Early Neurological Recovery Research Articles

Chronic Kidney Disease and Outcome Following Endovascular Thrombectomy for Acute Ischemic Stroke

Background and Objectives: Chronic kidney disease (CKD) is present in 20% to 35% of acute ischemic stroke patients and may increase the risk of poor functional outcome or death. We aimed to determine whether CKD was associated with worse outcome in stroke patients treated with endovascular thrombectomy (EVT). Design, Setting, Participants, and Measurements: Consecutive EVT patients were identified from a prospective registry and dichotomized into patients with and without CKD, defined as an eGFR of less than 60 mL/min/1.73m2. The primary outcome was 3-month mortality following EVT. Secondary outcomes included symptomatic intracerebral hemorrhage (defined by the Safe Implementation of Thrombolysis in Stroke-Monitoring Study), early neurological recovery (defined as change in National Institutes of Health Stroke Scale [NIHSS] score of ≥8 at 24 hours or an NIHSS of 0-1 at 24 hours) and functional independence (defined as a modified Rankin Scale [mRS] score of 0, 1 or 2) at 3 months. Results: 378 EVT patients (223 men; mean ± SD age 65 ± 15 years) were included. The median (IQR) admission eGFR was 71 (58-89) mL/min/1.73 m² and 117 (31%) patients had CKD. Multiple logistic regression adjusted for potential confounders demonstrated that CKD was a significant predictor of lower rates of functional independence (OR = .54, 95% CI, .31 to .90, P = .02), higher mRS scores (common OR = 1.78, 95% CI, 1.14 to 2.81, P = .01), and increased mortality (OR = 2.19, 95% CI, 1.16 to 4.12, P = .01). There was no association between CKD and early neurological recovery (OR = .92, 95% CI, .55 to 1.49, P = .71) or symptomatic intracerebral hemorrhage (OR = 1.18, 95% CI, .38 to 3.69, P = .77). Conclusions: CKD was a significant predictor of worse functional outcome and mortality in stroke patients treated with EVT. The presence of CKD should not preclude patients from proceeding to EVT, but may help with prognostication and improve shared decision-making between patients, families and physicians.

Abstract TMP6: Optimal Early Clinical Endpoints for Long-Term Functional Outcome Prediction After Thrombectomy

Background: Early neurological recovery (ENR) is an attractive surrogate marker for long-term functional outcome of endovascularly-treated stroke patients. However, the optimal definition of 24-hour ENR that best predicts 90-day functional independence (modified Rankin Scale, mRS, 0-2) has not been established. We sought to determine ENR measure that best predicts 90-day mRS 0-2. Methods: The prospective BEST cohort study includes consecutive adult patients treated with endovascular therapy at 12 comprehensive stroke centers. In this post-hoc analysis, we measured the ability of various thresholds of both 24-hour NIHSS and αNIHSS (baseline minus 24-hour) to predict 90-day mRS 0-2 using Youden’s index. The strength of the associations were assessed using logistic regression adjusted for age, glucose, hypertension, ASPECT score, time to recanalization, recanalization status, and thrombolytic treatment. Results: Of 485 patients in the BEST cohort, 447 with 90-day follow-up were included in this study (228 females, mean age 68.05 ±15 years). The optimal Youden’s Index was achieved at 24 hour NIHSS of ≤7 (sensitivity 80.1%, specificity 80.4%, area under the curve [AUC] 0.855 [0.819-0.887], p<0.001; Figure). The optimal for αNIHSS cut point was ≥4 points (sensitivity 79%, specificity 58.5%, AUC 0.73 [0.685-0.77], p<0.001; Figure), which performed less well at outcome prediction than 24 hour NIHSS (difference between the AUCs 0.126, p<0.001; Figure). Strength of association between other common early clinical endpoints and outcome in this cohort are listed in the Table. Conclusions: A 24-hour NIHSS ≤7 was the optimal measure to predict functional independence at 90 days in our multicenter, prospective cohort. Among αNIHSS thresholds, ≥4 points was optimal but performed less well. These findings should be validated in independent endovascular cohorts to establish a standard short-term outcome measure for both clinical and research scenarios.

A Novel Method to Predict Early Neurologic Recovery after Pediatric Spine Surgery.

A Novel Method to Predict Early Neurologic Recovery after Pediatric Spine Surgery.

