Favorable Long-term Functional Outcome Research Articles

Predictors of favorable functional outcomes for elderly patients undergoing endovascular thrombectomy for acute ischemic stroke

PurposeThe aim of this study was to identify factors that predict favorable functional outcomes in elderly patients with large-vessel occlusion acute ischemic stroke (LVO-AIS) who underwent mechanical thrombectomy (MT).MethodsWe conducted a retrospective observational study using the prospectively maintained Bigdata Observatory for Stroke of China (BOSC) to identify eligible patients who underwent MT for LVO-AIS at four comprehensive stroke centers between August 2019 and February 2022. Inclusion criteria included patients aged 80 years or older with a baseline modified Rankin Scale (mRS) 0–2, baseline National Institutes of Health Stroke Scale (NIHSS) > 6, baseline Alberta Stroke Program Early CT Score (ASPECTS) > 6 who received treatment within 24 h from symptom onset. Pertinent demographic, clinical, and procedural variables were collected. Multivariable regression analyses were performed to identify predictors of favorable long-term functional outcomes, defined as mRS 0–2 at 90 days.ResultsA total of 63 patients were included in the study with a mean age of 83 years. Patients with previous diagnosis of atrial fibrillation were more likely to have a favorable functional outcome (OR 2.09, 95% CI 2.09–407.33, p = 0.012), while a higher baseline NIHSS was associated with a less favorable functional outcome (OR 0.64, 95% CI 0.46–0.89, p = 0.007). In addition, there was an observed trend suggesting an association between higher baseline ASPECTS and favorable functional outcomes. This association did not reach statistical significance (OR 2.49, 95% CI 0.94–6.54, p = 0.065).ConclusionIn this study, we identified factors that predicted a favorable functional outcome in elderly LVO-AIS patients undergoing MT. A higher baseline NIHSS decreased the odds of mRS 0–2 at 90 days, whereas a history of atrial fibrillation increased the odds of a favorable functional outcome. These results emphasize the complex relationship between clinical factors and functional recovery in this vulnerable population.

Abstract TP199: Prominent Laterality of the Posterior Cerebral Artery on MR Angiography Before Mechanical Thrombectomy in Patients With the Middle Cerebral Artery Occlusion Predicts Long-Term Functional Outcome

Background and Purpose: Well-developed collateral flow is reported to be associated with a reduction of infarct volume, successful reperfusion, and better functional outcome in acute ischemic stroke (AIS). Relatively increased visualization of posterior cerebral artery (PCA) ipsilateral to the ischemic lesion on MR angiography (MRA), a sign of prominent PCA laterality (PCAL), represents the development of collateral flow from PCA to middle cerebral artery (MCA) territory. However, the prognostic value of PCAL on functional outcome in AIS patients having MCA occlusion and undergoing mechanical thrombectomy, is not well known. Methods: We retrospectively reviewed initial MRA scans of pre-morbidly independent patients treated with mechanical thrombectomy for M1-segment occlusion from September 2017 to May 2022. PCAL was defined as better visualization of ipsilateral PCA, compared to contralateral PCA, by one or more segments on MRA. We divided patients into two groups, those presenting PCAL and not, and compared the background characteristics, in-hospital management, and functional outcome between the two groups. Factors associated with favorable outcome (mRS score 0-2) at 3 months after onset were assessed using multivariate logistic regression analysis. Results: In total, 172 patients (76 female [44%], median age 77 [IQR 74.5-78.0] years, median NIHSS score 16 [15-18]) were included. Of these, 86 patients (50%) presented PCAL on initial MRA. There is no significant difference between the two groups in age, sex, major vascular risk factors, NIHSS on admission, DWI-ASPECTS, onset-to-recanalization time (OTR), and preclinical modified Rankin scale. Multivariate logistic regression analysis showed an adjusted odds ratio of 2.11 for a favorable outcome in patients with PCAL (95% CI: 0.986 to 4.53, P=0.054). When focused on the cases with OTR >6 hours (n=53), PCAL was independently associated with favorable outcome (OR 5.77, 95% CI: 1.28 to 26.0, P=0.022). Conclusion: PCAL on initial MRA in patients with M1-segment occlusion predicts favorable long-term functional outcome after mechanical thrombectomy, especially in the case taking longer time from onset to recanalization.

