Endovascular Thrombectomy for Mild Strokes: How Low Should We Go? A Multicenter Cohort Study

Background and Purpose:Endovascular thrombectomy (EVT) is effective for acute ischemic stroke with large vessel occlusion (LVO) and NIHSS ≥6. However, EVT benefit for mild deficits LVOs (NIHSS Methods: A retrospective cohort of patients with anterior circulation LVO and NIHSSoutcome; mRS=0–2 was the secondary. Symptomatic intracerebral hemorrhage (sICH) was the safety outcome. Clinical outcomes were compared through a multivariable logistic regression after adjusting for age, presentation NIHSS, time-last-seen-normal-to-presentation, center, IV-alteplase, ASPECTS, and thrombus location. We then performed propensity score matching as a sensitivity analysis. Results were also stratified by thrombus location. Results: 214 patients (EVT-124, medical management-90) were included from 8 US and Spain centers between January/2012 and March/2017. The groups were similar in age, ASPECTS, IValteplase rate and time-last-seen-normal-to-presentation. There was no difference in mRS=0–1 between EVT and medical management (55.7% versus 54.4%, respectively, aOR=1.3, 95%CI=0.64–2.64, p=0.47). Similar results were seen for mRS=0–2 (63.3% EVT versus 67.8% medical management, aOR=0.9, 95%CI=0.43–1.88, p=0.77). In a propensity matching analysis, there was no treatment effect in 62 matched pairs (53.5%EVT, 48.4% medical management; OR=1.17, 95%CI=0.54–2.52, p=0.69). There was no statistically significant difference when stratified by any thrombus location; M1 approached significance (p=0.07). sICH rates were higher with thrombectomy (5.8% EVT versus 0% medical management, p=0.02). Conclusions: Our retrospective multicenter cohort study showed no improvement in excellent and independent functional outcomes in mild strokes (NIHS

Incidence and rehabilitation of lower limb amputation in Canada, and feasibility of a novel training program

Background: There is a dearth of evidence about lower limb amputation (LLA) incidence, rehabilitation, and practice in Canada. Such data are crucial for assessing the burden of the disability and making informed healthcare decisions. We know from the literature that the current resource-intensive rehabilitation model is costly and perhaps not sustainable. This highlights the need for exploring interventions that are less resource-intensive and, therefore, more cost-effective. Purpose: To gain an understanding about the incidence of LLA, current practices, and rehabilitation services provided in Canada and to design and evaluate a novel approach that may ultimately provide cost-effective LLA rehabilitation. Methods: Five studies were conducted. Studies 1-2) analyses of Canadian data to determine the incidence of LLA and the provision of inpatient rehabilitation services from 2006 to 2011; studies 3-4) a Canadian survey to describe prosthetic rehabilitation practices and to explore therapists’ perspectives about the use of commercial games, particularly the Nintendo Wii Fit, in rehabilitation; and study 5) a feasibility randomized controlled trial (RCT) to evaluate the use of Wii Fit intervention (named Wii.n.Walk) in LLA rehabilitation. Results: The age-adjusted incidence of LLA was 22.9 per 100,000 individuals. Although there was a decline in the incidence rates, the number of LLAs increased for older age categories. In total, 18.0% (n=2,902/16,114) of the individuals received inpatient rehabilitation in Canada over the study years. When asked about the use of commercial games, 43.9% (n=36/82) of the therapists indicated that they use the Wii Fit in rehabilitation. Our feasibility RCT showed the intervention adherence was 83.4%. No adverse events occurred. Conclusions: Although the age-adjusted incidence rates have declined, the number of LLAs has increased in individuals older than 50. Given the increase in number of LLAs and the fact that only 18% of individuals receive inpatient rehabilitation, there is a need for other service deliveries. The Wii Fit is prevalently used in prosthetic rehabilitation in Canada and was found to be feasible for LLA rehabilitation. A future powered RCT is required to provide more evidence about the efficacy and cost-effectiveness of the Wii Fit in prosthetic rehabilitation.Medicine, Faculty ofGraduat

Jarus T: Virtual reality rehabilitation from social cognitive and motor learning theoretical perspectives in stroke population. Rehabil Res Pract 2014

