Thrombectomy With and Without Computed Tomography Perfusion Imaging in the Early Time Window: A Pooled Analysis of Patient-Level Data

Background and Purpose: The optimal imaging paradigm for endovascular thrombectomy (EVT) patient selection in early time window (0–6 hours) treated acute ischemic stroke patients remains uncertain. We aimed to compare post-EVT outcomes between patients who underwent prerandomization basic (noncontrast computed tomography [CT], CT angiography only) versus additional advanced imaging (computed tomography perfusion [CTP] imaging) and to determine the association of performance of prerandomization CTP imaging with clinical outcomes. Methods: The HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) pooled patient-level data from randomized controlled trials comparing EVT with usual care for acute ischemic stroke due to anterior circulation large vessel occlusion. Good functional outcome, defined as modified Rankin Scale score 0 to 2 at 90 days, was compared between randomized patients with and without CTP baseline imaging. Univariable and multivariable binary logistic regression analysis was performed to determine the association of baseline CTP imaging and good functional outcome. Results: We analyzed 1348 patients 610 (45.3%) of whom underwent CTP prerandomization. The benefit of EVT compared with best medical management was maintained irrespective of the baseline imaging paradigm (90-day modified Rankin Scale score 0–2 in EVT versus control patients: with CTP: 46.0% (137/298) versus 28.9% (88/305), without CTP: 44.1% (162/367) versus 27.3% (100/366). Performance of CTP baseline imaging compared with baseline noncontrast CT and CT angiography only yielded similar rates of good outcome (odds ratio, 1.05 [95% CI, 0.82–1.33], adjusted odds ratio, 1.04, [95% CI, 0.80–1.35]). Conclusions: Rates of good functional outcome were similar among patients in whom CTP was or was not performed, and EVT treatment effect in the 0- to 6-hour time window was similar in patients with and without baseline CTP imaging.

Abstract 1122‐000123: Association of 24‐hour Blood Pressure Parameters Post‐Thrombectomy with Functional Outcomes According to Collateral Status

Introduction : Higher blood pressure (BP) most post mechanical thrombectomy (MT) can restore perfusion to the ischemic brain tissue depending on collateral status. We aim to determine the association of 24‐hour post‐MT BP parameters with the functional outcome depending on the pre‐MT collateral status. Methods : We performed a retrospective chart review of patients who underwent MT at a comprehensive stroke center from 7/2014 to 12/2020. The patients were divided into two groups (good versus bad) depending on collateral status. A board‐certified neuroradiologist, who was blinded to the clinical outcomes, used collateral grading scales of Mass ≥3 and modified‐Tan>50% to designate good collaterals on the pre‐MT CT Angiogram. A binary logistic regression analysis was performed, controlling for age, sex, NIHSS, ASPECTS≥6, TICI score≥2b, time to thrombectomy, LDL, Hemoglobin‐A1C, intravenous‐alteplase, with the 24‐hour post‐MT BP parameters as the predictors. The outcomes were good functional outcome (3‐month mRS≤2) and mortality. Results : 220 patients met the inclusion criteria. 24‐hour BP parameters of standard deviation (SD) SBP (OR, 1.16; 95% CI,1.01‐1.33; P 0.047) and maximum DBP (OR, 1.05; 95% CI,1.01‐1.09; P 0.036) had an association with a good functional outcome, while SD SBP (OR, 1.15; 95% CI,1.01‐1.31; P 0.045), coefficient variation (CV) SBP (OR, 1.19; 95% CI,1.01‐1.41; P 0.043), SBP range (OR, 1.04; 95% CI,1.01‐1.07; P 0.046), maximum DBP (OR, 0.95; 95% CI,0.91‐0.99; P 0.016), pulse pressure (OR, 1.09; 95% CI,1.02‐1.16; P 0.022) and SBP ≥140 (OR, 5.85; 95% CI,1.11‐30.85; P 0.038) had an association with mortality in patients with good collaterals according to Mass grading. 24‐hour BP parameters of SD SBP (OR, 1.13; 95% CI,1.04‐1.24; P 0.007), CV SBP (OR, 1.18; 95% CI,1.05‐1.32; P 0.006), SBP range (OR, 1.04; 95% CI,1.01‐1.06; P 0.008) and maximum DBP (OR, 0.97; 95% CI,0.94‐1; P 0.02) had an association with mortality in patients with good collaterals according to modified‐Tan grading. There was no such association in patients with bad collaterals Conclusions : Various 24‐hour BP parameters post‐MT are associated with a functional outcome or mortality in patients with good collaterals, unlike in patients with bad collaterals.

