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Who Can Help a Post Stroke Patient on Tube Feed Eat Again

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Introduction

Stroke is the fourth leading cause of decease in the USA [1] and one of the major causes of disability generating a massive economical burden [two]. Ischemic strokes account for 65–85% of stroke patients in the Western world, and the rest are hemorrhagic strokes which are more than disabling [3]. Merely 10–20% of hemorrhagic stroke patients will recover functional independence [4]. In order to improve neurological and cognitive functions of stroke patients, numerous rehabilitation interventions are implemented, including nutritional interventions, in attempt to overcome the metabolic consequences of stroke [5, half-dozen].

Even though malnutrition in stroke patients is under-recognized and undertreated, its prevalence on access is estimated to be around 20% [7, viii]. Notwithstanding, the prevalence of malnutrition after acute stroke varies widely ranging between vi.1 and 62% [9, 10]. This broad range has been attributed to different timing of assessment, patients' characteristics, and nearly importantly, nutrition cess methods [10]. Malnutrition before and later acute stroke is responsible for extended hospital stay, poorer functional outcome, and increased mortality rates at 3–6 months after stroke [xi,12,13]. The metabolic requirements and the resting energy expenditures (REEs) depend on the type of stroke with subarachnoid hemorrhage (SAH) requiring the most caloric intake when compared to ischemic strokes and intracerebral hemorrhage (ICH). As a result, the hasty identification of malnutrition using torso mass alphabetize (BMI) or anthropometric measures or laboratory parameters after the acute consequence is fundamental to avert poor outcomes [x, 14, 15]. The type of feeding depends on the swallowing status of the stroke patient; if dysphagia is present, enteral nutrition (EN) through nasogastric tube (NGT) or percutaneous endoscopic gastrostomy/jejunostomy (PEG/J) is a preferred intervention to oral feeding [14]. Although the verbal twenty-four hour period of initiation of feeding after an acute stroke result remains debatable, information technology is preferable to beginning feeding later on the clinical stabilization of patients in order to reduce complexity rates and better overall recovery [xvi,17,xviii].

The aim of this review article is to discuss the risk factors for malnutrition in stroke patients and its cess, the metabolic requirements for each blazon of stroke, and the importance of early feeding using the appropriate feeding method. We reviewed all English language papers on run a risk factors, cess, and management of malnutrition in stroke patients using Google Scholar and PubMed. Relevant studies are included in this review.

Risk Factors for Malnutrition in Stroke Patients

Elderly, women, preexisting malnutrition, poor family or nursing care, presence of malignancy, delayed rehabilitation, and history of astringent alcoholism accept been associated with malnutrition and aridity (Table 1) [11, 19,20,21]. On admission, polypharmacy, eating difficulties, chronic diseases, functional disabilities, and high National Institutes of Health Stroke Calibration (NIHSS) are associated with high risk of malnutrition in the elderly [11, 22]. Diabetes mellitus, hypertension, and stroke history increased the hazard of malnutrition on admission by 58 and 71%, respectively [9, 14]. Interestingly, micronutrients deficiency such as antioxidants (vitamin A, C, E, zinc), B vitamins, vitamin D was also associated with an increased risk of cognitive impairment and stroke in the elderly [five, 7].

Table 1 Risk factors for malnutrition in stroke patients

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The presence of dysphagia is a major adventure gene for developing malnutrition in stroke patients [11]. In the acute stage of stroke, dysphagia occurs in 30–50% of the patients and leads to a 12-fold increase in developing aspiration pneumonia and subsequent malnutrition [16, 23, 24]. Patients without dysphagia may still suffer from malnutrition when they are non well fed, particularly of protein [10, twenty]. Moreover, the presence of cognitive impairments, visual, language, and speech deficits can hinder constructive communication near food preference and satiety leading to malnutrition [xiv].

It is quite common that stroke patients suffer from depression and taking into consideration the side effects of the prescribed antidepressants such as xerostomia can help reduce feeding difficulties [14]. It is also possible that stroke patients may feel fatigue while eating leading to premature suspension of feeding [19].

Other important factors that should non exist overlooked when assessing the risk of developing malnutrition in stroke patients include reduced level of consciousness, reduced mobility, facial or arm weakness, and poor oral hygiene [25]. Type and severity of stroke are considered major risk factors for malnutrition, especially that subarachnoid hemorrhage produce a hypercatabolic land in the body [26, 27]. In contrast, the location of the stroke, paresis of the dominant arm, pedagogy, and socioeconomic status were not significantly related to malnutrition [nine, 14].