Pre-Existing Cerebral Small Vessel Disease Limits Early Recovery in Patients with Acute Lacunar Infarct

Background and Purpose: To assess whether neuroimaging markers of chronic cerebral small vessel disease (cSVDm) influence early recovery after acute ischemic stroke (AIS). Methods: Retrospective analysis of patients diagnosed with AIS and included in the Spanish Neurological Society Stroke Database. Inclusion criteria: (1) Brain MRI performed after acute stroke and (2) Premorbid modified Rankin scale (mRS) = 0. Exclusion criteria: (1) Uncommon stroke etiologies, (2) AIS not confirmed on neuroimaging, or (3) Old territorial infarcts on neuroimaging. Patients scored from 0 to 2 according to the amount of cSVDm. Patients were divided into lacunar ischemic stroke (LIS) and nonlacunar ischemic stroke (NLIS) groups according to TOAST classification. Primary outcome: Distribution of mRS at discharge. Secondary outcomes: NIHSS improvement more than or equal to 3 at 24 hours and at discharge, NIHSS worsening more than or equal to 3 points at 24 hours. Results: We studied 4424 patients (3457 NLIS, 967 LIS). The presence of cSVDm increased the risk of worsening 1 category on the mRS at discharge in the LIS group ([1] cSVDm: OR 1.89 CI 95% 1.29-2.75, P = .001. [2] cSVDm: OR 1.87, CI 95% 1.37-2.56 P = .001) and was an independent factor for not achieving an improvement more than or equal to 3 points on the NIHSS at discharge for all the patients and the LIS group (all stroke patients: [1] cSVDm: OR 0.81 CI 95% .68-.97 P = .022. [2] cSVD: OR 0.58 CI95% .45-.77, P = .001./LIS: [1] cSVDm: OR 0.64, CI 95% .41-.98, P = .038. [2] cSVDm: OR 0.43, CI 95% .24-.75 P = .003). Conclusions: Pre-existing SVD limits early functional and neurological recovery after AIS, especially in LIS patients.

Toll-like receptor 4 deficiency or inhibition does not modulate survival and neurofunctional outcome in a murine model of cardiac arrest and resuscitation.

BackgroundPatients experiencing cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) often die or suffer from severe neurological impairment. Post resuscitation syndrome is characterized by a systemic inflammatory response. Toll-like receptor 4 (TLR4) is a major mediator of inflammation and TLR4 has been implicated in the pathogenesis of post-resuscitation encephalopathy. The aim of this study was to evaluate whether TLR4 deficiency or inhibition can modulate survival and neurofunctional outcome after CA/CPR.MethodsFollowing intubation and central venous cannulation, CA was induced in wild type (C57Bl/6J, n = 38), TLR4 deficient (TLR4-/-, n = 37) and TLR4 antibody treated mice (5mg/kg MTS510, n = 15) by high potassium. After 10min, CPR was performed using a modified sewing machine until return of spontaneous circulation (ROSC). Cytokines and cerebral TNFalpha levels were measured 8h after CA/CPR. Survival, early neurological recovery, locomotion, spatial learning and memory were assessed over a period of 28 days.ResultsFollowing CA/CPR, all mice exhibited ROSC and 31.5% of wild type mice survived until day 28. Compared to wild type mice, neither TLR4-/- nor MTS510 treated wild type mice had statistically significant altered survival following CA/CPR (51.3 and 26.7%, P = 0.104 and P = 0.423 vs. WT, respectively). Antibody-treated but not TLR4-/- mice had higher IL-1β and IL-6 levels and TLR4-/- mice had higher IL-10 and cerebral TNFalpha levels. No differences existed between mice of all groups in early neurological recovery, locomotion, spatial learning ability or remembrance.ConclusionTherapeutic strategies targeting TLR4 may not be suitable for the reduction of mortality or neurofunctional impairment after CA/CPR.

Efficacy and Safety of Endovascular Thrombectomy for Ischemic Stroke in Nonagenarians

Introduction: Increased life expectancy results in a rapid increase of nonagenarian patients presenting with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). We conducted this study to assess the efficacy and safety of endovascular thrombectomy (ET) in this age group with use of imaging-based selection. Methods: We retrospectively analyzed clinical and imaging data from 2 different comprehensive stroke centers and compared the outcomes of ET versus intravenous thrombolysis (IVT) alone among eligible nonagenarians with LVO in anterior circulation and evidence of salvageable tissue on brain magnetic resonance imaging (MRI). Results: A total of 617 patients of AIS had been treated with IVT or ET, including 23 eligible nonagenarians. Among these, 9 patients were treated with IVT alone (IVT group) and 14 patients received ET group. Notably, the symptomatic intracranial hemorrhage rates were significantly lower after ET than after IVT (European-Australasian Acute Stroke Study II criteria, 0 vs. 33.3%; p = 0.047; National Institute of Neurological Disorders and Stroke criteria, 7.1 vs. 66.7%; p = 0.005). Moreover, although there were no statistically significant differences between the 2 groups on efficacy, ET tended to lead to greater early neurologic recovery at discharge (71.4 vs. 33.3%, p = 0.102) and improve functional outcome at 90 days (71.4 vs. 44.4%, p = 0.383), respectively. Conclusion: By using MRI-based selection, ET in nonagenarians with AIS caused by LVO within anterior circulation was safe and may lead to improve early neurologic recovery and functional independence at 90 days, as compared with IVT alone. Randomized trial in larger sample size testing efficacy of ET using diffusion-weighted imaging-fluid attenuated inversion recovery mismatch selection in this age group appears feasible.

