location and Swallowing Difficulty among Stroke
Patients, A Retrospective Cohort Study

Rawan Azzam1*, Dina Emam1, Mamoun Nor Eldein1, Olfa Al-Mannai1

Volume 3 Issue 2, Year 2024
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v3i2.3074
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: May 29, 2024
Accepted: June 30, 2024
Published: July 03, 2024

Post-stroke dysphagia (PSD), a neurological or mechanical disorder that hinders food transport 
from the oral cavity to the stomach. It has been widely associated with severe complications 
with higher mortality and morbidity rates. Traditional therapies for the treatment of  dysphagia 
mainly focused on compensatory methods and behavioural rehabilitation approaches. The 
retrospective cohort study aimed to determine the association and correlation between 
developments of  dysphagia in relation to the location of  the stroke and to identify the 
swallowing recovery period following the stroke. A retrospective cohort study investigated 
swallowing difficulties in 64 stroke patients at an ambulatory care centre over a year. Data 
collection involved reviewing medical records and imaging reports, with analyses conducted 
using SPSS software, ANOVA and chi-square methods to assess associations between injury 
location and swallowing difficulty. Hemorrhagic stroke was more prevalent (65.6%) than 
ischemic stroke (34.4%). A significant association was found between gender and stroke type, 
with males exhibiting a higher prevalence of  ischemic strokes (71.4%) compared to females 
(29.8%). Age differences between stroke types, gender and affected swallowing phases and 
stroke type and affected swallowing phase revealed no significant associations. Distinct 
differences were noted in swallowing difficulties across stroke types. Furthermore, recovery 
time varied depending on the intervention method, with speech therapy linked to shorter 
recovery periods. The study underscores the importance of  considering gender and stroke-
type-specific differences in stroke prevalence, age distribution, and swallowing difficulties. 
These findings contribute valuable insights to understanding stroke characteristics and their 
implications for clinical management and rehabilitation strategies. 

Keywords
Stroke, Post-Stroke Dysphagia, 
Swallowing, Speech Therapy, 
Video Fluoroscopy

1 Hamad Medical Corporation, Doha, Qatar
* Corresponding author’s e-mail: Rnajlaa@hamad.qa

INTRODUCTION
Stroke has been one of  the major leading causes of  
mortality and morbidity globally.  In recent years, the 
number of  stroke patients in the world has increased, 
simultaneously increasing the cost of  health care (Qiao 
et al., 2022). Cardiovascular disease (CVD) has been 
included as the major cause of  mortality, accounting for 
931,578 deaths in the United States (US) in 2021. After 
cancer and other CVDs, stroke has been ranked as the 
third major cause of  about 150,000 deaths in the US 
(Goldstein, 2019; Heart Disease and Stroke Statistics 
Update Fact Sheet, 2024). In 2021, stroke accounted 
for 1 in every 21 US deaths, with an average death every 
3 minutes 14 seconds. In the US, the stroke death rate 
increased by 8.4% from 2011, while the total number 
of  deaths increased 26.3%. Globally, 7.44 million deaths 
were attributable to stroke in 2021 (Heart Disease and 
Stroke Statistics Update Fact Sheet, 2024). Patients who 
have been affected by the stroke face several severe 
clinical conditions such as oesophagal or oropharyngeal 
dysphagia, hemiparesis, cognitive impairment, loss of  
dexterity and others (Goldstein, 2019; Qiao et al., 2022).
Swallowing dysfunction or Oropharyngeal dysphagia 
is a neurological or mechanical disorder that hinders 
food transport from the oral cavity to the stomach. It 
involves the coordination of  multiple muscle groups to 
transport food from the oral cavity to the gastric region 

while protecting the airway (Jones et al., 2020; Qiao et 
al., 2022). Post-stroke dysphagia (PSD) has been widely 
associated with severe complications, mortality and 
morbidity rate in 29-78% of  patients (Zhong et al., 2021). 
The most typical symptoms of  dysphagia include cough, 
nasal regurgitation, weight loss, throat clearing, residue 
in the mouth, and others. This condition can lead to 
complications such as malnutrition, dehydration, frailty, 
respiratory infections, and pneumonia (Serra-Prat et al., 
2012; Wilmskoetter et al., 2020). 
The primary condition of  PSD has been associated 
with the physiological and biochemical swallowing 
complexities in patients that might result in the disruption 
of  brain activities. The incidence, severity and patterns of  
PSD have been associated with brain lesions at different 
brain locations where the stroke of  the brainstem has 
been the major incentive (Zhong et al., 2021). During 
PSD, swallowing difficulties might occur in four phases: 
oral, pharyngeal, oral preparatory, and oesophagal phases. 
The condition of  PSD might show improvements in the 
early days of  stroke treatment. However, in some cases, 
it might also persist as a chronic condition, leading to 
severe complications such as aspiration, pneumonia, and 
malnourishment (Jones et al., 2020).
PSD has been the major cause of  morbidity in patients 
with stroke that might arise from various types of  brain 
injuries, such as unilateral or bilateral cerebral hemispheres, 