Long-term functional outcomes and complications of microsurgical resection of brainstem cavernous malformations: a systematic review and meta-analysis.

Brainstem cavernous malformations (CMs) encompass up to 20% of all intracranial CMs and are considered more aggressive than cerebral CMs because of their high annual bleeding rates. Microsurgical resection remains the primary treatment modality for CMs, but long-term functional outcomes and complications are heterogenous in the literature. The authors performed a systematic review on brainstem CMs in 4 databases: PubMed, EMBASE, Cochrane library, and Google Scholar. We included studies that reported on the long-term functional outcomes and complications of brainstem CMs microsurgical resection. A meta-analysis was performed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search yielded 4781 results, of which 19 studies met our inclusion criteria. Microsurgery was performed on 940 patients (mean age 35years, 46.9% females). Most of the brainstem CMs were located in the pons (n = 475). The pooled proportions of improved, stable, and worsened functional outcomes after microsurgical resection of brainstem CMs were 56.7% (95% CI 48.4-64.6), 28.6% (95% CI 22.4-35.7), and 12.6% (95% CI 9.6-16.2), respectively. CMs located in the medulla were significantly (p = 0.003) associated with a higher proportion of improved outcome compared with those in the pons and midbrain. Complete resection was achieved in 93.3% (95% CI 89.8-95.7). The immediate postoperative complication rate was 37.2% (95% CI 29.3-45.9), with new-onset cranial nerve deficit being the most common complication. The permanent morbidity rate was 17.3% (95% CI 10.5-27.1), with a low mortality rate of 1% from the compiled study population during a mean follow-up of 58months. Our analysis indicates that microsurgical resection of brainstem CMs can result in favorable long-term functional outcomes with transient complications in the majority of patients. Complete microsurgical resection of the CM is associated with a lower incidence of CM hemorrhage and the morbidity related to it.

162. Predictors of a sustained clinical benefit following adult spinal deformity correction with a minimum 3-year follow-up

<h3>BACKGROUND CONTEXT</h3> Despite multiple reports showing favorable long-term functional outcomes following adult spinal deformity (ASD) correction, it is still unclear which patient factors may impact the sustainability of these outcomes. <h3>PURPOSE</h3> To assess the sustainability of functional gains following ASD correction and determine predictors for postoperative loss of patient functionality. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort. <h3>PATIENT SAMPLE</h3> A total of 689 ASD patients. <h3>OUTCOME MEASURES</h3> Sustained clinical benefit, Oswestry Disability Index (ODI), reoperation, mechanical failure, proximal junctional failure (PJF) <h3>METHODS</h3> ASD patients with baseline (BL) and three-year (3Y) follow-up data were considered for analysis. Only patients who met the definition of sustained clinical benefit (SCB) at one-year (1Y) were included: 1)Passias et al's threshold for ODI (ODI<31.3), 2) did not develop PJF, and 3) did not have a reoperation for a mechanical failure. Patient groups were created by those who met SCB at 3Y, and those who did not. SCB outcomes were also reported at five-years (5Y) postoperatively. Means comparison tests assessed differences in patient groups. Factors predicting SCB were identified using adjusted regression and conditional inference tree (CIT) analysis. <h3>RESULTS</h3> A total of 157 patients met inclusion criteria and had SCB at 1Y. Patient breakdown for SCB was 75.0% at 3Y. Gender (78% vs 81%), BMI (25.5 vs 26.4), levels fused (10.6 vs 10.5), operative time (345 vs 362 min), and surgical invasiveness were similar between groups, all P>.05. Following surgery, patient groups were similarly aligned to Lafage et al's age-adjusted PT, PI-LL, and SVA, all P>.05. Regression and CIT analysis adjusting for BL deformity determined that patients who met SCB at 3Y were 95.4% less likely to have an ASD-mFI score > 11 (.046[.005-.420], p=0.006), 73.1% less likely to be older than 55 years at DOS (.269[.091-.798], p=.018), 69.4% less likely to have a CCI score > 0(.306[.116-.811], p=.017), and 86.9% less likely to have a BL EQ5D score < .723 (.131[.029-.585], p=.008). Adjusted for patients without follow-up, sustained clinical benefit at 5Y was 57.9%. Predictors of SCB from 3Y to 5Y included age, CCI and EQ5D, all P < .05. <h3>CONCLUSIONS</h3> Sustained clinical benefit was maintainable for 75.0% of the operative ASD cohort at 3Y. Similarly, a 57.9% maintenance rate of sustained clinical benefit at 5Y reflects the longevity of ASD correction. Independent predictors of sustained clinical benefit included age, frailty, comorbidities and the patient health state. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Clinical characteristics, long-term functional outcomes and relapse of anti-LGI1/Caspr2 encephalitis: a prospective cohort study in Western China.