Intracranial bailout stenting with the Acclino (Flex) Stent/NeuroSpeed Balloon Catheter after failed thrombectomy in acute ischemic stroke: a multicenter experience

Background and purposeTo report on the feasibility, safety, and outcome of acute intracranial stenting (ICS) with the Acclino (Flex) Stent and NeuroSpeed Balloon Catheter in cases of failed mechanical thrombectomy...

Abstract WP84: Hemispheric White Matter Sparing and Neurological Outcome After Recanalization Treatment in ESCAPE Trial

Background: Ischemic tolerance differs between white matter (WM) and grey matter. Timely reperfusion may result in preferential sparing of WM. We investigated if the degree of WM sparing after recanalization therapy has an impact on early neurological recovery and functional outcomes. Methods: Patients from ESCAPE trial were included if they had follow-up MRI brain. WM involvement was scored on a semiquantitative scale which divides hemispheric WM into twelve regions (Figure), adding one point for each area involved. Using receiver operating characteristics analysis and Youden J, optimum cutoff value of WM score for favorable outcome (90-day mRS≤2) was calculated and then used to classify patients into WM spared vs involved groups. Early neurological recovery was compared using difference in median 24-h NIHSS. Multivariable logistic regression was used to test the association between the WM score and outcome. Results: Among 108 patients, median WM score was 2 (IQR 1-4) in EVT (endovascular thrombectomy) arm (n= 70) and 3 (IQR 1-6) in control arm (n= 38). The threshold of ≤2 (WM spared) had sensitivity 69.1 and specificity of 69.8% for favorable outcome (AUC 0.74; 95% CI, 0.65 to 0.82; P<0.001). WM sparing was independently associated with favorable outcome after adjusting for age, baseline NIHSS, EVT use, cortical involvement, infarct volume and symptomatic hemorrhage (adjusted OR 5.34; 95% CI, 1.62-17.9, P=0.006). These patients had better neurological recovery (median 24-h NIHSS 4 in WMspared vs 11 in WMinvolved group; P <0.001) and lower infarct volumes (8 ml vs 47 ml; P <0.001). Patient with WMspared also had numerically lower incidence of malignant brain edema (0 vs 5.6%; P=0.24), intracerebral hemorrhage (symptomatic 0 vs 7.4%; P=0.12), and mortality (3.7 vs 11.1%; P=0.27) than WM involved group. Conclusion: White matter sparing was an independent predictor of early neurological recovery, and functional outcomes in the ESCAPE trial.

Abstract 154: Non-Contrast Computed Tomography Based Patient Selection Achieves Similar Outcomes to Advanced Neuroimaging in Late Time Window Endovascular Thrombectomy

Background and Aims: Endovascular Thrombectomy (EVT) for anterior circulation large vessel occlusion(LVO) in late time windows (over 6 hours) has been validated. Studies utilised advanced neuroimaging to select patients with small ischaemic cores. We have evaluated if routine imaging with non-contrast CT (NCCT) is inferior to CT Perfusion (CTP) to select patients for EVT in late time windows. Method: A prospectively maintained database of all EVT patients at two tertiary referral centres was retrospectively interrogated to identify anterior circulation LVO patients, with groin puncture times over 6 hours from symptom onset or time last seen well. Subjects were divided into those that underwent CTP in addition to routine NCCT and CT angiography (CTA) and those that were selected by NCCT/CTA alone. Results: A total of 85 patients were included, 39 (46%) had CTP (CTP+). No significant difference between baseline characteristics of CTP+ vs CTP- groups such as age (mean 66 vs 74, p=0.26), gender (male 49% vs 59%, p=0.36), median ASPECT (8 vs 8, p=0.84) and median NIHSS (13 vs 13, p=0.42) were observed. The two groups were also well matched with respect to time metrics including onset to imaging time (mean 519 vs 477 mins, p=0.41), time to groin puncture (mean 733 vs 690 mins, p=0.90) and procedure time (mean 41 vs 38 mins, p=0.94). No significant difference between early neurological recovery (36% vs 44%, p=0.48), 90 day mean utility weighted mRS (6.2, 95% CI [5.1, 7.4] vs 6.4, 95% CI [5.2, 7.5] p=0.75), rates of functional independence at 90 days (60% vs 64%, p=0.76), and rates of symptomatic haemorrhage (8 vs 9%, p=0.41) was observed between the groups. Conclusion: In late time windows, anterior circulation LVO patients selected for EVT based on routine imaging had non-inferior outcomes to those who underwent CTP. Our data suggests that late time window patients who do not have access to advanced neuroimaging should not be excluded from EVT.