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while the supratentorial anatomical location, specifically 
associated with healthy swallowing has remained unclear 
(Shi et al., 2017). Studies employing magnetic resonance 
imaging (MRI) or computed tomography (CT) images 
of  focal lesions in stroke patients have often focused on 
unilateral ischemic strokes affecting either hemisphere 
of  the brain (Dehkharghani & Andre, 2017; Zameer et 
al., 2021). While some research suggests lateralization 
of  swallowing actions to the left and right hemispheres, 
its exact nature and implications for dysphagia remain 
uncertain (Cheng et al., 2022).
Specifically, it has been proposed that damage to the right 
hemisphere (RHD) may be associated with dysmotility 
and aspiration during the pharyngeal stage of  swallowing, 
while damage to the left hemisphere (LHD) may affect 
oral stage function. RHD has also been linked to persistent 
dysphagia and aspiration. However, these hemisphere-
specific variations in swallowing behaviour, severity, 
pharyngeal transit durations, lingual coordination, or 
aspiration incidence have not been consistently observed 
across studies (Daniels et al., 2019; Galera et al., 2019).
Stroke patients often experience PSD, while up to 50% of  
the patients spontaneously recover within the first seven 
days of  stroke treatment (Coleman et al., 2017). Therapies 
for the treatment of  PSD might help the patients who may 
not be improved by medications. Several interdisciplinary 
professionals collaborate to manage the symptoms of  
PSD (Cabib et al., 2016; Cohen et al., 2016; Lindsay et al., 
2020). New technologies like Brain-Computer Interface 
Devices and Virtual Reality-Based therapy might improve 
swallowing rehabilitation. 
Traditional therapies for the treatment of  dysphagia 
mainly focused on compensatory methods and 
behavioural rehabilitation approaches. It is necessary 
to understand that the spontaneous recovery of  post-
stroke swallowing problems has been constantly evolving 
with the development of  novel treatment methods and 
implementation on PSD patients to understand better, 
manage, and enhance the recovery phase of  PSD. These 
treatments have been patient-specific, and successful 
therapies for one patient might not generate the same 
results for other patients (Fang et al., 2022; Felix et al., 
2019). 
Speech therapy (ST) has been one of  the most important 
treatment methods to improve or treat the symptoms 
of  PSD. ST for dysphagia treatment involves various 
techniques and exercises aimed at improving swallowing 
function. Sensory and motor effects are generated by 
stimulating the swallowing-related muscle activity. These 
effects enhance the motor ability and the coordination 
of  laryngeal life and pharyngeal muscles utilized in 
swallowing and also help restore the linguistic and 
swallowing abilities of  the patient (Fang et al., 2022). 
Speech-language pathologists (SLPs) employ oral motor 
exercises to strengthen swallowing muscles, muscles 
coordination, and diet modifications to ensure safe 
swallowing. Compensatory strategies like chin tucks 
and sensory stimulation techniques may also be utilized 

(Caesar & Kitila, 2020; Murry et al., 2020).
Video fluoroscopy (VF) for dysphagia detection has 
been a diagnostic procedure used to assess swallowing 
function by using VFS equipment to provide real-time 
assessment/visualization by capturing real-time X-ray 
images (fluoroscopy) of  the oral and pharyngeal phases 
of  swallowing (González-Fernández et al., 2015). VF 
can identify aspirations or silent (aspirations aspiration 
without the presence of  a cough reflex), a factor of  20% 
mortality rate in elderly stroke patients within a year 
(Carucci & Turner, 2015). During the therapy, the patients 
were usually asked to consume food or liquid (mixed 
with a contrast agent) under professional’ observation 
(Thiyagalingam et al., 2021). The fluoroscopic images 
allowed the health care professionals to assess the 
movement of  food or liquid passing from the oral cavity 
to the pharynx. This procedure provides insight into 
detecting abnormalities or difficulties in swallowing in 
PSD patients (Carbo et al., 2021; Matsuo & Palmer, 2016).
Simultaneously, with the continuous development of  
understanding the difficulties in swallowing after stroke, 
advanced treatment methods combined with traditional 
therapies highlighted the better management and 
enhancement of  treatment methods for PSD (Fang et al., 
2022). 
However, 10%-50% of  patients with chronic PSD 
might not be recovered (Sheng et al., 2023). Therefore, 
the retrospective cohort study aimed to explore the 
relationship between injury location and swallowing 
difficulty among stroke patients and identify the 
swallowing recovery period following stroke.

METHODOLOGY
Area of  Study
A retrospective cohort study was conducted in the 
ambulatory care centre, Hamad Medical Corporation, 
from July 2021 to July 2022. The study aimed to investigate 
the swallowing difficulties in stroke patients. A total of  64 
individuals with documented swallowing issues in their 
medical records were identified and included in the study 
after obtaining their consent. 

Inclusion and Exclusion Criteria
The study population consisted of  individuals meeting 
the specific criteria, including radiological evidence of  
stroke, a Glasgow Coma Scale (GCS) score of  15, age 
exceeding 18 years, and assessments conducted using 
Fiber Optic Endoscopic Evaluation of  Swallowing 
(FEES). Exclusion criteria included participants under 
the age of  18, those with a history of  previous strokes, 
unconscious individuals, and those with Traumatic Brain 
Injury (TBI). Additionally, patients with PSD unrelated 
to stroke and those with brain lesions other than 
cerebrovascular accident (CVA) were excluded. 