Objective:To study the clinical characteristics of anti-leucine-rich glioma-inactivated 1 (LGI1) encephalitis and anti-contactin-associated protein-like 2 (Caspr2) encephalitis and to investigate factors associated with poor long-term neurological functional outcomes and relapse among patients in western China.Methods:In this single-center prospective cohort study, we consecutively enrolled patients with anti-LGI1 encephalitis and anti-Caspr2 encephalitis from April 2014 to February 2021. Patient outcomes were assessed using the modified Rankin scale. Predictors of long-term functional outcomes and relapse were analyzed.Results:Forty-four anti-LGI1 encephalitis patients [median age: 44 years, range: 18–82 years; females: 25 (56.8%)], 35 anti-Caspr2 encephalitis patients [median age: 43 years, range: 14–80 years; females: 19 (54.3%)], and 5 dual-positive patients [median age: 44 years, range: 36–58 years; females: 5 (100%)] were enrolled. Overall, 86.4% anti-LGI1 encephalitis patients and 80% anti-Caspr2 encephalitis had a favorable neurological functional outcome (mRS 0-2). Tumor occurrence and weight loss were associated with poor long-term functional outcomes in anti-LGI1 encephalitis, whereas in anti-Caspr2 encephalitis, predictors included behavioral disorder at acute phase, abnormalities in brain magnetic resonance imaging, higher modified Rankin scale scores at onset, poor response to the initial immunotherapy at 4 weeks, age at onset<30 years, and relapse (p<0.05). Overall, 13.6% of anti-LGI1 encephalitis patients and 20% of anti-Caspr2 encephalitis patients had at least one relapse. Sleep disorder at the acute phase was the risk factor of relapse in anti-LGI1 encephalitis, while female, age at onset <30 years, and behavioral disorder at acute phase were the risk factors of relapse in anti-Caspr2 encephalitis (log rank p<0.05).Conclusion:The clinical characteristics such as age, gender, and tumor occurrence rates of anti-LGI1 encephalitis and anti-Caspr2 encephalitis in western China are different from those in the Western countries. Most patients in our study had favorable long-term functional outcomes. The relapse rates are still high in both types of encephalitis, which warrants caution.

Free Flap Reconstruction of Traumatic Pediatric Foot and Ankle Defects: An Analysis of Clinical and Functional Outcomes.

Traumatic lower extremity injuries involving the foot and ankle can have devastating consequences and represent a complex reconstructive challenge. To date, there are limited reports on microsurgical reconstruction for foot and ankle defects in children. This study aims to evaluate clinical and functional outcomes of free flaps for pediatric foot and ankle injuries. This is a retrospective review of patients undergoing free flaps for traumatic foot and ankle defects at a pediatric trauma center between 2000 and 2015. Patients with less than 5-year follow-up were excluded. Demographics, clinical characteristics, and postoperative outcomes were evaluated. Thirty patients undergoing 30 flaps were analyzed. The mean age was 11.9 years (range: 2 to 17 years). Muscle flaps (n = 21, 70%) were more common than fasciocutaneous flaps (n = 9, 30%). Limb salvage with functional ambulation was achieved in 96.7% of patients (n = 29). The complication rate was 33.3% (n = 10), with wound breakdown (n = 6, 20.0%) as most common feature. There were no significant differences in limb salvage, total or partial flap loss, fracture union, and donor-site complications based on flap type. Fasciocutaneous flaps were more likely to require revision procedures for contour compared with muscle flaps (55.6 vs. 9.5%, p = 0.013). Mean follow-up was 8.5 years. Microsurgical reconstruction of pediatric foot and ankle defects results in high rates of limb salvage. A defect- and patient-centered approach to reconstruction, emphasizing durable coverage and contour, is critical to facilitating ambulation and ensuring favorable long-term functional outcomes.