Abstract 1122‐000093: Association of Pre‐Mechanical Thrombectomy Collateral Scores with Functional‐Outcome in Short Versus Extended Window for Thrombectomy

Introduction : We aim to determine the utility of pre‐mechanical‐thrombectomy (MT) collateral scores in the short (<6 hours from onset) versus extended (6‐24 hours from onset) window for MT with respect to a good functional‐outcome. Methods : We performed a retrospective chart review of patients who underwent MT for anterior circulation LVO at a comprehensive stroke center from 7/2014 to 12/2020. A board‐certified neuroradiologist, who was blinded to the clinical‐outcomes, used collateral grading scales of Miteff (ordinal), Mass (ordinal), and modified‐Tan (dichotomous) to designate collateral scores on the pre‐MT CT Angiogram. The patients were divided into short (<6 hours from onset) versus extended (6‐24 hours from onset) groups depending on their timing of presentation to the emergency department. A binary logistic regression analysis was performed, controlling for age, sex, NIHSS, ASPECTS≥6, TICI score≥2b, recanalization time, mean arterial pressure, blood glucose, location of occlusion, atrial fibrillation, LDL, hemoglobin‐A1C, and administration of intravenous‐alteplase, with the pre‐MT collateral grading scores as predictors. The primary outcome was a good functional‐outcome (3‐month mRS≤2) Results : 162 patients met our inclusion criteria for patients who presented in the short window. The pre‐MT scales of Mass (OR, 0.35; 95%CI, 0.16‐0.78; P 0.01) and modified‐Tan (OR, 0.35; 95%CI, 0.16‐0.78; P 0.01) were associated with a good functional‐outcome, unlike the Miteff scale (OR, 0.46; 95% CI, 0.18‐1.18; P 0.103). 58 patients met our inclusion criteria for patients who presented in the extended window. The pre‐MT scales of Mass (OR, 0.75; 95% CI, 0.23‐2.48; P 0.63), Miteff scale (OR, 0.78; 95%CI, 0.17‐3.64; P 0.746) and modified‐Tan (OR, 1.14; 95%CI, 0.1‐12.98; P 0.918) were not associated with a good functional‐outcome. Conclusions : Our study demonstrates that good collateral grades on Mass and modified‐Tan scales are associated with a good functional outcome for patients who present to the ED in the short window for MT. We did not find an association of any pre‐MT collateral scores with a good functional‐outcome for patients presenting in the extended window for MT.

Evaluation of Elbow Range of Motion Following Delayed Surgical Fixation of Pediatric Supracondylar Humerus Fractures: A Prospective Study

Introduction: To achieve excellent functional outcome in Pediatric Supracondylar fractures, early surgical fixation is recommended. Unfortunately, there are still some cases which have delayed presentation to the medical health care, leading to delay in appropriate management required for a good functional outcome. We studied the functional outcome, in terms of range of motion following fixation of type III supracondylar fracture of humerus in children presenting 10 days after initial injury. Materials & Methods: This was a prospective study conducted at The Children Hospital and Institute of Child Health, Lahore between February 1st, 2020 and July 30th 2021. Following approval from the Institutional Ethical committee, 44 pediatric patients presenting to the Emergency and outpatient department with initial trauma to affected elbow more than 10 days old with Supracondylar Fracture of Humerus extension type III were admitted and Open Surgical Fixation with K-wires was performed and Half Cast above elbow was applied for 3 weeks. Goniometer was used to measure range of motion of the effected elbow following the removal of half cast on the day of removal of cast, at 1 week, 2 weeks, and then at 2 weekly intervals until 90 % of Range of motion of the contralateral normal elbow was achieved. Results: The mean delay in presentation was 13.20 ± 2.66 days. None of the patients had close manipulation attempted. Mean Hospital stay was 40.20 ± 1.46 hours. It took a mean of 35.25±2.79 and 49.43± 1.21 days to achieve 90% range of motion in extension and flexion (p-value ≤ 0.001). On average extension was achieved earlier than flexion range of motion. Conclusion: Our study showed good functional outcome in terms of elbow flexion and extension in patients managed after delayed presentation of supracondylar humerus fracture but taking longer time to achieve 90% ROM of the normal elbow. Despite delayed presentation being common in our population, it is not associated with increased peri and post-op complications. Because the ROM improves over time, prolonged follow up is all that is required in such patients. Key words: Delayed fixation, Pediatric, Supracondylar Fracture

Effectiveness of Thrombectomy in Stroke According to Baseline Prognostic Factors: Inverse Probability of Treatment Weighting Analysis of a Population-Based Registry