Data Collection
Data collection involved a comprehensive review of  
medical records and imaging reports. The primary 



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variables of  interest included injury location, age, GCS 
score, and the presence or absence of  swallowing 
difficulty. Descriptive statistics were employed to 
summarize demographics, and the association between 
injury location and swallowing difficulty along with 
the recovery period was assessed through appropriate 
statistical tests, such as the chi-square test and logistic 
regression.
This study design ensured a focused examination of  
swallowing difficulties in stroke patients while adhering 
to specific inclusion and exclusion criteria to maintain the 
integrity and validity of  the findings.

Data Analysis
Data analysis for the retrospective cohort study was 
conducted using the SPSS (Statistical Package for Social 
Science) software version 26 for Windows and Microsoft 
Excel 2020. Descriptive metrics, including mean, 
standard deviation, and frequency, were calculated to 
summarize the demographic characteristics of  the study 

population, such as age, GCS scores, and injury locations. 
The relationship between injury location and swallowing 
difficulty was assessed for the primary analysis. Chi-
square tests were utilized to analyze categorical variables, 
and logistic regression models were employed to explore 
associations while adjusting for potential confounding 
factors. The significance level was set at 0.05. Furthermore, 
Microsoft Excel 2020 was utilized for data visualization, 
including the formation of  graphs and charts to illustrate 
the distribution of  injury locations and the prevalence of  
swallowing difficulty among stroke patients.

RESULTS
Medical Records of  Patients
A total of  64 patients were identified in the medical 
records. Table 1 represents the sociodemographic profile 
of  the patients. The profile included 57 males (89.1%) and 
seven females (10.1%). The mean age of  the patients was 
69.41 ± 8.1 years, with a mean age of  68.51 ± 7.926 years 
for males and 76.71 ± 5.707 years for females, respectively.

Table 1: Sociodemographic Profile of  The Patients
Categories Frequency Percentage

Gender Male 57 89.06
Female 7 10.94

Type of  Stroke Ischemic 22 34.375
Hemorrhagic 42 65.625

Location Bulbar 55 85.9375
Pseudobulbar 9 14.0625

Affected Swallowing Phase Pharyngeal 46 71.875
Oral Propulsive 5 7.8125
Esophageal 11 17.1875
Oral Preparatory 2 3.125

Total 64 100

Association of  Gender with Stroke
According to the Kolmogorov-Smirnov test results, the 
data has a normal distribution (p = 0.091). The prevalence 

of  different types of  strokes among the participants was 
investigated. The majority of  patients (65.6%, n = 42) 
experienced Hemorrhagic Strokes (HS), while 34.4% 

Figure 1: Prevalence of  Ischemic and Homographic Stroke



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(n = 22) had Ischemic Strokes (IS). A cross-tabulation 
analysis revealed a significant association between the 
gender and stroke types (χ² = 4.784, p = 0.029), with a 
higher prevalence of  IS among females (71.4%, n = 17) 
compared to males (29.8%, n = 5) and higher prevalence 
of  HS among males (70.2%, n = 40) as compared to 
female (28.6%, n = 2) as shown in Figure 1.

Association of  Age with Stroke Types
An analysis of  variance (ANOVA) was performed to 
examine age differences across different types of  strokes, 
as shown in Figure 2. The mean age of  patients with IS 

(M = 67.8, SD = 7.5) was compared to HS (M = 62.2, SD 
= 9.1), revealing a non-significant difference, F (1, 198) = 
0.734, p = 0.395). The analysis of  age distribution across 
different stroke types revealed distinct characteristics. 
Patients with IS exhibited a higher mean age (M = 73.36, 
SD = 8.215) than those with HS (M = 67.33, SD = 
7.311). The 95% confidence interval for the mean age of  
patients with IS ranged from 69.72 to 77.01, while for HS, 
it ranged from 65.06 to 69.61. These findings suggested 
notable differences in the age distribution between the 
two types of  strokes.

Figure 2: Age Distribution Between the Two Types of  Strokes

Association of  Mean Age with Affected Swallowing 
Phases
An independent samples t-test was conducted to 
compare the mean age with the affected swallowing 
phases in patients with IS and HS. The results indicated 
a statistically significant difference. Patients with IS (M 

= 73.36 ± 8.215) were older than HS patients (M = 
67.33 ± 7.311), t (198) = 3.003, p = 0.004. The analysis 
of  variance (ANOVA), as shown in Figure 3. indicated 
a non-significant difference in the mean age across the 
various affected swallowing phases, F (3, 60) = 0.922, p 
= 0.436.

Figure 3: Mean Age by Affected Swallowing Phases



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Association of  Gender and Affected Swallowing Phases
The chi-square test examined whether a significant 
association existed between gender and the affected 

swallowing phases. Statistically, no significant association 
has been found between gender and the affected 
swallowing phases (χ² (3) = 4.577, p = 0.206).