Abstract TP26: Benefit of Endovascular Therapy Across Clinical Trial Design and Technique: A Single Center Pooled Analysis

Introduction: Endovascular therapy practice has evolved dramatically over the last decade. Various randomized trials have investigated the benefit of thrombectomy using different selection criteria including patient populations based on time of presentation, imaging criteria, and procedural technique. We sought to understand the benefit of thrombectomy in patients treated within the context of a clinical trial regardless of trial design at a single academic center. Methods: Data were analyzed from patients enrolled in randomized controlled trials investigating the benefit of endovascular thrombectomy over medical management (IMSIII, ESCAPE, SWIFT PRIME and DAWN) between 2007 and 2017 at a single academic referral center. Results: A total of 130 patients (intervention group, n=80; medical group, n=50) were identified across four clinical trials (IMSIII, n=46; ESCAPE, n=24; SWIFT PRIME, n=14; DAWN, n=46). There were no significant differences between the treatment arm and control arm in terms of age, gender, baseline NIHSS, baseline ASPECTS and occlusion location. There were no differences in rates of sICH, PH-2 or mortality. Rates of good outcome were superior in the intervention group with early neurological recovery (defined as NIHSS of 0-1 or drop in NIHSS of 8 points at 24 hours) at a higher rate of 53% vs 14% (p=<0.001) and higher rates of functional independence (90 day mRS 0-2 of 54% vs 26%, p=0.002). In multivariate logistic regression analysis, lower NIHSS and younger age were predictors of good outcome. There were comparable rates of good outcome irrespective of clinical trial, imaging selection criteria (CTP vs MRI), early versus late time window design (0-6 hours vs 6-24 hours) and procedural technique (Merci vs Solitaire/Trevo). Conclusions: At a large academic center, the benefit of endovascular therapy over medical therapy is observed irrespective of clinical trial design, patient selection or procedural technique.

Abstract 94: Blood Pressure After Endovascular Stroke Therapy (BEST): Final Results of a Prospective Multicenter Cohort Validation Study

Background: Limited data currently inform optimal post-endovascular therapy (EVT) blood pressure management. Systolic BP (SBP) >160 mmHg during the 24-hrs post-EVT correlated with worse outcomes in our retrospective multicenter study. To prospectively determine and potentially validate the specific post-EVT SBP threshold that discriminates functional outcomes, we designed a multicenter, prospective cohort study - “Blood Pressure after Endovascular Stroke Therapy (BEST)” - with a prespecified analysis plan. Methods: Consecutive EVT-treated adult patients with ICA, M1, or M2 occlusions were enrolled at 12 comprehensive stroke centers, excluding those with disability, terminal diagnoses, LVAD, and in-hospital stroke. Baseline, treatment characteristics, and all SBP values during the 24 hrs post-EVT were captured. The primary outcome was 90d mRS (0-2 vs 3-6) adjusted for age, baseline NIHSS, glucose, ASPECTS, time to reperfusion, and history of hypertension. Secondary outcomes were intracerebral hemorrhage (ICH), symptomatic ICH, mRS distribution, and early neurologic recovery (ENR). A sample size of 340 was calculated to provide 80% power to detect a 1.36 odds ratio (i.e., 8% difference in mRS 3-6 rate) at α=0.05; inflated to 450 patients for up to 25% loss to follow up. The threshold of peak SBP that best discriminates mRS 0-2 vs. 3-6 will be identified with Youden’s index, and its association with outcomes will be quantified using logistic regression. Subgroup analysis by mTICI score and associations of other BP parameters with outcomes will be explored. Missing 90d outcomes will be imputed. Results: We enrolled 457 patients from 11/2017 to 7/2018 with mean age 68y (±15), 52% females, median NIHSS 16 (IQR 11,20), and ASPECTS 8 (IQR 7,10). 221 (48%) patients received alteplase and 402 (88%) achieved mTICI 2b-3. Mean peak SBP was 165±24 mmHg in mTICI2b-3 group and 171±22 in mTICI 0-2a group, and 352 (77%) received an IV antihypertensive. 331 (73%) patients have outcomes available at 90d; rest are expected by 10/2018. Final results will be presented at ISC. Conclusion: Expected results from BEST will inform clinical care and guide a developing randomized trial of targeted antihypertensive treatment in EVT-treated stroke patients.