Assessment of the Nutritional Status in Stroke Patients

The assessment of the nutritional condition in stroke patients is frequently challenging because of lack of a universally accepted definition of malnutrition and a gold standard for nutritional status cess [28]. Later on stroke, elevation of plasma catecholamines, glucagon, cortisol, interleukin-6, interleukin-1RA, and acute phase proteins results in alteration of the metabolic requirements [29]. Apply of barbiturates or induced hypothermia to lower intracranial force per unit area (ICP) also leads to a decrease in caloric demands [30].

Assessment of the nutritional status should always start past obtaining a thorough nutritional history that includes food intake, recent weight history, and the hazard factors discussed in the previous department. When a stroke patient cannot provide a history because of limited cerebral function, history should exist taken from family members or caregivers [xiv]. Table ii summarizes the of import elements of the cess of the nutritional condition in stroke patients.

Table 2 Cess of the nutritional condition in stroke patients

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Estimating BMI from simple measurement of weight and top in stroke patients is not e'er practical, especially in immobile patients [15]. Specialized equipment such equally weighing scales or beds which suit wheelchairs can be used in assessing the weight of immobile patients [xv]. Using more than complex anthropometric measures such as triceps skin-fold thickness (TFT) and mid-arm muscle circumference (MAMC) is attainable and requires the employ of a measure tape and trained personnel [14]. Unfortunately, BMI, TFT, and MAMC take low sensitivity and specificity [31]. Davalos and colleagues [32] assessed poly peptide–energy status by TFT, MAMC, and serum albumin level; protein–free energy malnutrition was defined as ane abnormal finding of the 3 used parameters. However, authors noted that TFT has depression sensitivity and intraobserver variability and therefore cannot be used dependably.

Laboratory parameters such equally total lymphocyte count, serum poly peptide, albumin, pre-albumin, and transferrin are readily bachelor; still, their values can exist affected by the presence of inflammation [12]. In the absenteeism of infection and inflammation, serum albumin level can give a fair estimate of the nutritional status [fourteen]. In acute settings, pre-albumin, transferrin, and C-reactive poly peptide (CRP) are used to monitor changes in inflammation [14]. Moreover, CRP has been found to predict vasospasms and long-term outcome in SAH patients [33, 34].

High-plasma total homocysteine (tHcy) has been associated with cerebral harm in patients with previous strokes or transient ischemic attacks [35]. Several studies assessed the effect of B vitamins on the outcome of stroke patients, and the results take been controversial. Hankey et al. [35] did not observe an improved cognitive issue when supplementing stroke patients with daily folic acid, vitamin B6, and vitamin B12, even though tHcy significantly decreased. On the other hand, serum levels of vitamin A, C, and East were found to exist low in acute stroke patients [v]. Reduced levels of these vitamins were associated with functional decline, larger cerebral infarctions, and higher mortality rates most probable due to increased oxidative stress in the acute period [v].

Over the past years, many studies attempted to validate a nutrition screening tool (NST) in stroke patients. In 2003, the Malnutrition Universal Screening Tool (MUST), which includes an cess of BMI, percentage of weight loss in the previous iii–6 months, and the effect of acute illness on dietary intake, was investigated for use in any patient [36] and was accepted for utilize in astute stroke patients [37, 38]. According to several studies [11, 39, forty], existence at high take a chance of malnutrition, as assessed by MUST, is a significant independent predictor of mortality, length of hospitalization, and hospitalization costs at vi months mail service-stroke. Other NSTs are readily available to utilise such equally Nutritional Risk Screening 2002 (NRS 2002), Mini-Nutritional Cess, and Subjective Global Cess [41].

Clinicians must be aware of the limitations of each parameter and should keep in heed that using a combination of these parameters helps understand the nutritional status of each patient [42]. According to the current guidelines, screening stroke patients on admission and periodically thereafter is strongly encouraged [16, 37, 38].

Energy Expenditure in Stroke Patients

A main concern in stroke patients is the accurate adding of REE in order to ensure acceptable feeding and avoid a negative free energy rest. A negative energy remainder is especially undesired in astringent SAH patients (Hunt and Hess grades 3, Iv, and V) because of the dreaded infectious complications and poorer outcomes [26, 43]. A summary of the major studies measuring REE and its significance are found in Tabular array iii.