Long-term Functional Outcomes and Relapse of Anti-NMDA Receptor Encephalitis: A Cohort Study in Western China.

ObjectiveTo study the factors associated with relapse and functional outcomes in patients with anti-NMDA receptor encephalitis in Western China.MethodsThe Outcome of the anti-NMDA receptor Encephalitis Study in Western China was initiated in October 2011 to collect prospective observational data from consecutively enrolled patients with anti-NMDA receptor encephalitis.ResultsWe consecutively enrolled 244 patients (median age: 26 years, range: 9–78 years; females: 128 [52.45%]) between October 2011 and September 2019. Fatality occurred in 17 (6.96%) patients, and tumors were found in 38 (15.57%) patients. The median follow-up duration was 40 (6–96) months. Of these patients, 84.8% showed clinical improvements within 4 weeks after immunotherapy, with a median modified Rankin Scale of 2 (interquartile range [IQR]: 2–3), and 80.7% (median: 1, IQR: 0–2) and 85.7% (median: 0, IQR: 0–1) had substantial recovery (i.e., mild or no residual symptoms) at 12 and 24 months, respectively. The overall prognosis was still improving at 42 months after onset. Disturbance of consciousness during the first month was the only independent predictor (OR: 2.91, 95% CI: 1.27–6.65; p = 0.01) of a poor functional neurologic outcome. Overall, 15.9% of the patients had one or multiple relapses, with 82.0% experiencing the first relapse within 24 months and 76.9% experiencing relapses that were less severe than the initial episodes. Relapse-related risk factors included the female sex and delayed treatment (p < 0.05).ConclusionsMost patients achieved favorable long-term functional outcomes. Some patients experienced one or multiple relapses, especially female patients. Timely immunotherapy at onset may reduce the risk of relapse.

Ultrarapid Endoscopic-Aided Hematoma Evacuation in Patients with Thalamic Hemorrhage.

Thalamic hemorrhage bears the worst outcome among supratentorial intracerebral hemorrhage (ICH). Minimally invasive endoscopic-aided surgery (MIS) has been proved to be safe and effective in evacuating ICH. However, the ideal timing of MIS is still a controversy. In this study, we present our experience in the treatment of patients with thalamic hemorrhage by ultrarapid MIS evacuation. This retrospective analysis enrolled seven patients treated with ultrarapid MIS evacuation of thalamic hemorrhage. Seven patients treated with EVD with similar ICH score were included as match control. Primary endpoints included rebleeding, morbidity, and mortality. Hematoma evacuation rate was evaluated by comparing the pre- and postoperative computed tomography (CT) scans. Glasgow Outcome Scale Extended (GOSE) and modified Rankin Score (mRS) were noted at the 6-month and 1-year postoperative follow-up. Among the seven patients, six were accompanied with intraventricular hemorrhage. All patients received surgery within 6 hours after the onset of stroke. The mean hematoma volume was 35 mL, and the mean operative time was 116.4 minutes. The median hematoma evacuation rate was 74.9%. There was no rebleeding or death reported after the surgery. The median GOSE and mRS were 3 and 5, respectively, at 6 months postoperatively. Further, 1-year postoperative median GOSE and mRS were 3 and 5, respectively. The data suggest that the ultrarapid MIS technique is a safe and effective way in the management of selected cases with thalamic hemorrhage, with favorable long-term functional outcomes. However, a large, prospective, randomized-controlled trial is needed to confirm these findings.

INNV-01. NEUROLOGIC IMPROVEMENT WITH CORTICOSTEROIDS PRIOR TO SURGERY IS PREDICTIVE OF DURABLE POST-OPERATIVE IMPROVEMENT IN MOTOR DEFICITS DUE TO BRAIN METASTASES

