Beyond the Acute Phase: Prevalence and Clinical Characteristics of Unreported Swallowing Impairments in Ambulatory Outpatient Stroke Survivors

Purpose: Unreported dysphagia, imaging-identified swallowing impairment without symptom reporting, remains poorly characterized beyond the acute phase of stroke. This study aimed to (a) quantify the point prevalence of unreported dysphagia in ambulatory stroke survivors, (b) examine demographic and clinical factors associated with the presentation of this phenomenon, and (c) evaluate concordance between patient-reported symptoms and imaging-derived impairments. Method: This retrospective secondary analysis included 45 ambulatory adults ≥ 3 months post–ischemic stroke who underwent videofluoroscopic swallow study and completed the Eating Assessment Tool-10 (EAT-10). Swallowing impairment was defined using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST Grade ≥ 1), and physiology was characterized using the Modified Barium Swallow Impairment Profile (MBSImP). Participants were classified as having no dysphagia (DIGEST = 0), overt dysphagia (DIGEST ≥ 1 and EAT-10 > 3), or unreported dysphagia (DIGEST ≥ 1 and EAT-10 ≤ 3). Group differences were examined using analysis of variance, Fisher's exact tests, and nonparametric analyses. Results: Sixteen percent (7/45) of participants demonstrated unreported dysphagia, while 44% (20/45) exhibited some degree of swallowing impairment. Unreported and overt dysphagia groups had similar DIGEST grades, yet the unreported dysphagia group reported minimal symptom burden (EAT-10: Mdn = 2) compared to the overt group (EAT-10: Mdn = 9). Significant correlations were observed between the EAT-10 and the MBSImP oral total ( r = .510, p < .008), but not DIGEST ( r = .21, p = .163). Age, lesion characteristics, time since stroke, and admission stroke severity were not significantly associated with unreported dysphagia. Conclusions: A clinically meaningful proportion of ambulatory, community-dwelling stroke survivors demonstrated persistent swallowing impairment without symptom reporting. Reliance on symptom-based referral pathways may fail to detect ongoing safety or efficiency deficits. These findings support the consideration of imaging-based surveillance strategies beyond the acute phase of stroke recovery.