Tabular array 3 Summary of studies reporting energy expenditures in stroke patients

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Indirect calorimetry (IC), when available, is considered the gold standard for assessing REE and the caloric requirements for stroke patients. IC is a noninvasive, reproducible, and quantitative tool for measuring energy expenditure at the bedside [44]. IC estimates cellular energy metabolism by quantitatively measuring carbon dioxide output and oxygen consumption [45]. Many studies tried to reproduce the accuracy of IC by using relationships including the Harris–Benedict equation (HBE) and metabolism nomograms, but the results were equivocal. HBE estimates the basal free energy expenditure (BEE) for men and women: for men, BEE (kcal/twenty-four hours) = 66.5 + xiii.75 ×West + 5.005 × H − 6.775 × A; for women, BEE (kcal/solar day) = 655.1 + 9.563 × Due west + 1.85 × H − 4.676 × A, where Westward is weight in kilograms, H is peak in centimeters, and A is patient age in years [46].

Ischemic stroke patients take been establish to have low–normal REE in about of the studies [29, 30, 47]. Leone and Pencharz [48] suggested that a lower REE in chronic stroke patients, who are dependent on tube feeding, is partially explained past paresis and hypothesized that decreased sympathetic nervous organisation activeness and historic period-related organ atrophy are other possible explanations [49]. Bardutzky et al. [xxx] concluded that REE is low in stroke patients who are sedated and receiving mechanical ventilation because of deep sedation and added that HBE can be used accurately to estimate REE. To the contrary, Finestone et al. [29] proposed to employ a caloric intake of 110% of estimated BEE in stroke patients. Gariballa et al. [50] institute that acute ischemic stroke patients without swallowing difficulties are malnourished and emphasized the importance of using oral nutritional support (ONS) and enteral sip feeding in improving outcomes and decreasing mortality after 3 months.

The metabolic profile in patients with ICH and intraventricular hemorrhage (IVH) patients is not well established. Although some studies suggested that spontaneous ICH patients are not hypermetabolic [30], other studies concluded that ICH and IVH patients are hypermetabolic and require monitoring using IC to avoid undernutrition or over-nutrition [51,52,53]. SAH patients are—with possible clan between cerebrovascular vasospasm and increased catabolic country, and that HBE can estimate caloric needs with a ten–thirty% correction cistron [26, 43, 52, 53]. In a larger-scale study on 229 SAH patients, malnutrition- and inflammation-mediated protein catabolism has been strongly associated with hospital-acquired infections. Pneumonia was the about common infection (33%) followed by urinary tract infections (21%) [27]. CRP-transthyretin ratio (TTR)—was implemented by Badjatia and colleagues to appraise inflammation-mediated protein–energy malnutrition and 3-month outcome [27]. They reported a new relationship between elevated CRP: TTR (loftier CRP and low TTR), higher Hunt and Hess scores, and delayed cerebral ischemia, which correlated with a poorer long-term result afterward SAH [27]. Loftier CRP levels in the acute setting of SAH were also linked to poor long-term outcomes [27, 33, 54].

Adverse Outcomes Related to Undernutrition in Stroke Patients

Undernutrition in ischemic and hemorrhagic stroke patients has been strongly associated with negative clinical outcomes. On the cellular level, protein and free energy malnutrition on admission has been constitute to impair the recovery of hippocampal fibers from ischemic brain injury by altering the expression of trkB and GAP-43 proteins [55]. In acute ischemic stroke patients, malnutrition on admission has been strongly associated with poor one-month and 3-months issue [6, 32, 50, 56].

Malnourished ischemic and hemorrhagic stroke patients suffer from higher rates of pressure ulcers, respiratory, and urinary tract infections [26, 27, 57]. The Feed or Ordinary Nutrition (FOOD) trial collaboration [13] followed 2955 stroke patients out of which 279 were malnourished. Of those 21% developed pneumonia, 23% developed other infections, 4% pressure sores, and 4% gastrointestinal hemorrhage. All these complications were statistically significant compared to normal or overweight patients. Moreover, the malnourished population had high mortality (37%) compared to patients (21%) with normal nutritional status [13].