Figure 4: Association Between Gender and the Affected Swallowing Phases

Association between Stroke Types and Affected 
Swallowing Phase
The chi-square test determined the association between 
stroke types and the affected swallowing phase. Among 
patients with IS, 15 individuals were observed to have 
difficulty in the pharyngeal phase, with 2 experiencing 
challenges in the oral propulsive phase, 4 in the oesophagal 
phase, and 1 in the oral preparatory phase, resulting in 22 
patients.
Conversely, among those with HS, more patients 

(42) exhibited difficulty across all phases: 31 in the 
pharyngeal phase, 3 in the oral propulsive phase, 7 
in the oesophagal phase, and 1 in the oral preparatory 
phase. When considering both stroke types, 46 patients 
experienced difficulty in the pharyngeal phase, 5 in the 
oral propulsive phase, 11 in the oesophagal phase, and 2 
in the oral preparatory phase, resulting in a cohort size of  
64 patients. However, no significant relationship has been 
found between the two variables (p = 0.946), as shown 
in Figure 5.

Figure 5: Association Between Type of  Stroke and the Affected Swallowing Phase

Association between Location of  Stroke and Affected 
Swallowing Phases
The chi-square test of  independence indicated a 
significant association between the location of  the stroke 

and the affected swallowing phases (χ² = 8.674, df  = 3, 
p = .034). It was found that most patients with bulbar 
strokes experienced difficulty in the pharyngeal phase 
(43 out of  55 cases), with fewer instances in the oral 



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propulsive, oesophagal, or oral preparatory phases, as 
shown in Figure 6.
Conversely, patients with pseudobulbar strokes exhibited 
a more evenly distributed pattern across the swallowing 
phases. The linear-by-linear association test supported 
these findings (χ² = 6.590, df  = 1, p = .010), indicating 

an observable pattern in the data. These results 
suggested a relationship between stroke location and 
the specific affected phases of  swallowing, underscoring 
the importance of  considering both factors in stroke 
management and rehabilitation strategies.

Figure 6: Association between the Location of  Stroke and the Affected Swallowing Phases

Descriptive Statistics for Recovery Time
According to different methods of  recovery and follow-
up, the descriptive statistics for recovery time (in months) 
have been presented in Table 2. Patients who underwent ST 
had a mean recovery time of  approximately 8.83 months 

(95% CI: 7.70 - 9.96), those who recovered spontaneously 
had a mean recovery time of  approximately 6.39 months 
(95% CI: 5.23 - 7.55), and patients who received VF had a 
mean recovery time of  approximately 8.91 months (95% 
CI: 7.20 - 10.62).

Table 2: Statistics for Recovery Time (in months)
Variable Method of  Recovery Mean Std. Error Std. Deviation 95% Confidence Interval for 

Mean
Lower Bound Upper Bound

Recovery 
Time 
(months)

Speech Therapy 8.83 0.555 3.285 7.700 9.957
Spontaneously 6.39 0.549 2.329 5.230 7.547
Video Fluoroscopy 8.91 0.768 2.548 7.197 10.621

The ANOVA results for the recovery time, as shown 
in Figure 7, revealed a statistically significant difference 
among the groups (F (2, 61) = 4.555, p = .014). This 
indicates that the mean recovery time varied significantly 
depending on the method of  recovery and follow-up. 
Based on the results of  Levene’s test for homogeneity 
of  variances, which yielded non-significant findings (p 
> 0.05), indicating the correlation of  the assumption 
of  homogeneity of  variances, Bonferroni correction 
was applied to assess pairwise differences in recovery 
time between different methods of  recovery. The results 
indicated significant differences in the recovery time 
between patients undergoing ST and those recovering 

spontaneously (mean difference = 2.43968, p = 0.017, 
95% CI [0.3466, 4.5328]), as well as between patients 
recovering spontaneously and those undergoing VF 
(mean difference = -2.52020, p = 0.085, 95% CI [-5.2820, 
0.2415]). However, there was no significant difference in 
the recovery time between patients undergoing ST and 
those receiving VF (mean difference = -0.08052, p = 
1.000, 95% CI [-2.5749, 2.4139]). These findings suggest 
that recovery time varies significantly depending on the 
intervention method, with ST showing a shorter recovery 
time than spontaneous recovery, while no significant 
difference was observed between VF and the other 
methods.



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Figure 7: ANOVA Results for the Recovery Time

Multiple Comparisons
Dependent Variable: Recovery Time 
Bonferroni
Based on the analysis conducted, the mean recovery 
time for patients with ischemic stroke was found to 
be 7.64 months (SD = 3.62), whereas for patients with 
hemorrhagic stroke, it was 8.43 months (SD = 2.79). 
An independent samples t-test was performed to 

compare the mean recovery time between these two 
groups, yielding a t-value of  -0.973 (df  = 62, p = 0.334), 
assuming equal variances. These results indicate that 
there is no significant difference in the mean recovery 
time between patients with ischemic and hemorrhagic 
strokes (p > 0.05). Therefore, stroke type does not 
appear to influence the duration of  recovery time 
significantly in our sample.

