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Objectives Many physicians debate the efficacy of mechanical thrombectomy for ischaemic stroke, but most agree that to establish potential benefit, patient selection must be examined further. People >80 years are a growing population of patients with ischaemic stroke but are largely excluded from clinical trials. The benefit of thrombectomy for them may be greatly reduced due to diminishing neuroplasticity and a larger number of medical comorbidities. To address this knowledge gap, we examined clinical and economic outcomes after mechanical thrombectomy in the ischaemic stroke population from the Nationwide Inpatient Sample. Our null hypotheses were that elderly patients (>80 years) would have a similar rate of inpatient mortality in comparison to their younger counterparts and incur a similar economic expense. Design Retrospective cohort study. Setting A 20% stratified sample of US community hospitals within the Nationwide Inpatient Sample. Participants All patients from 2008 to 2010 with a primary diagnosis of ischaemic stroke that received mechanical thrombectomy were included. Primary and secondary outcome measures The primary outcome was inpatient mortality. Secondary outcomes included hospital charges and length of stay. Results Less than 1% of all ischaemic stroke cases (9300) were treated with mechanical thrombectomy. Of these, 18% involved patients over 80 years of age. The odds of inpatient mortality in elderly patients treated with mechanical thrombectomy were approximately twice that of their younger counterparts (OR1.993, p

OBJECT.: There is limited information regarding patient outcomes following interventions for stroke during the window for endovascular therapy. Studies have suggested that recently approved stent retrievers are safer and more effective than earlier-generation thrombectomy devices. The authors compared cases in which the Solitaire-FR device was used to those in which a MERCI or Penumbra device was used.This study is a single-center retrospective review of 102 consecutive cases of acute stroke in which patients were treated with mechanical thrombectomy devices between 2007 and 2013. Multivariate models, adjusted for confounding factors, were used to investigate functional independence (modified Rankin Scale [mRS] score ≤ 2, and successful reperfusion (thrombolysis in cerebral infarction [TICI] score ≥ 2b).Thrombectomy device had a significant impact on functional independence (mRS score ≤ 2) at discharge from the hospital (p = 0.040). Solitaire-FR treatment resulted in significantly more patients being discharged as functionally independent in comparison with MERCI treatment (p = 0.016). A multivariate model found the use of Solitaire-FR to improve the odds of good clinical outcome in comparison with prior-generation devices (OR 6.283, 95% CI 1.785-22.119, p = 0.004). Additionally, the use of Solitaire-FR significantly increased the odds of successful reperfusion (OR 3.247, 95% CI 1.160-9.090, p = 0.025).The stent retriever Solitaire-FR significantly improved the odds of functional independence and successful revascularization of the arterial tree. New interventional technology for stroke continues to mature, but randomized trials are needed to establish the actual benefit to specific patient populations.

The timing of tracheostomy in stroke patients unable to protect their airway has become a topic of debate. Proponents for early tracheostomy cite benefits including less ventilation-associated pneumonia, less sedative drug use, shorter length of stay, and reduced mortality in comparison to late tracheostomy. We examined the timing of tracheostomy on stroke patient outcomes across the United States using the Nationwide Inpatient Sample (2008-2010). Our hypothesis was that patients receiving an early tracheostomy would fare better at discharge in comparison to their counterpart receiving a late tracheostomy. Independent samples t-tests and chi-squared tests were used to make comparisons between early (≤10 days) and late (11-25 days) tracheostomy. Multivariable models, adjusted for confounding factors, investigated outcome measures. There were 13,165 stroke cases included in the study (5,591 in the early tracheostomy group and 7,574 in the late tracheostomy group). Univariate comparisons between groups can be found in the included table. Patients receiving an early tracheostomy had a significant reduction in the odds of ventilator-associated pneumonia in comparison to the late tracheostomy group (OR: 0.688, 95% CI: 0.495 - 0.956, P=.026). The adjusted length of stay for patients receiving an early tracheostomy was significantly lower in comparison to the late tracheostomy group (P

