Dysphagia is a common and clinically significant problem in stroke patients with disorders of consciousness (DoC). Although videofluoroscopic swallowing study (VFSS) is considered the gold standard for assessing swallowing function, it carries potential risks, including radiation exposure and aspiration. Therefore, we aimed to determine whether lower consciousness levels are associated with higher aspiration risk and to identify a candidate threshold for considering VFSS in patients with stroke and DoC.

This single-center retrospective study included adults with stroke admitted for inpatient rehabilitation (2011–2024) who underwent Coma Recovery Scale–Revised (CRS-R) assessment and VFSS within 5 days and 2 years of stroke onset. We examined associations between CRS-R and aspiration using logistic regression analyses adjusted for age, sex, body mass index, and tracheostomy status. We performed operating characteristic curve analyses and selected candidate CRS-R cut-off values using the Youden index.

We included 251 patients in the final analysis. Patients were categorized as vegetative state/unresponsive wakefulness syndrome (VS/UWS), minimally conscious state (MCS−), or MCS + based on CRS-R assessment. Aspiration was most prevalent in the VS/UWS group (84.4%), followed by the MCS− (77.2%) and MCS+ groups (60.9%) (P = 0.009). Compared with MCS+, VS/UWS (adjusted odds ratio [aOR], 4.58; 95% confidence interval [CI], 1.70–13.6) and MCS− (aOR, 2.83; 95% CI, 1.48–5.54) had higher odds of aspiration. Total CRS-R score was inversely associated with VFSS-confirmed aspiration. Youden-derived CRS-R cut-off value was 13.5 (area under the ROC curve [AUC], 0.658) for aspiration.

Lower consciousness levels were associated with higher odds of aspiration on VFSS. The CRS-R threshold may aid bedside risk estimation and support more selective VFSS planning in patients with stroke and DoC. However, the discriminative performance of these cut-offs was limited, and external validation is required before clinical application.