Abstract Corticosteroids reduce vasogenic cerebral edema and are thought to improve related neurologic deficits or symptoms of increased intracranial pressure. Brain metastases are typically associated with a large amount of edema and, consequently, come with a disproportionate degree of mass effect that may cause such deficits. There remains no standard approach to pre-operative corticosteroid therapy, nor is it understood what clinical characteristics are associated with a neurologic response to pre-operative steroids. We examined characteristics of steroid responders versus non-responders and, further, evaluated whether a response to preoperative steroids is predictive of durable improvement in neurologic function. Patients with pathology-proven brain metastases who underwent open surgical resection between 2009 and 2019 were identified from departmental records. Charts were reviewed to identify patients with motor dysfunction who received corticosteroids prior to surgery. Multiple patient and clinical characteristics were extracted and compared using student t-, chi-square, and Fisher’s exact tests. 90 patients exhibited pre-operative motor deficits, 69 of whom received corticosteroids prior to surgery (dose 2 – 112 mg; median 25 mg). 34 patients neurologic function improved prior to surgery, whereas 35 patients had no demonstrable improvement. All 34 patients (100%) whose motor function improved pre-operatively with steroids had sustained improvement at follow-up, whereas 27 of 35 (77%) patients who did not improve pre-operatively were better at follow-up (p = 0.005). All other clinical characteristics were similar between responders and non-responders. All motor deficits related to brain metastases that responded to steroids prior to surgery demonstrated durable improvement at follow-up, suggesting such an improvement portends a favorable long-term functional outcome. Conversely, a failure to improve with steroid therapy confers a more guarded prognosis.

Evolution of Basic Activities of Daily Living Function in Older Patients One Year After Transcatheter Aortic Valve Implantation.

BACKGROUND/OBJECTIVESTo assess the course and prediction of basic activities of daily living (ADL) function in patients after transcatheter aortic valve implantation (TAVI).DESIGNThis was a prospective cohort study.SETTINGThe setting was a single academic center in Switzerland.PARTICIPANTSParticipants included individuals aged ≥70 years (n = 330) undergoing TAVI.MEASUREMENTSA frailty index (based on geriatric assessment) and cardiac risk scores (EuroSCORE, Society of Thoracic Surgeons [STS] score) were determined in patients before TAVI. Basic ADL function was measured with patient or proxy interviews at baseline and 1‐year follow up. We used logistic regression models to investigate the association between baseline factors and functional decline.RESULTSAt 1‐year follow up, 229 (69.4%) of the 330 patients had stable or improved basic ADL function, 49 (14.8%) experienced a decline in basic ADL function, and 52 (15.8%) died. The frailty index, but not cardiac risk scores, significantly predicted decline in basic ADL function. Among the 34 surviving very frail patients, 12 (35.3%) experienced a functional status decline, and the remaining 22 (64.7%) had stable or improved functional status at 1‐year follow up.CONCLUSIONThis study confirms that a frailty index, and not cardiac risk scores, identifies patients at an increased risk of functional status decline after TAVI. Identifying patients with a high frailty index before TAVI is clinically relevant as these patients might benefit from targeted geriatric management and rehabilitation after TAVI. However, based on current data, it is not justified to use information on frailty status as the criterion for identifying patients in whom TAVI might be futile. Although the probability of poor outcome is high, very frail patients also have a high probability of favorable long‐term functional outcome.

Long-term functional outcome following minimally invasive endoscopic intracerebral hemorrhage evacuation

Background and purposePreclinical studies suggest that clot removal may mitigate primary and secondary brain injury following intracerebral hemorrhage (ICH). Although the MISTIE trial did not demonstrate an overall outcome benefit,...

Favorable Functional Recovery in Severe Traumatic Brain Injury Survivors beyond Six Months.

Favorable long-term functional outcomes after severe traumatic brain injury (TBI) may be underestimated. We analyzed 24-month functional outcomes from a consecutive series of severe TBI survivors. A prospective, observational database of severe TBI survivors from a single institution was analyzed. Glasgow Outcome Scale-Extended (GOS-E) scores were obtained at 3, 6, 12, and 24 months post-injury. GOS-E scores were dichotomized into unfavorable and favorable outcomes, and the proportion of survivors changing from unfavorable to favorable outcomes was calculated using Wilcoxon signed-rank tests. Surviving adults (N = 304; mean age ± standard deviation = 35.06 ± 15.11; 80.92% male; mode of initial GCS = 7) were analyzed. A statistically significant mean increase in GOS-E was noted from 3 to 6, 6 to 12, 12 to 24, and 6 to 24 months after injury (0.65 [p < 0.0001], 0.42 [p < 0.0001], 0.23 [p = 0.020], and 0.61 [p < 0.0001], respectively). Moreover, 43% of survivors from 3 to 6 months, 36% from 6 to 12 months, 38% from 12 to 24 months, and 54% from 6 to 24 months progressed from an unfavorable to a favorable outcome. Two thirds of survivors in the unfavorable category at 3 months had favorable outcomes at 2 years. Overall, 74% of surviving adults with a documented GOS-E at 2 years after injury had a favorable outcome. Severe TBI survivors demonstrated significant improvement in functional outcomes from 3 to 24 months after injury. At 2 years, three fourths of survivors had a favorable outcome. Long-term prognosis in severe TBI is better than broadly appreciated.