Objectives. To identify the virtual reality (VR) interventions used for the lower extremity rehabilitation in stroke population and to explain their underlying training mechanisms using Social Cognitive (SCT) and Motor Learning (MLT) theoretical frameworks. Methods. Medline, Embase, Cinahl, and Cochrane databases were searched up to July 11, 2013. Randomized controlled trials that included a VR intervention for lower extremity rehabilitation in stroke population were included. The Physiotherapy Evidence Database (PEDro) scale was used to assess the quality of the included studies. The underlying training mechanisms involved in each VR intervention were explained according to the principles of SCT (vicarious learning, performance accomplishment, and verbal persuasion) and MLT (focus of attention, order and predictability of practice, augmented feedback, and feedback fading). Results. Eleven studies were included. PEDro scores varied from 3 to 7/10. All studies but one showed significant improvement in outcomes in favour of the VR group ( < 0.05). Ten VR interventions followed the principle of performance accomplishment. All the eleven VR interventions directed subject's attention externally, whereas nine provided training in an unpredictable and variable fashion. Conclusions. The results of this review suggest that VR applications used for lower extremity rehabilitation in stroke population predominantly mediate learning through providing a task-oriented and graduated learning under a variable and unpredictable practice

Feasibility of the Nintendo WiiFit™ for improving walking in individuals with a lower limb amputation

Objectives: To evaluate the feasibility of the Nintendo WiiFit™ as an adjunct to usual therapy in individuals with a lower limb amputation. Methods: The study was a Multiple Baseline (AB) Single Subject Research Design. Subjects were ≥19 years old, had their first unilateral transtibial or transfemoral amputation  ≤12 months ago, and were participating in prosthetic training. WiiFit training was provided for 30 min, 5 times a week, for a minimum of 2 and a maximum of 6 weeks in addition to usual therapy. Feasibility indicators were safety, post-intervention fatigue and pain levels, adherence, and subject’s acceptability of the program as measured by the Short Feedback Questionnaire–modified (SFQ-M). The primary clinical outcome was walking capacity assessed by the 2 Minute Walk Test (2MWT). The secondary clinical outcomes were the Short Physical Performance Battery, L-test, and Activities-Specific Balance Confidence. Results: Subjects (4 transtibial; 2 transfemoral) had a median age of 48.5 years (range = 45–59 years). No adverse events associated with the intervention occurred. Median pain and fatigue levels were 1.3 (range = 0.5–3.5) and 3.1 (range = 1.4–4.1), respectively. Median adherence was 80%. Subjects found the WiiFit enjoyable and acceptable (median SFQ-M = 35). Five subjects showed statistical improvement on the 2MWT and four on the secondary outcomes ( p < 0.05). Conclusion: The WiiFit intervention was found to be feasible in individuals with unilateral lower limb amputation. This research provides the foundation for future clinical research investigating the use of the WiiFit as a viable adjunctive therapy to improve outcomes in individuals with unilateral lower limb amputation who are participating in prosthetic training

Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT): A Prospective, Multicenter Cohort Study of Imaging Selection