Lumbopelvic Fixation and Sacral Decompression for U-shaped Sacral Fractures: Surgical Management and Early Outcome.

U-shaped sacral fractures are rare and often difficult to diagnose primarily due to the difficulty in obtaining adequate imaging and the severe associated injuries. These fractures are highly unstable and frequently cause neurological deficits. The majority of surgeons have limited experience in management of U-shaped sacral fractures. No standard treatment protocol for U-shaped sacral fractures has been available till now. This study aimed to examine the management of U-shaped sacral fractures and the early outcomes. Clinical data of 15 consecutive patients with U-shaped sacral fracture who were admitted to our trauma center between 2009 and 2014 were retrospectively analyzed. Demographics, fracture classification, mechanism of injury and operative treatment and deformity angle were assessed. All the patients were treated with lumbopelvic fixation or (and) sacral decompression. EQ-5d score was applied to evaluate the patients' quality of life. Of the 15 consecutive patients with U-shaped sacral fracture, the mean age was 28.8 years (range: 15-55 years) at the time of injury. There were 6 females and 9 males. The mean followup time was 22.7 months (range: 9 47 months) and mean full weight-bearing time was 9.9 weeks (range: 8-14 weeks). Ten patients received lumbopelvic fixation and sacral decompression, one lombosacral fixation, and 4 merely sacral decompression due to delayed diagnosis or surgery. The post-operation deformity angle (mean 27.87°, and range: 8°-90°) of the sacrum was smaller than that pre-operation (mean 35.67; range: 15-90) with no significance difference noted. At the latest follow-up, all patients obtained neurological recovery with different extents. Visual analogue score (VAS) was reduced from preoperative 7.07 (range: 5-9) to postoperetive 1.93 (range: 1-3). All patients could walk without any aid after treatment. Eight patients were able to care for themselves and undertook some daily activities. Five patients had returned to work foil time. In conclusion, lumbopelvic fixation is an effective method for stabilization of U-shaped sacral fractures with fewer complications developed. Effective reduction and firm fixation are the prerequisite of early mobilization and neurological recovery. Sacral decompression effectively promotes neurological recovery even in patients with old U-shaped sacral fractures.

A concomitant bone fracture delays cognitive recovery from traumatic brain injury.

Brain injury progression after severe traumatic brain injury (TBI) is associated with worsening cerebral inflammation but it is unknown how a concomitant bone fracture (BF) affects this progression. Enoxaparin (ENX) decreases penumbral leukocyte mobilization after TBI and improves neurologic recovery. We hypothesized that a concomitant BF worsens learning/memory recovery weeks after TBI and that ENX improves this recovery. CD1 male mice underwent controlled cortical impact or sham craniotomy with or without tibial fracture, receiving either daily ENX (0.8 mg/kg) or saline for 14 days after injury. Randomization defined four groups (Sham, TBI only, TBI + Fx, TBI + Fx + ENX, n = 5/each). Body weight loss and neurologic recovery (Garcia Neurologic Test, max score = 18) were assessed each day. Mouse learning (swimming time [s] and total distance [m] to reach the submerged platform Days 14 to 17 after TBI) and memory (swimming time [s] in platform quadrant after platform removed [probe]) was assessed by the Morris water maze. Ly-6G (cerebral neutrophil sequestration) and glial fibrillary acidic protein were evaluated by immunohistochemistry in brain tissue post mortem. Analysis of variance with Tukey's post hoc test determined significance (p < 0.05). A concurrent BF worsened Garcia Neurologic Test scores post-TBI Days 2 to 4 (p < 0.01) as compared with TBI only, and ENX reversed this worsening on Day 4 (p < 0.01). Learning was significantly slower (greater swimming time and distance) in TBI + Fx versus TBI only on Day 17 (p < 0.01). This was despite similar swimming velocities in both groups, indicating intact extremity motor function. Memory was similar in isolated TBI and Sham which was significantly better than in TBI + Fx animals (p < 0.05). Glial fibrillary acidic protein-positive cells in penumbral cortex were most prevalent in TBI + Fx animals, significantly greater than in Sham (p < 0.05). A long BF accompanying TBI worsens early neurologic recovery and subsequent learning/memory. Enoxaparin may partially counter this and improve neurologic recovery.

