What percentage of patients can come off a percutaneous endoscopic gastrostomy (PEG) tube after a brain bleed affecting the left insula?

PEG Tube Discontinuation After Left Insular Hemorrhage

The available evidence does not provide specific data on PEG tube discontinuation rates for left insular hemorrhages specifically, but general stroke data shows that 73-86% of dysphagia resolves within 7-14 days, and lesions of the insular cortex are predictors for prolonged dysphagia (>14 days). 1

Key Prognostic Factors for Dysphagia Recovery

Left insular involvement is a specific predictor of prolonged dysphagia beyond 14 days, which significantly impacts the likelihood of PEG tube removal. 1 Other factors associated with prolonged dysphagia include:

• Severity of stroke 1
• Presence of aphasia 1
• Frontal cortex lesions 1
• Brain stem involvement 1

General Recovery Timeline for Stroke-Related Dysphagia

In the general stroke population, dysphagia resolves within 7-14 days in 73-86% of cases, suggesting that the majority of patients can potentially discontinue tube feeding within this timeframe. 1 However, this data is not specific to insular strokes, which carry a worse prognosis for swallowing recovery.

Factors Associated with Poor Long-Term Recovery

For patients with severe initial disability after intracerebral hemorrhage, several hospital events strongly predict inability to achieve functional independence (which would include PEG dependence):

• Gastrostomy tube placement itself (adjusted OR 0.30 for good outcome, indicating those requiring PEG have worse prognosis) 2
• Persistent hydrocephalus by day 30 (adjusted OR 0.37) 2
• Acute ischemic stroke complications (adjusted OR 0.44) 2
• Severe leukoaraiosis (adjusted OR 0.30) 2
• Diabetes (adjusted OR 0.50) 2

Positive predictors for recovery include:

• Resolution of hemorrhage by day 30 (adjusted OR 1.82) 2
• Resolution of intraventricular hemorrhage by day 30 (adjusted OR 2.19) 2

Clinical Decision-Making Algorithm

For left insular hemorrhages specifically:

1. Anticipate prolonged dysphagia (>14 days) given the insular involvement 1

2. Start with nasogastric tube feeding initially rather than rushing to PEG placement, as the prognosis for swallowing recovery needs time to declare itself 1

3. Consider PEG placement only if:

   • Dysphagia persists beyond 14 days 1
   • Nasogastric tube is repeatedly dislodged or not tolerated 1
   • Patient requires mechanical ventilation >48 hours 1

4. Reassess swallowing function regularly with formal dysphagia evaluation, as recovery can occur even in patients with initial severe disability 2

5. Monitor for positive prognostic indicators by day 30:

   • Resolution of hemorrhage on imaging 2
   • Absence of hydrocephalus 2
   • Improving neurological examination 2

Important Caveats

The decision for PEG placement should not be made prematurely, as 40% of patients with severe initial disability (mRS 4-5 at day 30) can achieve good functional outcome (mRS 0-3) by one year. 2 This suggests that early pessimistic prognostication should be avoided, and decisions about long-term feeding access should be delayed until after the acute treatment phase when recovery trajectory becomes clearer. 2

Dysphagia therapy should start immediately regardless of feeding route, as nasogastric tube feeding does not worsen dysphagia or impede rehabilitation. 1