Efficacy and safety of cilostazol-nimodipine combined therapy on delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage: a prospective, randomised, double-blinded, placebo-controlled trial protocol.

INTRODUCTION: Delayed cerebral ischaemia (DCI) due to cerebral vasospasm (cVS) remains the foremost contributor to morbidity and mortality following aneurysmal subarachnoid haemorrhage (aSAH). Past efforts in preventing and treating DCI have failed to make any significant progress. To date, our most effective treatment involves the use of nimodipine, a calcium channel blocker. Recent studies have suggested that cilostazol, a platelet aggregation inhibitor, may prevent cVS. Thus far, no study has evaluated the effect of cilostazol plus nimodipine on the rate of DCI following aSAH. METHODS AND ANALYSIS: This is a multicentre, double-blinded, randomised, placebo-controlled superiority trial investigating the effect of cilostazol on DCI. Data concerning rates of DCI, symptomatic and radiographic vasospasm, length of intensive care unit stay, and long-term functional and quality-of-life (QoL) outcomes will be recorded. All data will be collected with the aim of demonstrating that the use of cilostazol plus nimodipine will safely decrease the incidence of DCI, and decrease the rates of both radiographic and symptomatic vasospasm with subsequent improvement in long-term functional and QoL outcomes when compared with nimodipine alone. ETHICS AND DISSEMINATION: Ethical approval was obtained from all participating hospitals by the Ascension Providence Hospital Institutional Review Board. The results of this study will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04148105.

Aesthetic Comparison between Subcuticular Suture and Staple Closure of Anterior Cervical Decompression and Fusion Incision Scars: A Prospective Controlled Single-blinded Trial.

INTRODUCTION: Anterior cervical decompression and fusion (ACDF) procedures are common and neck scar appearance is important aesthetically. This study compared subcuticular suture closure with staple closure regarding the aesthetics of the neck incision scar. METHODS: A single-blinded comparative prospective study with two cohorts involving one facility and multiple surgeons was done to study all consecutive patients who underwent one/two-level ACDF operations from 2015-2016. We excluded patients with corpectomies, postoperative wound infection, reoperations in the same admission, any previous ACDF operations, non-compliance in follow-up, and inability to give informed consent. We did single-layer skin stapling without platysma closure or subcuticular suture with platysma closure. Patients followed up between 1.5 and six months. We used the Stony Brook Scar Evaluation Scale (SBSES), range 0-5 with five being the best score. Digital images were taken in a standardized manner and saved in a secure database. A blinded plastic surgeon and a blinded neurosurgeon, not involved in the operation, evaluated the scars using SBSES. A priori sample size using a clinically significant difference of one was determined. Wilcoxon rank-sum test was used; a p-value <0.05 was considered statistically significant. RESULTS: We studied 93 staple and 66 suture closures. There is no significant difference between the groups regarding age, sex, the incidence of diabetes, smoking, obesity (body mass index (BMI) >30 kg/m2), chemotherapy or the length of the incision. There is no statistically significant difference regarding SBSES as evaluated by the plastic surgeon (staples vs. sutures, median 2 vs. 2, range 0-5, p = 0.32). There is a statistically significant difference as evaluated by the neurosurgeon (staples vs. sutures, median 4 vs. 3, range 0-5, p = 0.003). Post hoc power analysis was 0.90. CONCLUSION: Using the validated SBSES to assess the aesthetic outcome of ACDF scars, we demonstrated that staples and sutures provide equivalent aesthetic outcomes per plastic surgeon evaluation, and staple closure results in statistically significant better aesthetic outcomes per neurosurgeon evaluation.

Outcome of mechanical thrombectomy in the very elderly for the treatment of acute ischemic stroke: the real world experience.

BACKGROUND: Although initial studies of neuroendovascular intervention did not review benefit over intravenous thrombolytics (iv r-tPA), recent studies have suggested otherwise. Elderly patients (age ≥80 years) are typically excluded from clinical trials. PURPOSE: To examine the utility of mechanical thrombectomy based on patient outcomes. MATERIAL AND METHODS: All stroke-alert activations at our health system from January 2011 to June 2014 were examined. All patients aged ≥80 years who had undergone mechanical thrombectomy were identified. Clinical characteristics included physiologic imaging findings, use of intravenous thrombolytics, baseline and postoperative National Institute of Health Stroke Scale (NIHSS), thrombolysis in cerebral infarction scores (TICI), and discharge destination. RESULTS: Mean NIHSS on presentation was 18.2 (range, 6-31), and 13.3 (range, 3-30) post thrombectomy. Three (16.6%) patients received iv r-tPA, two (11.1%) had symptomatic intracranial hemorrhage. Eight (44.4%) died, eight (44.4%) were discharged to nursing homes, and two (11.7%) were discharged to inpatient rehab and subsequently home. Favorable outcome was achieved in five (27.7%) patients. Fourteen (77.7%) patients had physiologic imaging prior to intervention. Three (75%) of four patients who did not have physiologic imaging prior to thrombectomy died. Thirteen (66.6%) patients had TICI 3 recanalization. CONCLUSION: Our study showed that although there remains a role of mechanical thrombectomy in the treatment of acute ischemic stroke in very elderly patients, it is associated with significant higher morbidity and mortality compared to younger patients, but should remain a very viable treatment option when quality of life is the most important consideration.