Relationships between selective neuronal loss and microglial activation after ischaemic stroke in man.

Modern ischaemic stroke management involves intravenous thrombolysis followed by mechanical thrombectomy, which allows markedly higher rates of recanalization and penumbral salvage than thrombolysis alone. However, <50% of treated patients eventually enjoy independent life. It is therefore important to identify complementary therapeutic targets. In rodent models, the salvaged penumbra is consistently affected by selective neuronal loss, which may hinder recovery by interfering with plastic processes, as well as by microglial activation, which may exacerbate neuronal death. However, whether the salvaged penumbra in man is similarly affected is still unclear. Here we determined whether these two processes affect the non-infarcted penumbra in man and, if so, whether they are inter-related. We prospectively recruited patients with (i) acute middle-cerebral artery stroke; (ii) penumbra present on CT perfusion obtained <4.5 h of stroke onset; and (iii) early neurological recovery as a marker of penumbral salvage. PET with 11C-flumazenil and 11C-PK11195, as well as MRI to map the final infarct, were obtained at predefined follow-up times. The presence of selective neuronal loss and microglial activation was determined voxel-wise within the MRI normal-appearing ipsilateral non-infarcted zone and surviving penumbra masks, and their inter-relationship was assessed both across and within patients. Dilated infarct contours were consistently excluded to control for partial volume effects. Across the 16 recruited patients, there was reduced 11C-flumazenil and increased 11C-PK11195 binding in the whole ipsilateral non-infarcted zone (P = 0.04 and 0.02, respectively). Within the non-infarcted penumbra, 11C-flumazenil was also reduced (P = 0.001), but without clear increase in 11C-PK11195 (P = 0.18). There was no significant correlation between 11C-flumazenil and 11C-PK11195 in either compartment. This mechanistic study provides direct evidence for the presence of both neuronal loss and microglial activation in the ipsilateral non-infarcted zone. Further, we demonstrate the presence of neuronal loss affecting the surviving penumbra, with no or only mild microglial activation, and no significant relationship between these two processes. Thus, microglial activation may not contribute to penumbral neuronal loss in man, and its presence in the ipsilateral hemisphere may merely reflect secondary remote degeneration. Selective neuronal loss in the surviving penumbra may represent a novel therapeutic target as an adjunct to penumbral salvage to further improve functional outcome. However, microglial activation may not stand as the primary therapeutic approach. Protecting the penumbra by acutely improving perfusion and oxygenation in conjunction with thrombectomy for example, may be a better approach. 11C-flumazenil PET would be useful to monitor the effects of such therapies.

Surgical treatment of complex Denis zone III sacral fractures

Objective To investigate the surgical treatment of complex Denis zone Ⅲ sacral fractures. Methods A retrospective study was conducted on the 15 complex Denis zone Ⅲ sacral fractures which had been treated from June 2011 to September 2015 in our hospital. They involved 9 men and 6 women, with an average age of 28.8 years (from 15 to 55 years). There were 8 U-shaped, 6 H-shaped and 3 lambda fractures. By the Gibbons grading for the sacral nerve injury, 3 cases were rated preoperatively as grade Ⅱ, 5 cases as grade Ⅲ and 7 as grade Ⅳ. Of them, 10 received π-shaped lumbopelvic fixation and sacral decompression 2 weeks after injury, one had lumbosacral fixation and sacral decompression 6 days after injury, and 4 underwent only sacral decompression 3 months after injury when they presented with symptoms of neural injury after fracture malunion. Their sacral malformation angle, visual analogue scale and EQ-5d scale were compared between pre-operation and postoperation. Results The 15 cases were followed up for 9 to 47 months (average, 24.9 months). Their full-weight-bearing time ranged from 8 to 14 weeks (average, 9.9 months). All the incisions healed well without any infection, pressure sore, implant loosening or breakage. There was no significant difference between the preoperative angle of malformation (35.7°±5.0°, from 15° to 90°) and the postoperative value (27.9°±6.0°, from 8° to 90°) (t=1.003, P=0.324). Their VAS pain score decreased significantly from preoperative 7.0±0.3 to postoperative 1.9±0.2, and their EQ-5D score increased significantly from preoperative 0.20±0.03 to postoperative 0.79± 0.04 (P<0.05). The final follow-ups revealed more or less recovery of neural function in all the patients. Conclusions π-shaped lumbopelivic fixation is an effective treatment for complex Denis zone Ⅲ sacral fractures. Effective decompression and stable fixation are prerequisites for early neurological and functional recovery. Simple sacral decompression can effectively promote nerve recovery in patients with old complex Denis zone Ⅲ sacral fractures. Key words: Sacrum; Fractures, bone; Fracture fixation, internal

