Radiologic drivers of dysphagia after intracerebral haemorrhage: a flexible endoscopic evaluation of swallowing-guided retrospective analysis on intensive care unit

INTRODUCTION: Dysphagia is a frequent and clinically relevant complication after intracerebral haemorrhage (ICH) and is associated with increased morbidity and mortality. While radiologic severity and lesion characteristics are known to influence neurological outcome, their relationship with objectively measured dysphagia severity (DS) and swallowing management remains insufficiently defined. This study investigated the association between radiologic ICH burden and DS assessed by flexible endoscopic evaluation of swallowing (FEES), and examined the clinical impact of FEES-guided swallowing management in an neuro intensive care unit (ICU) cohort. METHODS: We conducted a retrospective analysis of consecutive ICH patients treated in neurological ICU who underwent standardized bedside dysphagia assessment, with FEES performed when clinically indicated and feasible. DS and functional oral intake were quantified using the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) and the Functional Oral Intake Scale (FOIS-G). Multivariable regression models adjusted for age and clinical severity were used to examine associations between radiologic parameters (hematoma volume, location, ICH score, intraventricular and subarachnoid haemorrhage) and dysphagia outcomes. RESULTS: Of 241 patients 120 (49.8%) were diagnosed with relevant dysphagia FEES was performed in 68 patients (28.2%) at a median of 13 days after admission. After FEES, the diet was modified in 67% of patients and the oral intake score improved from a median of one to four. Radiologic severity was independently associated with dysphagia outcomes: higher ICH score predicted lower odds of of favourable FOIS-G and FEDSS scores. Deep intracerebral haemorrhage, intraventricular haemorrhage and subarachnoid haemorrhage were associated with worse functional oral intake. FEES led to a modification of swallowing management in 67% of examined patients, most frequently allowing safer and more liberal oral intake compared with bedside assessment alone. CONCLUSION: In ICU-treated patients with ICH, dysphagia is common and closely linked to radiologic severity and lesion characteristics. FEES frequently reveals clinically relevant discrepancies between bedside assessment and actual swallowing function and substantially influences swallowing management. Integrating radiologic risk stratification with FEES-guided decision-making may improve safety, nutrition, and rehabilitation planning in this high-risk population.