Background and Purpose In real-world practice, the benefit of mechanical thrombectomy (MT) is uncertain in stroke patients with very favorable or poor prognostic profiles at baseline. We studied the effectiveness of MT versus medical treatment stratifying by different baseline prognostic factors. Methods Retrospective analysis of 2,588 patients with an ischemic stroke due to large vessel occlusion nested in the population-based registry of stroke code activations in Catalonia from January 2017 to June 2019. The effect of MT on good functional outcome (modified Rankin Score ≤2) and survival at 3 months was studied using inverse probability of treatment weighting (IPTW) analysis in three pre-defined baseline prognostic groups: poor (if pre-stroke disability, age >85 years, National Institutes of Health Stroke Scale [NIHSS] >25, time from onset >6 hours, Alberta Stroke Program Early CT Score <6, proximal vertebrobasilar occlusion, supratherapeutic international normalized ratio >3), good (if NIHSS <6 or distal occlusion, in the absence of poor prognostic factors), or reference (not meeting other groups’ criteria). Results Patients receiving MT (n=1,996, 77%) were younger, had less pre-stroke disability, and received systemic thrombolysis less frequently. These differences were balanced after the IPTW stratified by prognosis. MT was associated with good functional outcome in the reference (odds ratio [OR], 2.9; 95% confidence interval [CI], 2.0 to 4.4), and especially in the poor baseline prognostic stratum (OR, 3.9; 95% CI, 2.6 to 5.9), but not in the good prognostic stratum. MT was associated with survival only in the poor prognostic stratum (OR, 2.6; 95% CI, 2.0 to 3.3).Conclusions Despite their worse overall outcomes, the impact of thrombectomy over medical management was more substantial in patients with poorer baseline prognostic factors than patients with good prognostic factors.

Clinico-radiological and functional outcome of surgical management of displaced two part, three part and four part proximal humeral fractures in adults treated by PHILOS plate in a tertiary care hospital in North India: a prospective study of 30 patients

Background: Treatment of proximal humeral fractures is challenging. In the past, the fractures were treated conservatively which compromised the functional results. PHILOS plate provides a good functional outcome with context to the early joint mobilization and rigid fixation of the fracture.Methods: This was the prospective study of 30 patients aged 20 to 60 years (mean age 48.4 years) with proximal humeral fractures including two part, three part and four part fractures based on Neer’s classification, treated by open reduction internal fixation with PHILOS plating. Functional outcome was assessed using Constant-Murley Score.Results: The final outcome was observed at 6 months follow up. The results were comparable with the existing literature. The Mean Constant Score at 6 month follow up was 79.4, range (38 to 92). Out of 30, (n = 12, 40%) had excellent outcome, (n = 9, 30%) had good functional outcome, 6 (20%) had moderate outcome, 3 (10 %) had poor outcome. Out of 30 patients, one patient with four part fracture had a lowest CS of 38. Complications were observed in 5, (16.7%) patients. Varus malunion in one patient, avascular necrosis in one patient, stiffness in one patient.Conclusions: PHILOS plate gives stable fixation, enables early range of motion and minimizes complications with good functional outcome if done with expert hands.

Study of the Various Factors Involved in Monteggia Fractures Treated by Open Reduction and Internal Fixation in Government Medical College, Trichur

BACKGROUND The various factors involved in Monteggia fractures treated by open reduction and internal fixation (ORIF) were studied in patients presenting to Government Medical College, Trichur. Its distribution based on age, gender, and nature of trauma, were observed in the patients. METHODS This study was a prospective descriptive study, conducted in Department of Orthopaedics, Medical College, Thrissur from 1, January, 2016 to 1, July, 2017. Patients were assessed according to age, sex, side of injury, co-morbidities and final functional assessment was made according to Broberg and Morrey score. A total of 37 patients were observed. The patients were assessed, deemed fit for the study, and subjected to operation. Radial head reduction, fixation if needed, then ulna fracture was opened, reduced, and fixed with plate and screws. Postoperative plaster slab was applied, then converted to full above elbow cast, and retained for as long as needed. Post-operative mobilization was by home physiotherapy only. RESULTS Our study showed that open reduction and internal fixation of ulna outcome in Monteggia fractures leads to good elbow function and minimal loss of physical capacity. Immobilization of more than 2 months have very high chances of elbow stiffness. Early active mobilization after surgery is necessary for good functional outcome. Other than mild stiffness and loss of range of motion in some cases, very few other complications were found in our series. CONCLUSIONS Rigid internal fixation of ulna and early active mobilization is the key to achieve a good functional outcome and minimal loss of physical capacity in Monteggia fractures. Very few of the complications that were described in the literature were seen in the study. Even with restricted resources and minimal facilities, almost no permanent or debilitating morbidity or complications were seen in our series. Early active mobilization after surgery was the most important deciding factor for good functional outcome. Prolonged immobilization of more than one month consistently produces poor results. KEYWORDS Monteggia, Broberg and Morrey, Bado Classification, Internal Fixation, Ulna Fracture