Factors Influencing Early Neurological Recovery in Patients with Acute Ischemic Stroke

The purposes of this cross-sectional descriptive study were to describe early neurological recovery in patients with acute ischemic stroke and to identify the statistical predictors of early neurological recovery at 24 h and 3 days after admission. A purposive random sampling was employed to recruit 220 AIS patients from 8 hospitals in the southern region of Thailand from January to May 2016, and the data was analyzed by using multivariate logistic regression analysis. The results revealed that moderate and severe stroke severity decreased neurological recovery at 24 h (OR = .095, p &lt; .001, and OR = .126, p &lt; .01, respectively), compared with mild stroke severity. In addition, onset time to rt-PA within 3 h and 3.0 - 4.5 h increased the neurological recovery at 24 h (OR = 22.22, P &lt; .001, and OR = 17.28, P &lt; .01, respectively), compared with those who did not receive rt-PA treatment. Lastly, age &gt; 80 years decreased neurological recovery at 24 h after admission (OR=.361, P &lt; .05). Neurological recovery at 3 days showed that moderate and severe stroke severity decreased neurological recovery (OR = .10, p &lt; .001, and OR = .09, p &lt; .001, respectively), compared with mild stroke severity. Stroke patients who had onset time to rt-PA within 3 h and within 3.0 - 4.5 h increased neurological recovery at 3 days (OR=16.95, P &lt; .05, and OR = 14.43, P &lt; .01, respectively), compared with those who did not receive rt-PA treatment. The findings of this study show that stroke severity and onset time to rt-PA influence early neurological recovery in AIS patients.

Mechanical Thrombectomy Using the new Solitaire™ Platinum Stent-retriever : Reperfusion Results, Complication Rates and Early Neurological Outcome.

The application of radiopaque markers to the Solitaire™ stent-retriever for better visibility during mechanical thrombectomy (MT) has the potential to alter the well-known characteristics of the device; however, it is uncertain whether this adjustment influences efficacy or safety of the enhanced stent-retriever. Retrospective analysis of stroke databases of three comprehensive stroke centers. Our investigation was focused on technical and angiographic parameters, including procedure times, reperfusion results (thrombolysis in cerebral infarction, TICI), periprocedural complications and favorable early neurological recovery at discharge (modified Rankin scale ≤2 or National Institutes of Health Stroke Scale, NIHSS = 0 or ∆NIHSS ≥ 10), from consecutive patients with acute anterior circulation ischemic stroke treated with aSolitaire™ Platinum stent-retriever between October 2016 and March 2017. A total of 75patients (male: n = 27, 36%, age in years: mean (SD):75 (±12), median baseline NIHSS:17 (interquartile range IQR: 11-21), n = 41, 54.7% received additional i. v. thrombolytics) were treated with amedian number of 2device passes (range:1-5). The median time from groin puncture to final TICI was 56 min (IQR:41-79). In 69patients (92%) TICI2b-3 was achieved. Early neurological recovery was seen in 47 (62.7%) patients. The following periprocedural complications occurred: vasospasms (n = 7, 9.3%), emboli into anew territory (n = 4, 5.3%), symptomatic intracranial hemorrhage (n = 3, 4%), difficulties during device delivery/deployment (n = 1, 1.3%). The usage of the Solitaire™ Platinum stent-retriever for MT in acute ischemic stroke patients was highly effective and was not accompanied by an increased periprocedural complication rate.

The degree of leukoaraiosis predicts clinical outcomes and prognosis in patients with middle cerebral artery occlusion after intravenous thrombolysis