Objective The primary imaging modalities used to select patients for endovascular thrombectomy (EVT) are noncontrast computed tomography (CT) and CT perfusion (CTP). However, their relative utility is uncertain. We prospectively assessed CT and CTP concordance/discordance and correlated the imaging profiles on both with EVT treatment decisions and clinical outcomes. Methods A phase 2, multicenter, prospective cohort study of large-vessel occlusions presented up to 24 hours from last known well was conducted. Patients received a unified prespecified imaging evaluation (CT, CT angiography, and CTP with Rapid Processing of Perfusion and Diffusion software mismatch determination). The treatment decision, EVT versus medical management, was nonrandomized and at the treating physicians’ discretion. An independent, blinded, neuroimaging core laboratory adjudicated favorable profiles based on predefined criteria (CT:Alberta Stroke Program Early CT Score ≥ 6, CTP:regional cerebral blood flow (\u3c30%) \u3c 70ml with mismatch ratio ≥ 1.2 and mismatch volume ≥ 10ml). Results Of 4,722 patients screened from January 2016 to February 2018, 361 patients were included. Two hundred eighty-five (79%) received EVT, of whom 87.0% had favorable CTs, 91% favorable CTPs, 81% both favorable profiles, 16% discordant, and 3% both unfavorable. Favorable profiles on the 2 modalities correlated similarly with 90-day functional independence rates (favorable CT = 56% vs favorable CTP = 57%, adjusted odds ratio [aOR] = 1.91, 95% confidence interval [CI] = 0.40–9.01, p = 0.41). Having a favorable profile on both modalities significantly increased the odds of receiving thrombectomy as compared to discordant profiles (aOR = 3.97, 95% CI = 1.97–8.01, p \u3c 0.001). Fifty-eight percent of the patients with favorable profiles on both modalities achieved functional independence as compared to 38% in discordant profiles and 0% when both were unfavorable (p \u3c 0.001 for trend). In favorable CT/unfavorable CTP profiles, EVT was associated with high symptomatic intracranial hemorrhage (sICH) (24%) and mortality (53%) rates. Interpretation Patients with favorable imaging profiles on both modalities had higher odds of receiving EVT and high functional independence rates. Patients with discordant profiles achieved reasonable functional independence rates, but those with an unfavorable CTP had higher adverse outcomes. Ann Neurol 2020;87:419–43

Outcomes of Endovascular Thrombectomy vs Medical Management Alone in Patients With Large Ischemic Cores

Importance The efficacy and safety of endovascular thrombectomy (EVT) in patients with large ischemic cores remains unknown, to our knowledge. Objective To compare outcomes in patients with large ischemic cores treated with EVT and medical management vs medical management alone. Design, Setting, and Participants This prespecified analysis of the Optimizing Patient’s Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) trial, a prospective cohort study of imaging selection that was conducted in 9 US comprehensive stroke centers, enrolled patients between January 2016 and February 2018, and followed them up for 90 days. Patients with moderate to severe stroke and anterior circulation large-vessel occlusion presenting up to 24 hours from the time they were last known to be well were eligible for the cohort. Of these, patients with large ischemic cores on computed tomography (CT) (Alberta Stroke Program Early CT Score \u3c6) or CT perfusion scanning (a volume with a relative cerebral blood flow \u3c30% of ≥50 cm3) were included in analyses. Exposures Endovascular thrombectomy with medical management (MM) or MM only. Main Outcomes and Measures Functional outcomes at 90 days per modified Rankin scale; safety outcomes (mortality, symptomatic intracerebral hemorrhage, and neurological worsening). Results A total of 105 patients with large ischemic cores on either CT or CT perfusion images were included: 71 with Alberta Stroke Program Early CT Scores of 5 or less (EVT, 37; MM, 34), 74 with cores of 50 cm3 or greater on CT perfusion images (EVT, 39; MM, 35), and 40 who had large cores on both CT and CT perfusion images (EVT, 14; MM, 26). The median (interquartile range) age was 66 (60-75) years; 45 patients (43%) were female. Nineteen of 62 patients (31%) who were treated with EVT achieved functional independence (modified Rankin Scale scores, 0-2) vs 6 of 43 patients (14%) treated with MM only (odds ratio [OR], 3.27 [95% CI, 1.11-9.62]; P = .03). Also, EVT was associated with better functional outcomes (common OR, 2.12 [95% CI, 1.05-4.31]; P = .04), less infarct growth (44 vs 98 mL; P = .006), and smaller final infarct volume (97 vs 190 mL; P = .001) than MM. In the odds of functional independence, there was a 42% reduction per 10-cm3 increase in core volume (adjusted OR, 0.58 [95% CI, 0.39-0.87]; P = .007) and a 40% reduction per hour of treatment delay (adjusted OR, 0.60 [95% CI, 0.36-0.99]; P = .045). Of 10 patients who had EVT with core volumes greater than 100 cm3, none had a favorable outcome. Conclusions and Relevance Although the odds of good outcomes for patients with large cores who receive EVT markedly decline with increasing core size and time to treatment, these data suggest potential benefits. Randomized clinical trials are needed