Table 3: Analysis of  Treatments
Variable Method of  Recovery Mean Std. Error Sig. 95% Confidence Interval for 

Mean
Lower Bound Upper Bound

Speech Therapy Spontaneously 2.43968* .85023 .017 .3466 4.5328
Video Fluoroscopy -.08052 1.01325 1.000 -2.5749 2.4139

Simultaneously Speech therapy -2.43968* .85023 .017 -4.5328 -.3466
Video fluoroscopy -2.52020 1.12184 .085 -5.2820 .2415

Video 
fluoroscopy

Speech therapy .08052 1.01325 1.000 -2.4139 2.5749
Spontaneously 2.52020 1.12184 .085 -.2415 5.2820

The mean difference is significant at the 0.05 level

Table 4: Correlation Analysis between Age and Recovery Time
Recovery Type of  stroke N Mean Std. Deviation St. Error Mean

Recovery Time (months) Ischemic 22 7.64 3.62 0.77
Hemorrhagic 42 8.43 2.79 0.43

The correlation analysis between age and recovery time, 
as shown in Figure 4, yielded a Pearson correlation 
coefficient of  0.300, statistically significant at the 0.05 
level (2-tailed), with a p-value of  0.016. This indicates 
a moderate statistically significant positive correlation 
between age and recovery time. As age increases, 
recovery time tends to increase as well, suggesting that 

older patients may require more recovery time than 
younger patients.
A multinomial logistic regression analysis was conducted 
to examine the relationship between the phase affected 
in swallowing (pharyngeal, oral propulsive, oesophagal) 
and covariates, including age and location of  stroke. 
Model fitting information revealed that the final model 



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did not significantly differ from the Intercept Only 
model (χ² = 9.580, df  = 6, p = 0.143), indicating 
adequate model fit.
Pseudo R-Square values indicated that the model 
explained 13.9% to 17.0% of  the variance in the 
dependent Variable. Likelihood ratio tests compared 
the final model to reduced models without covariates. 

Results showed that neither the location (χ² = 6.635, df  
= 3, p = 0.084) nor age (χ² = 2.173, df  = 3, p = 0.537) 
significantly improved model fit. Parameter estimates 
revealed that the location of  the stroke had a borderline 
significant effect on the likelihood of  the pharyngeal 
phase (p = 0.144), while age did not significantly predict 
the phase of  swallowing, as shown in Table 5.

Table 5: Pseudo R-Square Test
Phase 
Affected

Covariate B St. Error Wald df Sig. Exp (B) 95% CI
Lower 
Bound

Upper 
Bound

Pharyngeal Intercept 15.995 7.938 4.06 1 0.044
Location -2.355 1.611 2.136 1 0.144 0.095 0.004 2.233
Age 8.848 8.512 1.081 1 0.299

Oral 
Propulsive

Intercept 8.848 8.512 1.081 1 0.299
Location -0.146 1.741 0.007 1 0.933 0.864 0.029 26.199
Age -0.103 0.111 0.868 1 0.351 0.902 0.726 1.121

Esophageal Intercept 12.408 8.13 2.329 1 0.127
Location -0.676 1.643 0.169 1 0.681 0.509 0.02 12.726
Age -0.133 0.105 1.596 1 0.207 0.876 0.713 1.076

DISCUSSION
This study provides valuable insights into the 
sociodemographic characteristics of  stroke patients and 
identifies significant associations between age, gender, 
type of  stroke, location of  stroke, recovery time and 
method that helped in recovery. The observed age 
difference across stroke types emphasizes the need 
for personalized approaches in stroke management. 
Additionally, the absence of  significant associations 
between gender and affected swallowing phase and type 
of  stroke and swallowing phase highlights the complexity 
of  these relationships. It underscores the importance 
of  further research in this area. The analysis revealed 
a statistically significant difference in recovery time 
based on the intervention approach. Patients receiving 
ST exhibit a shorter recovery time compared to those 
recovering spontaneously. In contrast, VF did not show a 
significant difference in recovery time compared to other 
methods. 
The Kolmogorov-Smirnov test confirmed a normal 
distribution of  the data, while the analysis of  stroke 
prevalence revealed a significant association between 
gender and stroke types. In the past few years, the 
prevalence of  IS has become higher in women compared 
to men. Women in middle age highlighted the higher risk 
IS with the onset of  menopause, oral contraceptive pill 
use, pregnancy, imbalance of  female sex hormones and 
hormone replacement therapy. After the era of  middle 
age, the incidence risk was reported to be higher in elderly 
women (age >85 years) than in elderly men (Roy-O’Reilly 
& McCullough, 2018). However, critical factors such as 
hypertension (weakened blood vessel walls, making them 
more prone to rupture and cause HS), smoking, obesity, 

