Use of botulinum toxin in patients with dysphagia and sialorrhea in acute ischemic stroke

Dysphagia and sialorrhea are common complications of stroke that worsen quality of life and increase the risk of aspiration pneumonia. Botulinum toxin type A (BoNT-A) injections are effective in the treatment of sialorrhea, but there are few data on the use of botulinum toxin in patients with dysphagia in acute stroke.
Objective: to evaluate the efficacy and safety of incobotulinumtoxin A in the treatment of sialorrhea and prevention of aspiration pneumonia in patients with acute ischemic stroke.
Material and methods. Twenty-seven patients with dysphagia and sialorrhea in acute ischemic stroke were included in the study. All patients received an ultrasound-guided injection of incobotulinumtoxin A in a total dose of 100 units, divided into four injections into parotid and submandibular salivary glands bilaterally. Posterior sialorrhea was visually verified by the endoscopic assessment, severity of dysphagia and aspiration risk were assessed at baseline, two weeks and one month post-injection using the Penetration Aspiration Scale (PAS), Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) and the Clinical Institute of the Brain (CIB) Dysphagia Scale. The control group consisted of 27 retrospectively analyzed patients who were matched for age, gender, stroke severity and dysphagia. Sialorrhea was assessed endoscopically, and dysphagia was assessed using the CIB dysphagia scale. All patients were routinely treated according to local standards of care depending on their condition at the admission. Aspiration complications and adverse events due to incobotulinumtoxin A were recorded throughout the study.
Results. All patients in the main group at baseline had severe dysphagia according to PAS, FEDSS and CIB dysphagia scales (5.88±1.37; 4.73±1.12 and 19.81±6.61 points, respectively) and sialorrhea. After 2 weeks and 1 month after the injection of incobotulinumtoxin A, there was a decrease in the amount of saliva without signs of posterior sialorrhea and a decrease in the severity of dysphagia. Dysphagia scores on the PAS, FEDSS and CIB scales reached a statistically significant difference (p<0.05) within one month compared to baseline (2.86±0.90; 2.57±0.66 and 11.43±2.14 points, respectively). No side effects such as weakness of the mimic and bulbar muscles were observed. In the control group, the severity of dysphagia also decreased according to the CIB scale, comparable to the main group, but sialorrhea persisted in 17 patients after 2 weeks and in 9 patients after 1 month. Aspiration pneumonia was diagnosed in 3 patients in the main group and in 7 patients in the control group.
Conclusion. Injections of incobotulinumtoxin A in patients with dysphagia in acute ischemic stroke are effective and safe in the treatment of sialorrhea and the prevention of aspiration pneumonia. BoNT-A injections could be considered as a routine, safe and cost-effective treatment for patients with dysphagia to prevent aspiration complications after stroke. Further studies are needed to substantiate this statement.

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