Many physicians debate the efficacy of mechanical thrombectomy (MT) for acute ischemic stroke (AIS), but most agree that to establish the true benefit there needs to be improved patient selection. The elderly are the fastest growing age group in the USA and present a growing population of AIS patients. The benefit of MT for these patients may be greatly reduced due to diminishing neuroplasticity and a larger number of medical co-morbidities at the time of intervention. The paucity of data on this intervention in the elderly limits the physician’s ability to adequately counsel patients and their families regarding any potential benefit from this emergent intervention. To address this knowledge gap, our objective was to examine clinical and economic outcomes after MT in the AIS population from the Nationwide Inpatient Sample (2008-2010). Our hypothesis was that patients > 80 years of age would fare worse at discharge in comparison to their younger counterpart. Independent samples t-tests and chi-squared tests were used to make comparisons. Multivariable models, adjusted for confounding factors, investigated outcomes. Less than 1% of all AIS cases were treated with MT. Of these, 18% (9300 cases) involved patients > 80 years. The odds of mortality in elderly patients treated with MT were more than double that of younger patients (OR:2.11, P 80 years experienced worse clinical outcomes than their younger counterpart. Studies to better identify specific subpopulations of patients, in all age groups, that would benefit from mechanical thrombectomy are needed urgently.

Endovascular clot retrieval is a technique available for removing intracranial arterial occlusions in acute ischemic stroke (AIS). This rescue therapy can be performed with moderate conscious sedation (CS) or general anesthesia (GA). The effect of GA on clinical outcome in AIS remains controversial. Therefore, we retrospectively investigated whether the use of CS or GA during endovascular intervention for AIS influenced outcomes.Patients who underwent emergent endovascular intervention for intracranial arterial occlusion during the years 2006 to 2012 were included in this study. Statistical analysis using the Spearman ρ was performed to examine demographic data and clinical outcomes between patients in the GA and CS groups. Binary logistic regression was used to determine the predictors of mortality.A total of 109 patients fit the inclusion criteria. Among them, 35 patients had GA and 74 patients had CS. Patients needing intubation upon admission for airway protection were more likely to receive GA (P0.001). The duration of the procedure and the time-to-revascularization from symptom onset were significantly longer in the GA group. Mortality was higher in the GA group compared with the CS group (40% vs. 22%, P=0.045). Multivariate analysis, controlled for confounding variables, identified GA and elevated postprocedure glucose level to be significant predictors of mortality.Larger prospectively randomized multicenter trials evaluating the effects of GA and CS on clinical and radiographic outcomes seems warranted.

The timing of tracheostomy in stroke patients unable to protect their airway has become a topic of debate. Proponents for early tracheostomy (ET) cite benefits including less ventilation-associated pneumonia, less sedative drug use, shorter length of stay, and reduced mortality in comparison with late tracheostomy (LT).We examined the timing of tracheostomy on stroke patient outcomes across the United States using the Nationwide Inpatient Sample (2008-2010). Independent samples t tests and chi-squared tests were used to make comparisons between early (≤10 days) and late (11-25 days) tracheostomy. Multivariable models, adjusted for confounding factors, investigated outcome measures.In total, 13,165 stroke cases were included in the study (5591 in the ET group and 7574 in the LT group). Patients receiving an ET had a significant reduction in the odds of ventilator-associated pneumonia in comparison with the LT group (OR: .688, P = .026). The length of stay for patients receiving an ET was significantly lower in comparison with the LT group (P .001) and was associated with an 18% reduction in total hospital costs (P .001).Early tracheostomy for stroke patients may reduce the incidence of ventilator-associated pneumonia, thereby shortening the hospital stay and lowering total hospital costs. These relationships warrant further investigation in a large prospective multicenter trial.

Context:Quadriceps dysfunction is a common consequence of knee joint injury and disease, yet its causes remain elusive.Objective:To determine the effects of pain on quadriceps strength and activation and to learn if simultaneous pain and knee joint effusion affect the magnitude of quadriceps dysfunction.Design:Crossover study.Setting:University research laboratory.Patients or Other Participants:Fourteen (8 men, 6 women; age = 23.6 ± 4.8 years, height = 170.3 ± 9.16 cm, mass = 72.9 ± 11.84 kg) healthy volunteers.Intervention(s):All participants were tested under 4 randomized conditions: normal knee, effused knee, painful knee, and effused and painful knee.Main Outcome Measure(s):Quadriceps strength (Nm/kg) and activation (central activation ratio) were assessed after each condition was induced.Results:Quadriceps strength and activation were highest under the normal knee condition and differed from the 3 experimental knee conditions (P < .05). No differences were noted among the 3 experimental knee conditions for either variable (P > .05).Conclusions:Both pain and effusion led to quadriceps dysfunction, but the interaction of the 2 stimuli did not increase the magnitude of the strength or activation deficits. Therefore, pain and effusion can be considered equally potent in eliciting quadriceps inhibition. Given that pain and effusion accompany numerous knee conditions, the prevalence of quadriceps dysfunction is likely high.