and the utilization of  opioids have been significantly 
associated with higher rates of  HS in men compared to 
women (Ahangar et al., 2018).
The analysis of  variance (ANOVA) comparing age 
differences across different types of  strokes did not yield 
a significant difference, indicating that the mean age of  
patients with IS was comparable to that of  patients with 
HS. However, upon further examination, patients with 
IS exhibited a notably higher mean age than those with 
HS. Ageing has been the most common factor of  stroke, 
varying from 6.6 to 11.4 in 100,000 adults per year, while 
in older people, the risk factors were higher (Lutski et 
al., 2017). Structural changes in blood vessels, such as 
atherosclerosis, where the arteries narrow and become less 
flexible (Okeahialam & Sirisena, 2023). This narrowing 
restricts blood flow to the brain, increasing the likelihood 
of  blood clots forming and causing an ischemic stroke (El 
Amki & Wegener, 2017). Additionally, higher prevalence 
of  risk factors for stroke in older individuals have been 
found, including high cholesterol, hypertension, diabetes, 
and atrial fibrillation. These conditions can damage blood 
vessels over time and promote the formation of  blood 
clots, further elevating the risk of  stroke (Hu et al., 2017; 
Morseth et al., 2021). 
According to the chi-square test results, no statistically 
significant association has been found between gender 
and the affected swallowing phases (χ² (3) = 4.577, p 
= 0.206). In contrast, the association of  stroke types 
and the affected swallowing in patients with IS and HS 
were observed to have difficulty in the pharyngeal, oral 
propulsive, oesophagal, and oral preparatory phases. 
Dysphagia following a stroke occurs due to disturbance 
of  upper motor neurons toward nuclei in the medulla 



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oblongata (pseudobulbar palsy) or brain stem lesions 
(bulbar palsy), resulting in delayed swallowing reflex, 
decreased movement of  larynx, residual food in the 
pyriform sinus, loss of  swallowing reflex, and insufficient 
opening of  the oesophagal orifice (Maeshima, 2019).
The chi-square test between the location of  the stroke 
and the affected swallowing phases revealed a significant 
association. It highlighted the importance of  considering 
both factors in stroke management and rehabilitation 
strategies, with bulbar strokes predominantly associated 
with difficulty in the pharyngeal phase and pseudobulbar 
strokes exhibiting a more evenly distributed pattern 
across swallowing phases. In cases of  bulbar strokes, this 
critical phase of  swallowing can be significantly impacted, 
leading to swallowing difficulties and an increased risk of  
aspiration. 
According to a study, the major cases of  PSD have 
been distributed into two categories: pseudo bulbar, 
responsible for disturbing the motor neurons on the 
upper side towards the medulla oblongata nuclei, while 
bulbar has been associated with the lower neurons from 
the nuclei of  the medulla in the brain stem (Maeshima, 
2019). Bulbar strokes affect the medulla oblongata, which 
controls various essential functions, including swallowing 
(Iordanova & Reddivari, 2019), while pseudobulbar strokes 
affect the corticobulbar pathways, which are responsible 
for transmitting motor signals from the cerebral cortex 
to the brainstem nuclei involved in swallowing and other 
functions (Iordanova & Reddivari, 2019).
According to the results of  ANOVA, patients who 
received ST recovered faster than those who recovered 
spontaneously. Meanwhile, VF showed a trend towards 
faster recovery than spontaneous healing. However, there 
was no significant difference between the ST and VF 
groups. The study highlights that the ST was linked to 
a shorter recovery than other therapies. This evidence 
has been supported by the findings of  several studies 
concluding that the ST showed a statistically significant 
improvement in dysphagia and assessment of  oral intake 
in stroke patients (Choy et al., 2024; Jones et al., 2018; 
Tanashyan et al., 2018; Turra et al., 2021). However, several 
studies have also identified video fluoroscopic swallowing 
training as being substantially effective in alleviating PSD 
(Carbo et al., 2021; Carucci & Turner, 2015; González-
Fernández et al., 2015; Thiyagalingam et al., 2021). The 
results suggested that ST may be the most promising 
strategy for quicker recovery from swallowing difficulties 
after a stroke.
These findings highlight significant factors leading to 
IS and HS, highlighting the importance of  considering 
them as potential factors in stroke subtype classification 
and management strategies. The findings contribute to 
the existing knowledge in stroke research and may guide 
healthcare professionals in tailoring interventions based 
on patient-specific characteristics.

Study Limitations and Future Recommendations
A few limitations were encountered in the study. The 

limitations include the relatively small sample size and 
the retrospective design, which might have constrained 
the generalizability of  the findings. While the study 
focused on the association between the stroke location 
and swallowing difficulty, the analysis did not encompass 
other potential factors, such as comorbidities or the 
severity of  the stroke. Additionally, the lack of  long-term 
follow-up information has limited the specific results 
of  the study to assess the persistence or resolution of  
swallowing difficulties over time. These limitations 
revealed the importance of  future research with large 
prospective studies, larger sample sizes, and long-
term follow-up assessments to understand better the 
effectiveness of  different rehabilitation approaches and 
the various factors responsible for chronic PSD.
However, further research is warranted to explore 
innovative approaches and technologies to improve 
swallowing function, reduce complications in this 
vulnerable population, and validate these findings in 
larger and more diverse patient populations.

CONCLUSION
Dysphagia is a common and significant complication 
of  stroke, with profound implications for patient health 
and well-being. This study provides valuable insights 
into stroke patients’ demographic characteristics and 
clinical features, particularly regarding stroke types, age 
differences, and affected swallowing phases. Significant 
associations between gender and stroke type, as well as 
stroke location and affected swallowing phases, have been 
found. Additionally, recovery time varied significantly 
depending on the method of  intervention, with ST 
associated with shorter recovery times. Notably, patients 
undergoing speech therapy exhibited shorter recovery 
times than spontaneous recovery, highlighting the 
efficacy of  this intervention. These findings underscore 
the importance of  considering these factors in stroke 
patients’ diagnosis, treatment, and management. 