Malnutrition has been associated with an increment in dependency, duration of hospitalization and rehabilitation, and bloodshed charge per unit [13, 58]. Moreover, effectually 40% of stroke patients, specially dysphagic patients, are at hazard of becoming malnourished in rehabilitation centers [59, lx]. Weight loss in stroke patients is correlated with difficulties in regaining concrete function in the long term [61]. Therefore, well-adjusted nutritional supplementation and maintenance of torso weight are essential in these patients to accelerate their recovery [60,61,62].

Nutritional Support

After acute stroke, oxidative stress suppresses protein synthesis, resulting in impairment in brain recovery [5, 63]. Nutritional support has been proven to strongly heighten the physical and mental functioning of stroke patients [64] past preserving the muscle and fat masses, shortening hospitalization stay, and improving functional outcome [five].

Screening for Dysphagia

All stroke patients should have a clinical bedside screening for dysphagia by a trained personnel or speech communication-language pathologist (SLP) shortly later on presentation to hospital (Tabular array four) [xiv]. It has been established that a formal and systematic dysphagia screening results in fewer rates of pneumonia and mortality [65].

Table 4 Screening tests for dysphagia in stroke patients

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Despite this evidence, Water-Swallowing-Examination accurateness has been questioned and was found to accept a sensitivity below eighty% in detecting aspiration when compared to videofluoroscopic swallowing written report (VFSS) and fiberoptic endoscopic evaluation (FEES) [66, 67]. On the other paw, the Multiple-Consistency-Test has been establish to take 100% sensitivity and 50% specificity when compared to FEES [68]. This depression specificity may effect in more than restricted nutrition and nasogastric tube insertions [68]. Finally, the Swallowing-Provocation-Test (SPT) has a sensitivity of 74.1% and a specificity of 100% in detecting aspiration when compared to FEES [69]. Hence, SPT cannot be used lone as a screening tool but more as a complementary tool [sixteen].

All stroke patients failing a dysphagia screening examination should be further assessed using VFSS or FEES by a trained personnel or SLP [16]. Furthermore, due to the insensitivity of bedside screening tests, all patients presenting with severe neurological deficits, facial palsy, aphasia, or marked dysarthria should be further evaluated even if their initial screening tests were normal [70, 71].

VFSS or modified barium swallow test, the gold standard test for assessment of dysphagia, requires the use of nonionic, non-irritating contrast agents allowing dynamic visualization of oral, pharyngeal, and esophageal phases of swallowing [72]. VFSS allows defining the defected phase, grading of penetration of contrast, and aspiration using the rating scale of Rosenbek et al. [73]. On the other manus, FEES allows visualization of the pharynx using a nasolaryngoscope [74]. FEES can exist used by bedside in severely uncooperative and handicapped patients, does not require radiation exposure, and allows detection of residues [75].

Early dysphagia screening and swallowing rehabilitation accept been recognized in helping in regaining swallowing functions [76]. Moreover, spontaneous improvement in dysphagia is expected during the beginning two weeks after stroke, especially with supratentorial lesions [77]; however, stroke recurrences are common occurring in v–ten% of patients in the first weeks necessitating a routine dysphagia screening in astute stroke patients [16].

Feeding Strategies

Co-ordinate to the second part of FOOD trial, tube feeding, when indicated, has demonstrated a decrease in mortality in dysphagic stroke patients, especially if started inside 7 days after the event [17, 18]. In mechanically ventilated patients, early tube feeding is beneficial and is preferred over parenteral nutrition (PN) [xvi]. Patients with astringent dysphagia are at high risk of aspiration pneumonia and malnutrition; even so, tube feeding does non forbid aspiration pneumonia nor does it increase its occurrence [17, 78]. Therefore, the indication of tube feeding in severe dysphagic patients is tailored to forestall malnutrition and better prognosis [l, 79].

When prolonged severe dysphagia is expected (more than 7 days), tube feeding is preferred to exist initiated within the first calendar week and preferably within 72 h [16]. Information technology is not advisable to get-go feeding on the kickoff day of stroke because many patients' status is still vague and some may require mechanical ventilation [sixteen]. The FOOD trials [17, 18] showed that patients who received tube feeding within 7 days [either NGT or PEG] had a reduction in mortality rate by 5.8%, which was not significant (p = 0.09). Feeding tubes are inserted preferably in gastric position every bit there is no sufficient evidence or statistical significance to advise an increase in aspiration pneumonia when compared to duodenal or jejunal feeding tubes [fourscore,81,82]. Loeb and colleagues [83] and Kostadima et al. [84] did not detect a significant difference between feeding into the small bowel versus nasogastric feeding regarding aspiration pneumonia, nutritional intake, and tube displacement. Therefore, the suggested use of post-pyloric tube feeding is considered on a example-to-example basis where at that place is suspicion of upper gastrointestinal dysfunction or delayed gastric emptying despite the use of prokinetic agents [82, 85].