Favorable Long-Term Functional Outcomes and Safety of Auditory Brainstem Implants in Nontumor Patients.

Auditory brainstem implants (ABIs) were designed to restore hearing in deaf patients with auditory tumors or those unable to receive cochlear implants. Although ABIs may help some patients, their long-term outcomes have been rarely studied. To assess the long-term benefits and safety of ABIs in nontumor patients with sensorineural hearing loss (SNHL). We retrospectively reviewed the histories of 15 deaf patients (8 females, 7 males; mean age, 15.5 yr; range, 1-56 yr) who received ABIs for treatment of SNHL at our hospital from July 2008 to November 2015. These included 11 children with narrow internal auditory canals and 4 deaf adults with severe cochlear ossification. In each patient, a 12-channel ABI electrode was placed in the cochlear nucleus complex via a retrosigmoid approach. Auditory performance was evaluated using the Categories of Auditory Performance (CAP) index and sound detection and word identification tests. One year after ABI placement, 13 of 15 patients showed adequate or significantly improved auditory function based on the CAP scores at the last follow-up. Generally, adult patients tended to show better CAP scores (3.50) than pediatric patients (2.15), but the difference was not significant (P = .058). Postoperative complications included electrode migration, cerebrospinal fluid leakage, nonauditory stimulation, and minor seizures without severe sequelae or mortality. ABIs show favorable functional outcomes and long-term safety in nontumor deaf patients with limited treatment options. Collectively, our data indicate that ABIs represent an important treatment option for SNHL.

Abstract WMP4: Thrombectomy-only versus Combined Intravenous Alteplase and Thrombectomy: Meta-analysis

Introduction: Contraindications for intravenous thrombolysis are not infrequent (eg. anticoagulation, recent surgery, unclear last known well). With overwhelming recent evidence supporting the use of endovascular thrombectomy for large-vessel occlusive stroke, we conducted a metaanalysis to compare long-term functional outcome between thrombectomy-alone versus combined IV-tPA and thrombectomy. Hypothesis: Patients with acute ischemic stroke ineligible for IV-tPA treated with thrombectomy-alone have equally favorable long-term functional outcomes to patients treated with combined IV-tPA and thrombectomy Methods: Searched PubMed from 2014-2016 using pre-specified terms for studies that report odds ratio of improvement in mRS score at 90 days comparing thrombectomy vs IV-tPA stratified by whether patients had received IV-tPA. Multivariate adjusted odds ratios were used for the metaanalysis. Pooled odds ratio estimates across trials were synthesized by using a random-effects model based on Mantel-Haenszel methods. The pooled estimates were compared between thrombectomy-alone and combined IV-tPA and thrombectomy. Forest plots constructed. Results: Of the 920 studies, 3 studies reported subgroup analysis with 822 participants, 19.5% (N=160) received thrombectomy-alone, 80.5% (N=662) received combined IV-tPA and thrombectomy. Among patients who received thrombectomy-alone, the pooled odds ratio of good functional outcome at 3 months was 2.48 (1.43-4.30), in the combined IV-tPA and thrombectomy group the pooled odds ratio was 1.85 (1.37-2.49). Conclusions: Endovascular therapy was an effective therapy for patients ineligible for IV-tPA presenting with acute ischemic stroke caused by large vessel occlusive disease. While IV-tPA should not be withheld before thrombectomy in IV-tPA eligible patients, prospective studies are needed to select those who may benefit more from thrombectomy-only treatment.