Context:Quadriceps and hamstrings weakness occurs frequently after anterior cruciate ligament (ACL) injury and reconstruction. Evidence suggests that knee injury may precipitate hip and ankle muscle weakness, but few data support this contention after ACL injury and reconstruction.Objective:To determine if hip, knee, and ankle muscle weakness present after ACL injury and after rehabilitation for ACL reconstruction.Design:Case-control study.Setting:University research laboratory.Patients or Other Participants:Fifteen individuals with ACL injury (8 males, 7 females; age = 20.27 ± 5.38 years, height = 1.75 ± 0.10 m, mass = 74.39 ± 13.26 kg) and 15 control individuals (7 men, 8 women; age = 24.73 ± 3.37 years, height = 1.75 ± 0.09 m, mass = 73.25 ± 13.48 kg).Intervention(s):Bilateral concentric strength was assessed at 60°/s on an isokinetic dynamometer. The participants with ACL injury were tested preoperatively and 6 months postoperatively. Control participants were tested on 1 occasion.Main Outcome Measures:Hip-flexor, -extensor, -abductor, and -adductor; knee-extensor and -flexor; and ankle–plantar-flexor and -dorsiflexor strength (Nm/kg).Results:The ACL-injured participants demonstrated greater hip-extensor (percentage difference = 19.7, F1,14 = 7.28, P = .02) and -adductor (percentage difference = 16.3, F1,14 = 6.15, P = .03) weakness preoperatively than postoperatively, regardless of limb, and greater postoperative hip-adductor strength (percentage difference = 29.0, F1,28 = 10.66, P = .003) than control participants. Knee-extensor and -flexor strength were lower in the injured than in the uninjured limb preoperatively and postoperatively (extensor percentage difference = 34.6 preoperatively and 32.6 postoperatively, t14 range = −4.59 to −4.23, P ≤ .001; flexor percentage difference = 30.6 preoperatively and 10.6 postoperatively, t14 range = −6.05 to −3.24, P < .05) with greater knee-flexor (percentage difference = 25.3, t14 = −4.65, P < .001) weakness preoperatively in the injured limb of ACL-injured participants. The ACL-injured participants had less injured limb knee-extensor (percentage difference = 32.0, t28 = −2.84, P = .008) and -flexor (percentage difference = 24.0, t28 = −2.44, P = .02) strength preoperatively but not postoperatively (extensor: t28 = −1.79, P = .08; flexor: t28 = 0.57, P = .58) than control participants. Ankle–plantar-flexor weakness was greater preoperatively than postoperatively in the ACL-injured limb (percentage difference = 31.9, t14 = −3.20, P = .006).Conclusions:The ACL-injured participants presented with hip-extensor, -adductor, and ankle–plantar-flexor weakness that appeared to be countered during postoperative rehabilitation. Our results confirmed previous findings suggesting greater knee-extensor and -flexor weakness postoperatively in the injured limb than the uninjured limb. The knee extensors and flexors are important dynamic stabilizers; weakness in these muscles could impair knee joint stability. Improving rehabilitation strategies to better target this lingering weakness seems imperative.

Numerous studies on the mechanisms of ankle injury deal with injuries to the syndesmosis and anterior ligamentous structures but a previous sectioning study also describes the important role of the posterior talofibular ligament (PTaFL) in the ankle’s resistance to external rotation of the foot. It was hypothesized that failure level external rotation of the foot would lead to injury of the PTaFL. Ten ankles were tested by externally rotating the foot until gross injury. Two different frequencies of rotation were used in this study, 0.5 Hz and 2 Hz. The mean failure torque of the ankles was 69.5±11.7 Nm with a mean failure angle of 40.7±7.3°. No effects of rotation frequency or flexion angle were noted. The most commonly injured structure was the PTaFL. Visible damage to the syndesmosis only occurred in combination with fibular fracture in these experiments. The constraint of the subtalar joint in the current study may have affected the mechanics of the foot and led to the resultant strain in the PTaFL. In the real world, talus rotations may be affected by athletic footwear that may influence the location and potential for an ankle injury under external rotation of the foot.