When oral food intake is challenging during the acute phase of stroke, smallest size NGT (viii-Fr, ten-Fr, 12-Fr) is the preferred method of enteral feeding [14]. Patients in the intensive care unit tin can have elevated ICP, which can delay gastric emptying and thus hindering a successful NGT feeding [14]. When enteral feeding is expected more than than 28 days, PEG should be placed after 14–28 days in a stable clinical stage [sixteen]. Likewise, mechanically ventilated patients should take a PEG placed at an earlier stage [xvi]. PEG feeding inside 24 h in mechanically ventilated stroke patients produced amend outcomes than NGT and decreased the incidence of ventilator-associated pneumonia [84]. Before insertion of PEG, severity of stroke, unfavorable prognosis, and ethical considerations should be intensively considered [86].

Dysphagia due to ischemic stroke resolved in 73–86% of the patients within seven–14 days and in a big proportion of patients within 3 months [87]; therefore, it is preferable to start with a less invasive feeding method than PEG. Norton et al. [88] compared NGT and PEG feeding and institute that the PEG group had amend nutritional status, shorter infirmary stay, and less mortality after half-dozen weeks of interventions [88]. On the other hand, FOOD written report did not find significant departure betwixt NGT grouping and PEG group regarding outcomes later half dozen months [17, 18]. Dislodgement of NGT can be managed by nasal loops, which take been demonstrated to be safe, constructive, and well tolerated in stroke patients without a departure in outcome after 3 months [89].

In order to avoid aspiration pneumonia, continuous application of feeding in improver to frequent clinical examinations, monitoring of balance volumes, and tiptop of the head of the bed are indicated in patients with history of gastroesophageal reflux (GERD), concurrent signs of GERD, and jejunal or duodenal tubes [90]. If at that place are no risk factors, intermittent bolus application (six times daily) for, respectively, one h is rubber [xvi].

NGT feeding was non plant to interfere with swallowing training and rehabilitation, and dysphagia therapy should be started as early on equally possible [91]. It is also preferable that conscious dysphagic stroke patients have oral feeding according to the severity and kind of dysphagia [92]. Oral hygiene is a chief business organization in dysphagic patients as the bacteria in the saliva is responsible for aspiration pneumonia [93] suggesting a strict oral hygiene in such patients [94].

PN is indicated when EN is not viable or contraindicated [16]. Moreover, if caloric requirements or sufficient hydration cannot be met in well-nourished patients, supplemental PN is recommended [95].

ONS, when tolerated, is institute to reduce morbidity and improve survival in malnourished elderly stroke patients [x]. Patients supplemented with ONS had a significantly improved caloric intake when compared to patients receiving hospital food only (1807 ± 318 kcal/d vs. 1084 ± 343 kcal/d, p < 0.0001), thus decreasing medical complications and decreasing bloodshed [50]. This was too supported past the Food trial [96], which showed a reduction in pressure sores and an improvement of outcome in malnourished stroke patients.

Nutritional Considerations

Enteral tube feeding formulas are well tolerated in stroke patients. The selection formula is usually 1–1.5 kcal/ml, polymeric, rich in poly peptide, and sometimes supplemented with elemental nutrients [fourteen]. Fiber-containing formulas are reserved for rehabilitation settings and are avoided in the acute settings when pressors are used. Medications should as well exist taken into consideration as some of them have nutritional impact (i.e., propofol gives 1.1 kcal/ml every bit fat, barbiturates cause a decrease in caloric requirements, narcotic agents cause constipation, and sorbitol causes diarrhea) [14].

Dysphagia diets were developed as National Dysphagia Diet (NDD) past the American Dietetic Association. NDD is divided into three levels with level 1 NDD being pureed (spoon-thick), level 2 NDD being mechanically altered (nectar-thick), and level 3 NDD being dysphagia avant-garde (dear-thick) [14].