Delayed neurological improvement is predictive to long-term clinical outcome on endovascular thrombectomy patients

Objectives This study aims at exploring the 3-month outcome predicting ability of delayed neurological improvement and the cause of delayed neurological improvement. Materials and methods Early neurological improvement and delayed neurological improvement were calculated to represent the neurological improvements. Good functional outcome was defined as a 90-day modified Rankin Scale score 0–2. We used multivariant logistic regression to explore the influential factors of good functional outcome as well as delayed neurological improvement. We applied net reclassification improvement and integrated discrimination improvement to assess the quantitative improvement of the predictive model. Results Early neurological improvement was observed in 50 (23%) patients and delayed neurological improvement exhibited in 67 (30%) patients. Early neurological improvement and delayed neurological improvement were both independent predictive factors to good functional outcome. In the basic model (adjusted for age, admission glucose level, baseline National Institute of Health Stroke Scale, and complications and number of retrieval attempts), early neurological improvement and delayed neurological improvement statistically improved the predictive ability (early neurological improvement: net reclassification improvement = 0.34, 95% confidence interval, 95% confidential interval (0.06, 0.69); integrated discrimination improvement = 0.05, p < 0.001; delayed neurological improvement: net reclassification improvement = 0.79, 95% confidential interval (0.47, 1.12); integrated discrimination improvement = 0.14, p < 0.001) delayed neurological improvement could predict clinical outcomes more accurately than early neurological improvement (early neurological improvement vs. delayed neurological improvement: integrated discrimination improvement = 0.09, p < 0.001). Moreover, delayed neurological improvement was affected by hypertension (odds ratio = 0.40, 95% CI (0.18, 0.88), p = 0.02), early neurological improvement (odds ratio = 20.10, 95% confidential interval (8.24, 19.02), p < 0.001), number of retrieval attempts (odds ratio = 0.39, 95% confidential interval (0.24, 0.66), p < 0.001), and complication (odds ratio = 0.25, 95% confidential interval (0.12, 0.54), p < 0.001). Conclusions Delayed neurological improvement could predict clinical outcomes more accurately than early neurological improvement. Hypertension, early neurological improvement, numbers of retrieval attempts, and complications were all predicting factors to delayed neurological improvement.

Middle Cerebral Artery M2 Thrombectomy in the STRATIS Registry

Background and Purpose: The safety and benefit of mechanical thrombectomy in the treatment of acute ischemic stroke patients with M2 segment middle cerebral artery occlusions remain uncertain. Here, we compare clinical and angiographic outcomes in M2 versus M1 occlusions in the STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) Registry. Methods: The STRATIS Registry was a prospective, multicenter, nonrandomized, observational study of acute ischemic stroke large vessel occlusion patients treated with the Solitaire stent-retriever as the first-choice therapy within 8 hours from symptoms onset. Primary outcome was defined as functional disability at 3 months measured by dichotomized modified Rankin Scale. Secondary outcomes included reperfusion rates and rates of symptomatic intracranial hemorrhage. Results: A total of 984 patients were included, of which 538 (54.7%) had M1 and 170 (17.3%) had M2 occlusions. Baseline demographics were well balanced within the groups, with the exception of mean baseline National Institutes of Health Stroke Scale score which was significantly higher in the M1 population (17.3±5.5 versus 15.7±5.0, P ≤0.001). No difference was seen in mean puncture to revascularization times between the cohorts (46.0±27.8 versus 45.1±29.5 minutes, P =0.75). Rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction≥2b) were similar between the groups (91% versus 95%, P =0.09). M2 patients had significantly increased rates of symptomatic ICH at 24 hours (4% versus 1%, P =0.01). Rates of good functional outcome (modified Rankin Scale score of 0–2; 58% versus 59%, P =0.83) and mortality (15% versus 14%, P =0.75) were similar between the 2 groups. There was no difference in the association of outcome and onset to groin puncture or onset to successful reperfusion in M1 and M2 occlusions. Conclusions: In the STRATIS Registry, M2 occlusions achieved similar rates of successful reperfusion, good functional outcome, and mortality, although increased rates of symptomatic ICH were demonstrated when compared with M1 occlusions. The time dependence of benefit was also similar between the 2 groups. Further studies are needed to understand the benefit of mechanical thrombectomy for M2 occlusions. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02239640.