Ethical Concern
The study was conducted after obtaining ethical approval 
from the Department of  Otolaryngology, HMC, Doha, 
Qatar. In addition, consent was obtained from the 
participants or their relatives, but participants could not 
provide consent due to their medical condition.

Acknowledgements
The authors extend their appreciation to the Iran 
University of  Medical Sciences.
 
REFERENCES
Ahangar, A. A., Saadat, P., Heidari, B., Taheri, S. T., 

& Alijanpour, S. (2018). Sex difference in types 
and distribution of  risk factors in ischemic and 
hemorrhagic stroke. International Journal of  Stroke, 
13(1), 83-86. 

Cabib, C., Ortega, O., Kumru, H., Palomeras, E., Vilardell, 
N., Alvarez‐Berdugo, D., Muriana, D., Rofes, L., 



Pa
ge

 
10

https://journals.e-palli.com/home/index.php/ajmsi

Am. J. Med. Sci. Innov. 3(2) 1-11, 2024

Terré, R., & Mearin, F. (2016). Neurorehabilitation 
strategies for poststroke oropharyngeal dysphagia: 
from compensation to the recovery of  swallowing 
function. Annals of  the New York Academy of  Sciences, 
1380(1), 121-138. 

Caesar, L. G., & Kitila, M. (2020). Speech-language 
pathologists’ perceptions of  their preparation 
and confidence for providing dysphagia services. 
Perspectives of  the ASHA Special Interest Groups, 5(6), 
1666-1682. 

Carbo, A. I., Brown, M., & Nakrour, N. (2021). 
Fluoroscopic swallowing examination: radiologic 
findings and analysis of  their causes and 
pathophysiologic mechanisms. Radiographics, 41(6), 
1733-1749. 

Carucci, L. R., & Turner, M. A. (2015). Dysphagia 
revisited: common and unusual causes. Radiographics, 
35(1), 105-122. 

Cheng, I., Takahashi, K., Miller, A., & Hamdy, S. (2022). 
Cerebral control of  swallowing: an update on 
neurobehavioral evidence. Journal of  the Neurological 
Sciences, 442, 120434. 

Choy, J., Pourkazemi, F., Bogaardt, H., Anderson, C., Chai, 
S. Y., & Pebdani, R. N. (2024). Factors influencing 
speech pathology practice in dysphagia after stroke: 
A qualitative focus group study. International Journal of  
Language & Communication Disorders. 

Cohen, D. L., Roffe, C., Beavan, J., Blackett, B., Fairfield, C. 
A., Hamdy, S., Havard, D., McFarlane, M., McLauglin, 
C., & Randall, M. (2016). Post-stroke dysphagia: a 
review and design considerations for future trials. 
International Journal of  Stroke, 11(4), 399-411. 

Coleman, E. R., Moudgal, R., Lang, K., Hyacinth, H. I., 
Awosika, O. O., Kissela, B. M., & Feng, W. (2017). 
Early rehabilitation after stroke: a narrative review. 
Current atherosclerosis reports, 19, 1-12. 

Daniels, S. K., Huckabee, M.-L., & Gozdzikowska, K. 
(2019). Dysphagia following stroke. Plural Publishing. 

Dehkharghani, S., & Andre, J. (2017). Imaging approaches 
to stroke and neurovascular disease. Neurosurgery, 
80(5), 681-700. 

El Amki, M., & Wegener, S. (2017). Improving cerebral 
blood flow after arterial recanalization: a novel 
therapeutic strategy in stroke. International journal of  
molecular sciences, 18(12), 2669. 

Fang, W.-j., Zheng, F., Zhang, L.-z., Wang, W.-h., Yu, C.-
c., Shao, J., & Wu, Y.-j. (2022). Research progress of  
clinical intervention and nursing for patients with 
post-stroke dysphagia. Neurological Sciences, 43(10), 
5875-5884. 

Felix, C. C., Joseph, M. E., & Daniels, S. K. (2019). Clinical 
decision making in patients with stroke-related 
dysphagia. Seminars in Speech and Language, 40(3), 187-
197. https://doi.org/10.1055/s-0039-1688442

Galera, P., Dulau‐Florea, A., & Calvo, K. R. (2019). Inherited 
thrombocytopenia and platelet disorders with germline 
predisposition to myeloid neoplasia. International Journal 
of  Laboratory Hematology, 41, 131-141. 

Goldstein, L. B. (2019). Epidemiology of  cerebrovascular 
disease. In Vascular Medicine: A Companion to Braunwald’s 
Heart Disease (pp. 361). Amsterdam, The Netherlands: 
Elsevier.

González-Fernández, M., Brodsky, M. B., & Palmer, J. 
B. (2015). Poststroke communication disorders and 
dysphagia. Physical Medicine and Rehabilitation Clinics, 
26(4), 657-670. 

Heart Disease and Stroke Statistics Update Fact Sheet. 
(2024).  American Heart Association, Inc. 

Hu, X., De Silva, T. M., Chen, J., & Faraci, F. M. (2017). 
Cerebral vascular disease and neurovascular injury in 
ischemic stroke. Circulation research, 120(3), 449-471. 