Malnutrition in Stroke Patients and Current Guidelines

Current clinical guidelines and recommendations either partially discuss [97,98,99] or practise not discuss at all nutritional support in stroke patients [100]. The recently published guidelines by the Society of Critical Intendance Medicine and American Gild for Parenteral and Enteral Nutrition [100] did not discuss nutritional support in critically ill stroke patients. The guidelines did recommend to: (1) screen all critically ill patients for malnutrition, (2) start EN within 24–48 h or when hemodynamically stable, and (3) utilize post-pyloric feeding if loftier hazard of aspiration. The European Lodge of Intensive Intendance Medicine supports the utilize of early EN to amend outcomes and mortality in all critically ill patients including ischemic and hemorrhagic stroke patients [98]. However, their guidelines do non openly talk over the indications of post-pyloric feeding and PEG tube insertions in stroke patients. The guidelines for the acute management of SAH [99], acute ischemic stroke [101], and spontaneous intracerebral hemorrhage [102] from American Eye Association/American Stroke Association practice non address nutrition at all. In the guidelines of management of large hemispheric infarctions, Torbey and colleagues [97] recommended to screen for dysphagia after weaning from sedation and ventilation, utilize early NGT if dysphagia is present, and discuss PEG tube insertion with family if high NIHSS and dysphagia persist. The clinical guidelines for nutrition in stroke patients by Wirth and colleagues [sixteen] reviewed the screening methods for dysphagia and aspiration pneumonia and unlike feeding strategies. Yet, the guidelines failed to include recommendations to assess energy requirements for the dissimilar types of strokes.

Conclusion and Recommendations

Stroke is a devastating event, leading to high morbidity and mortality. Malnutrition is prevalent in stroke patients and its early recognition significantly affects the outcomes. All stroke patients should be assessed thoroughly for malnutrition by checking their nutritional status and run a risk factors. IC helps in understanding the energy expenditure in stroke patients, and when it is non accessible, metabolism equations can fairly estimate the metabolic requirements in stroke patients. Dysphagia is quite common in stroke patients and has major impacts on short-term and long-term outcomes. If a stroke patient cannot tolerate oral feeding, tube feeding via NGT or PEG is beneficial and improves long-term outcomes. Despite these facts, more than studies are required to analyze the optimal timing and method of diet. Moreover, big studies are required to assess the energy requirements in all stroke patients as previous studies are not conclusive. Time to come guidelines should identify a unified nutrition screening method, appraise and evaluate reliable methods for energy needs, clarify timing of initiation of feeding, and specify when to use intragastric versus small bowel feeding. Quality of life is affected by enteral feeding, and ethical bug should be given intensive considerations, especially in patients with poor outcomes.

Based on the current literature bachelor, nosotros can make the post-obit recommendations for nutrition in stroke patients:

  • Appraise risk factors for malnutrition in stroke patients past performing a thorough history and physical examination. Nutritional screening using run a risk scores can besides be implemented (NRS 2002, MUST, etc.).

  • Appraise for dysphagia and aspiration pneumonia.

  • Standard protocols to assess energy requirements, initiation, and maintenance of nutrition should be made for the unlike types of strokes.

  • EN is preferred over PN. EN should be initiated once the patients are hemodynamically stable.

  • The preferred EN method is feeding via NGT. Post-pyloric feeding is decided on instance-to-case ground to subtract hazard of aspiration pneumonia.

  • Additionally, to decrease risk of aspiration pneumonia, elevation of the caput of the bed past 30–45° and use prokinetic medications are recommended.

  • PEG tube feeding tin exist discussed with families when long-term tube feeding is provisioned.

  • Multidisciplinary approach is strongly recommended.

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Acknowledgements

Funding was provided by National Institute of Neurological Disorders and Stroke (Grant No. U10NS086484).

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Affiliations

  1. Cerebrovascular and Neurocritical Care Division, Department of Neurology, Wexner Medical Center, The Ohio State Academy, Columbus, OH, United states

    Toni Sabbouh & Michel T. Torbey

  2. Department of Neurosurgery, The Ohio State University Wexner Medical Eye, 410 W. 10th Avenue, Columbus, OH, 43210, U.s.

    Michel T. Torbey

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Correspondence to Michel T. Torbey.

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Sabbouh, T., Torbey, M.T. Malnutrition in Stroke Patients: Gamble Factors, Assessment, and Management. Neurocrit Care 29, 374–384 (2018). https://doi.org/x.1007/s12028-017-0436-i

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Keywords

  • Stroke
  • Calorimetry
  • Diet
  • Risk factors

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