Abstract WMP5: Endovascular Therapy Stroke Outcome in Very Elderly: Meta-analysis

Introduction: Very elderly (age ≥80yo) individuals account for about one-third of all stroke admissions with mixed literature demonstrating relative poor stroke outcomes. With overwhelming recent evidence supporting the use of intra-arterial thrombectomy in addition to IV thrombolysis for large-vessel occlusive stroke, we conducted a metaanalysis to assess long-term functional outcome following mechanical thrombectomy in very elderly. Hypothesis: Very elderly patients with acute ischemic stroke treated with thrombectomy have equally favorable long-term functional outcomes to their younger counterparts Methods: Stroke endovascular trials published in New England Journal of Medicine 2014-2015 were included if they reported odds ratio of good functional outcome (improvement in modified Rankin score, mRS) comparing thrombectomy vs IV-tPA dichotomized by age groups (age ≤ 80yo vs &gt;80yo, 2 studies dichotomized age at 70yo). Multivariate adjusted odds ratios and the corresponding standard errors were used for the metaanalysis. Pooled odds ratio estimates across trials were synthesized by using a random-effects model based on Mantel-Haenszel methods. The pooled estimates with 95% confidence interval were compared between elderly and younger age groups. Forest plots constructed. Results: Of the 5 recent intraartrial thrombectomy trials, 4 studies reported subgroup analysis by age with 1,206 participants, 28% (N=334) were above the age of 80yo, 72% (N=872) were ≤80yo. Among very elderly patients undergoing thrombectomy, the pooled odds ratio of good functional outcome at 3 months was 1.91 (1.13-3.24), in the younger group the pooled odds ratio was 1.95 (1.50-2.53). Conclusions: Endovascular therapy was an effective therapy for very elderly individuals presenting with acute ischemic stroke caused by large vessel occlusive disease. Future studies are needed to further assess the safety and effectiveness of thrombectomy in this growing population.

Long-term medication persistence in stroke patients treated with intravenous thrombolysis

ObjectiveThere are no data regarding long-term medication persistence in stroke survivors treated with intravenous thrombolysis (IVT), which is one of the most important determinants of treatment success. Our objective was to determine long-term medication persistence in stroke patients treated with IVT. MethodsThis retrospective observational study included 203 IVT-treated and 197 non-IVT treated patients with acute ischemic strokes (IS) admitted to the Stroke Unit between January 2007 and January 2013. ResultsDuring a median follow-up period of 3 years (range 1–7 years), 56 (21.6%) patients in the IVT-group and 62 (23.9%) patients in the non-IVT-group died. There was a higher medication persistence for all secondary stroke prevention medications (anti-thrombotic agents, anti-hypertensive drugs, statins and hypoglycemic drugs) in the IVT-group compared to the non-IVT group (88.7% vs. 69.0%; OR=3.68, 95% CI=2.17–6.23). After adjusting for baseline characteristics and possible confounders IVT was the independent predictor of medication persistence (OR=2.93, 95% CI=1.48–5.81, p=0.002). Higher medication persistence was observed in patients with favorable long-term functional outcome, both in the IVT-group (OR=4.37, 95% CI=1.83–10.40, p<0.001) and the non-IVT-group (OR=3.46, 95% CI=1.84–6.52, p<0.001). ConclusionMedication persistence was higher among IVT-treated patients compared to non-IVT-treated patients. The higher rate of non- medication persistence was recorded among patients with more pronounced disabilities after stroke.

Mini-Abdominoplasty in Burn Reconstruction

The excision of excessive fat and subcutaneous tissue in the infraumbilical region, also known as "mini-abdominoplasty, " can be used to harvest skin for burn reconstruction. The resultant full-thickness grafts are less prone to contracture than split-thickness grafts. They are particularly useful in areas where mobility is important, such as the neck and areas overlying major joints. It allows a single-stage reconstruction with little donor site morbidity and favorable long-term functional outcomes. Multiple other donor sites have been reported, most commonly the groin and small pinch grafts on the trunk, but they provide only small amounts of skin when compared with the abdomen. The authors report 12 cases of patients who were treated for sequelae of burns with full-thickness abdominal skin grafts that were procured by mini-abdominoplasties for the sole purpose of obtaining the skin. The mini-abdominoplasty in this series was found to be an effective, safe technique that provides large amounts of full-thickness skin for reconstruction. While the size of the grafts varied with age and size of the abdomen, up to 40 × 15 cm can be obtained in adults. The donor site complications are rare but most commonly include seromas and dehiscence of the wound.