Iordanova, R., & Reddivari, A. K. R. (2019). Neuroanatomy, 
medulla oblongata. In StatPearls. Treasure Island, FL: 
StatPearls Publishing.

Jones, C. A., Colletti, C. M., & Ding, M.-C. (2020). Post-
stroke dysphagia: recent insights and unanswered 
questions. Current neurology and neuroscience reports, 20, 
1-12. 

Jones, O., Cartwright, J., Whitworth, A., & Cocks, N. 
(2018). Dysphagia therapy post stroke: An exploration 
of  the practices and clinical decision-making of  
speech-language pathologists in Australia. International 
Journal of  Speech-Language Pathology, 20(2), 226-237. 

Lindsay, L. R., Thompson, D. A., & O’Dell, M. W. (2020). 
Updated approach to stroke rehabilitation. Medical 
Clinics, 104(2), 199-211. 

Lutski, M., Zucker, I., Shohat, T., & Tanne, D. (2017). 
Characteristics and outcomes of  young patients with 
first-ever ischemic stroke compared to older patients: 
the National Acute Stroke ISraeli Registry. Frontiers in 
Neurology, 8, 283442. 

Maeshima, A. O. a. S. (2019). Swallowing Disorders in 
Patients with Stroke. https://doi.org/10.5772/
intechopen.88341 

Matsuo, K., & Palmer, J. B. (2016). Video fluoroscopic 
techniques for the study of  oral food processing. 
Current opinion in food science, 9, 1-10. 

Morseth, B., Geelhoed, B., Linneberg, A., Johansson, L., 
Kuulasmaa, K., Salomaa, V., Iacoviello, L., Costanzo, 
S., Söderberg, S., & Niiranen, T. J. (2021). Age-specific 
atrial fibrillation incidence, attributable risk factors 
and risk of  stroke and mortality: results from the 
MORGAM Consortium. Open Heart, 8(2), e001624. 

Murry, T., Carrau, R. L., & Chan, K. (2020). Clinical 
management of  swallowing disorders. Plural Publishing. 

Okeahialam, B. N., & Sirisena, A. I. (2023). The Physics 
of  Stroke. Journal of  Stroke Medicine, 6(1), 7-10. 

Qiao, J., Wu, Z.-m., Ye, Q.-p., Dai, M., Dai, Y., He, Z.-t., & 
Dou, Z.-l. (2022). Characteristics of  dysphagia among 
different lesion sites of  stroke: A retrospective study. 
Frontiers in Neuroscience, 16, 944688. 

Serra-Prat, M., Palomera, M., Gomez, C., Sar-Shalom, 
D., Saiz, A., Montoya, J. G., Navajas, M., Palomera, 
E., & Clavé, P. (2012). Oropharyngeal dysphagia as 
a risk factor for malnutrition and lower respiratory 
tract infection in independently living older persons: 



Pa
ge

 
11

https://journals.e-palli.com/home/index.php/ajmsi

Am. J. Med. Sci. Innov. 3(2) 1-11, 2024

a population-based prospective study. Age and ageing, 
41(3), 376-381. 

Sheng, R., Chen, C., Chen, H., & Yu, P. (2023). 
Repetitive transcranial magnetic stimulation for 
stroke rehabilitation: insights into the molecular and 
cellular mechanisms of  neuroinflammation. Frontiers 
in Immunology, 14, 1197422. 

Shi, Y., Yang, D., Zeng, Y., & Wu, W. (2017). Risk factors 
for post-stroke depression: a meta-analysis. Frontiers in 
aging neuroscience, 9, 218. 

Tanashyan, M., Berdnikovich, E., & Lagoda, O. (2018). 
Post-stroke dysphagia: Novel treatment approaches. 
Neurology, Neuropsychiatry, Psychosomatics, 10(2), 57-62. 

Thiyagalingam, S., Kulinski, A. E., Thorsteinsdottir, B., 
Shindelar, K. L., & Takahashi, P. Y. (2021). Dysphagia 
in older adults. Mayo Clinic Proceedings, 96(5), 1245-1257.

Turra, G. S., Schwartz, I. V. D., Almeida, S. T. d., Martinez, 
C. C., Bridi, M., & Barreto, S. S. M. (2021). Efficacy 

of  speech therapy in post-intubation patients with 
oropharyngeal dysphagia: A randomized controlled 
trial. CoDAS, 33(5), e20200215. https://doi.
org/10.1590/2317-1782/2020202015

Wilmskoetter, J., Daniels, S. K., & Miller, A. J. (2020). 
Cortical and subcortical control of  swallowing—can 
we use information from lesion locations to improve 
diagnosis and treatment for patients with stroke? 
American journal of  speech-language pathology, 29(2S), 
1030-1043. 

Zameer, S., Siddiqui, A. S., & Riaz, R. (2021). Multimodality 
imaging in acute ischemic stroke. Current Medical 
Imaging, 17(5), 567-577. 

Zhong, L., Rao, J., Wang, J., Li, F., Peng, Y., Liu, H., 
Zhang, Y., & Wang, P. (2021). Repetitive transcranial 
magnetic stimulation at different sites for dysphagia 
after stroke: a randomized, observer-blind clinical 
trial. Frontiers in Neurology, 12, 625683.


