Neurological Severity Versus Biomarker Dynamics in Post-Stroke Dysphagia: A Dual-Pathway Model for Functional Recovery and Feeding Transition

Background: Post-stroke dysphagia is a frequent complication associated with aspiration, malnutrition, and prolonged dependence on enteral feeding. Systemic inflammation and impaired nutritional status may adversely affect neuromuscular recovery; however, their relative and combined associations with swallowing recovery and transition from enteral to oral feeding remain insufficiently characterized. Objective: This study aimed to examine the independent associations of inflammatory and nutritional indices with swallowing function recovery and to evaluate their relationship with enteral-to-oral feeding transition in patients with post-stroke dysphagia. Methods: In this retrospective observational study, patients with dysphagia following ischemic stroke were evaluated before (T0) and after (T1) routine dysphagia rehabilitation. Inflammatory indices including the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic immune–inflammation index (SII), systemic inflammation response index (SIRI), and pan-immune–inflammation value (PIV), as well as the prognostic nutritional index (PNI), were calculated at both time points. Changes in indices (Δ = T1 − T0) were analyzed in relation to changes in swallowing function assessed by the Functional Oral Intake Scale (FOIS) and the Penetration–Aspiration Scale (PAS). Results: Changes in PNI were independently associated with greater improvement in functional oral intake (ΔFOIS) and reductions in aspiration severity for both liquid and soft consistencies (ΔPAS; all p < 0.01). In contrast, changes in inflammatory indices (ΔSIRI, ΔSII, ΔPLR, and ΔPIV) were consistently associated with less favorable swallowing outcomes. In multivariable logistic regression analysis, baseline stroke severity (NIHSS) was the only independent determinant of transition from enteral to oral feeding (OR = 0.72, p = 0.002). The model demonstrated good discrimination (AUC = 0.81). Conclusions: Changes in nutritional status, as reflected by ΔPNI over time, were the biomarker most consistently associated with functional swallowing recovery and reduced aspiration severity in patients with post-stroke dysphagia. While inflammatory burden was associated with less favorable swallowing physiology, transition from enteral to oral feeding appeared to be primarily driven by neurological severity rather than inflammatory or nutritional indices alone. These findings may support the clinical value of monitoring nutritional reserve alongside inflammatory burden during dysphagia rehabilitation.