Patient-Reported Outcomes After Simple Dislocation of the Elbow

The current study was designed to investigate the epidemiology and long-term clinical and patient-reported outcomes following simple dislocation of the elbow in adults. We identified all adult patients treated at our trauma center for a simple dislocation of the elbow during a ten-year period. One hundred and forty patients were eligible for review, and 110 (79%) were reviewed at a mean of eighty-eight months (range, sixteen to 171 months) after the injury. This review included clinical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Oxford elbow questionnaire, and a patient satisfaction questionnaire. Patients reported long-term residual deficits in the range of elbow motion. The mean DASH score was 6.7 points (95% confidence interval, 4 to 9 points). The mean Oxford elbow score was 90.3 points (95% confidence interval, 87.8 to 92.9 points). The mean satisfaction score was 85.6 points (95% confidence interval, 82.2 to 89 points). Sixty-two patients (56%) reported residual subjective stiffness of the elbow. Nine patients (8%) reported subjective instability, and sixty-eight (62%) reported residual pain. The satisfaction and DASH scores showed good correlation with absolute range of motion in the injured elbow, as did the overall Oxford elbow score and the pain and function components of that score. Multivariate analysis demonstrated that loss of elbow flexion (p = 0.001) and female sex (p = 0.002) were both independent predictors of a poorer DASH score. Reduced elbow flexion also predicted a poorer score on the function component of the Oxford elbow score (p = 0.02). A reduced flexion-extension arc of motion predicted a poorer overall Oxford elbow score (p = 0.02), a poorer score on the pain component of the Oxford elbow score (p = 0.02), and poorer overall satisfaction (p = 0.005). Female sex predicted a poorer score on the psychosocial component of the Oxford elbow score (p < 0.05). Although patients generally report a favorable long-term functional outcome after simple dislocation of the elbow, these injuries are not entirely benign. The rate of residual pain and elbow stiffness is high. Functional instability is less common and does not often limit activities.

Does non-perimesencephalic type non-aneurysmal subarachnoid hemorrhage have a benign prognosis?

We reviewed and compared the clinical course and long-term prognosis of patients with non-aneurysmal subarachnoid hemorrhage (SAH) with and without a perimesencephalic pattern of hemorrhage on CT scan. In 876 patients with spontaneous SAH, 52 (5.9%) were diagnosed with non-aneurysmal SAH. Based on their CT scans, the SAH was classified as perimesencephalic non-aneurysmal SAH (PNSH) in 23 patients and non-perimesencephalic (non-PNSH) in 29 patients. The patients in the non-PNSH group were further divided into diffuse type (19 patients) and localized type (10 patients). We performed follow-up three-dimensional-CT angiography (3D-CTA) in all possible patients at least 1 year after the attack. The PNSH group had a lower rate of acute hydrocephalus (8.7%) and angiographic vasospasm (0%) complications than the non-PNSH group (37.9% and 27.6%, respectively). Only one case of rebleeding occurred in the non-PNSH group. No demonstrable source of bleeding was found on follow-up 3D-CTA, which was performed 1 year after the attack. All patients with non-aneurysmal SAH had similarly favorable long-term functional outcomes. Based on our study, patients with non-PNSH have a more complicated clinical course than those with PNSH. However, the long-term prognosis was similarly favorable for both the PNSH and non-PNSH in limited circumstances when they showed normal findings on a series of two-dimensional and 3D angiographic work-ups.

Nonconstrained Elbow Replacement in Dogs

To review development of a nonconstrained total elbow replacement system for use in dogs and report the surgical technique used for implantation. Descriptive report. Dogs with chronic elbow osteoarthritis (OA) unresponsive to medical management for at least 1 year. A nonconstrained elbow replacement system (radioulnar and humeral components) was developed and used in dogs with medically nonresponsive elbow OA. The components were refined based on evaluation of clinical outcome. Changes in humeral stem design for composite fixation, the contours of the articulating surfaces, and in the humeral component to increase range of motion were incorporated. Drilling and cutting guides were developed to facilitate accuracy of implantation. With component refinement, more favorable long-term functional outcome was achieved. Design improvements incorporated into the elbow replacement system should increase treatment success. Total elbow replacement in dogs is possible and good long-term outcome can be achieved.