Leukoaraiosis (LA) is common in elderly patients with ischemic stroke on magnetic resonance imaging. In this study, we investigate whether the degree of LA is associated with clinical outcomes and prognosis of patients with middle cerebral artery occlusion following intravenous thrombolytic. Ninety-seven patients were recruited and divided into three groups based on the degree of LA (no, mild and moderate to severe LA) by the Fazekas scale. Clinical outcomes, recurrent stroke, Fugl-Meyer rating scale (FMS) and complications of intravenous thrombolysis were assessed. The association between the degree of LA and functional outcomes was analyzed by multivariable logistic regression model. Patients enrolled were divided into three groups: 26 patients with no LA, 43 patients with mild LA and 28 patients with moderate to severe LA. Impressively, the patients with mild LA were better in early neurological recovery and 90-day FMS score than patients in the other two groups. Multivariate logistic analysis revealed that moderate to severe LA was an independent predictor of poor functional outcome (OR: 10.482; 95% CI: 1.442–76.181; P = .020). Moreover, the patients with moderate to severe LA have a higher rate of hemorrhagic transformation and recurrent stroke as compared with two other groups during 90-day follow-up. Different degrees of LA differentially affect clinical outcome and prognosis in patients with middle cerebral artery occlusion following intravenous thrombolytic. Moderate to severe LA is a risk factor of poor prognosis. Mild LA is associated with early neurological recovery and good motor functional outcome.

Clinical characteristics and temporal profile of recovery in patients with favorable outcomes at 6 months after severe traumatic brain injury.

OBJECTIVE Early withdrawal of life-sustaining treatment due to expected poor prognosis is responsible for the majority of in-house deaths in severe traumatic brain injury (TBI). With increased focus on the decision and timing of withdrawal of care in patients with severe TBI, data on early neurological recovery in patients with a favorable outcome is needed to guide physicians and families. METHODS The authors reviewed prospectively collected data obtained in 1241 patients with head injury who were treated between 1986 and 2012. Patients with severe TBI, motor Glasgow Coma Scale (mGCS) score < 6 on admission, and those who had favorable outcomes (Glasgow Outcome Scale [GOS] score of 4 or 5, indicating moderate disability or good recovery) at 6 months were selected. Baseline demographic, clinical, and imaging data were analyzed. The time from injury to the first record of following commands (mGCS score of 6) after injury was recorded. The temporal profile of GOS scores from discharge to 6 months after the injury was also assessed. RESULTS The authors studied 218 patients (183 male and 35 female) with a mean age of 28.9 ± 11.2 years. The majority of patients were able to follow commands (mGCS score of 6) within the 1st week after injury (71.4%), with the highest percentage of patients in this group recovering on Day 1 (28.6%). Recovery to the point of following commands beyond 2 weeks after the injury was seen in 14.8% of patients, who experienced significantly longer durations of intracranial pressure monitoring (p = 0.001) and neuromuscular blockade (p < 0.001). In comparison with patients with moderate disability, patients with good recovery had a higher initial GCS score (p = 0.01), lower incidence of anisocoria at admission (p = 0.048), and a shorter ICU stay (p < 0.001) and total hospital stay (p < 0.001). There was considerable improvement in GOS scores from discharge to follow-up at 6 months. CONCLUSIONS Up to 15% of patients with a favorable outcome after severe TBI may begin to follow commands beyond 2 weeks after the injury. These data caution against early withdrawal of life-sustaining treatment in patients with severe TBI.

Long-term reintegration and quality of life in patients with subarachnoid hemorrhage and a good neurological outcome: findings after more than 20 years

OBJECTIVE The goal of this study was to examine long-term quality of life (QOL) and reintegration in patients with good neurological recovery after aneurysmal subarachnoid hemorrhage (aSAH) and SAH of unknown cause (SAH NUD). METHODS A long-term follow-up was performed in an original cohort of 113 individuals who had suffered SAH (93 with aSAH and 20 with SAH NUD) between 1977 and 1984. Self-reporting assessments, performed > 20 years after the bleeding episode, included the Quality of Life Scale (QOLS), Psychological General Well-Being (PGWB) index, and Reintegration to Normal Living (RNL) index, along with information on sleep disturbances and work status. RESULTS Seventy-one survivors were identified. Questionnaires were returned by 67 individuals who had suffered SAH 20-28 years previously. The QOL was rated in the normal range for both the QOLS score (aSAH 90.3 vs SAH NUD 88.6) and the PGWB index (aSAH 105.9 vs SAH NUD 102.8). Ninety percent of patients had returned to their previous employment. Complete RNL was reported by 40% of patients with aSAH and by 46% of patients with SAH NUD; mild to moderate readjustment difficulties by 55% and 38%, respectively; and severe difficulties by 5% of patients with aSAH and 15% of patients with SAH NUD. Self-rated aspects of cognition, mood, and energy resources in addition resulted in a substantial drop in overall reintegration. Sleep disturbances were reported by 26%. CONCLUSIONS More than half of patients with SAH who had early good neurological recovery experienced reintegration difficulties after > 20 years. However, the general QOL was not adversely affected by this impairment. Inability to return to work after SAH was associated with lower QOLS scores. Sleep disturbances were associated with lower PGWB scores.