Anticoagulation Protocol for Secondary Prevention of Acute Ischemic Stroke Associated with Nonvalvular Atrial Fibrillation.

OBJECTIVES: There is no clear evidence regarding when to initiate oral anticoagulants (OACs) for secondary prevention of recurrent stroke in patients with atrial fibrillation (AF). Therefore, this study aimed to evaluate the safety and efficacy of a novel OAC initiation protocol for secondary prevention of acute ischemic stroke associated with AF. MATERIALS AND METHODS: In this multicenter prospective study 597 consecutive Japanese patients with acute ischemic stroke associated with nonvalvular AF received post-stroke OACs according to a protocol based on severity (clinical (NIHSS) and radiological (ASPECTS + W)), rt-PA use, reperfusion, and hemorrhagic transformation (HT). Primary outcomes of safety and efficacy, including symptomatic hemorrhage, cerebral stroke, and disability were evaluated at 14 and 90 days. RESULTS: Mean OAC initiation time was 2.60±2.14 days from onset. The shortest and longest mean initiation times were 0.47±0.50 and 6.16±0.72 days, respectively. Following OAC administration, no ICH was observed within 90 days. A significantly higher incidence of acute recurrent ischemic events occurred 14 days prior to OAC (4.7%) compared with chronic recurrence within 90 days (0.8%) (P = 0.00013, McNemar's test) . Recurrence prior to OAC use was significantly correlated with days to treatment (P = 0.00224), severity (NIHSS, ASPECTS+W: P = 0.0223, P = 0.0393, respectively), and HAS-BLED (P = 0.0395) and there were no correlations with CHADS2 (P = 0.277) or CHA2DS2-VASc (P = 0.246) (Wilcoxon rank sum-test). CONCLUSIONS: This comprehensive OAC initiation protocol was relatively safe and effective for secondary prevention of stroke in patients with AF. Risk of acute recurrence was high, indicating that OACs should be started as early as possible. (clinical trial registration number: 15B 128).

Preoperative Predictive Factors of Short-Term Outcome in Idiopathic Normal Pressure Hydrocephalus.

BACKGROUND: Surgical treatment of idiopathic normal pressure hydrocephalus (iNPH) by ventriculoperitoneal (VP) or lumboperitoneal (LP) shunting can achieve long-term recovery of activities of daily living; however, in a subset of patients, maintenance of independence lasted for <6 months. This study examined positive preoperative predictive factors of short-term outcome for shunted iNPH patients. METHODS: Over a 9-year period, consecutive patients from multiple centers diagnosed with probable iNPH underwent either VP or LP shunt surgery. Preoperative variables of age, symptom duration, iNPH severity, tap test response, and magnetic resonance imaging findings of disproportionately enlarged subarachnoid space hydrocephalus (DESH) or incomplete DESH were retrospectively evaluated in relation to 1-year postoperative outcome. RESULTS: Outcome for 154 shunt patients (12 VP, 142 LP) as measured by postoperative disability modified Rankin Scale (mRS) and iNPH-gait disturbance (GD) was the same regardless of age. Symptom duration was inversely correlated with both iNPH severity (P < 0.0001) and postoperative improvement at 1 year (P = 0.0015). Severity also correlated inversely with postoperative improvement at 1 year (P < 0.0001). Age was not significantly correlated with the degree of postoperative improvement (mRS: P = 0.487; iNPH grading scale [GD]: P = 0.725). Outcome at 1 year (mRS, gait domain, and activities of daily living significantly improved in patients with a good response to the tap test (P < 0.0001) Preoperative DESH correlated with improvement in mRS and GD (P < 0.0001). CONCLUSIONS: Mild preoperative iNPH severity, shorter preoperative symptom duration, good tap test response, and complete DESH were associated with good short-term postoperative outcome at 1 year. These positive factors may be useful for prediction of short-term surgical outcome in iNPH patients.

Ultra-Early Combination Antiplatelet Therapy with Cilostazol for the Prevention of Branch Atheromatous Disease: A Multicenter Prospective Study.

BACKGROUND AND PURPOSE: The optimal use of antiplatelet therapy for intracranial branch atheromatous disease (BAD) is not known. METHODS: We conducted a prospective multicenter, single-group trial of 144 consecutive patients diagnosed with probable BAD. All patients were treated within 12 h of symptom onset to prevent clinical progression using dual antiplatelet therapy with cilostazol plus one oral antiplatelet drug (aspirin or clopidogrel). Endpoints of progressive BAD in the dual therapy group at 2 weeks were compared with a matched historical control group of 142 patients treated with single oral antiplatelet therapy using either cilostazol, aspirin, or clopidogrel. RESULTS: Progressive motor paresis occurred in 14 patients (9.7%) in the aggressive antiplatelet group, compared with 48 (33.8%) in the matched single antiplatelet group. Multivariate logistic regression analysis revealed the following variables to be associated with a better prognosis for BAD: baseline modified Rankin Scale score, dual oral antiplatelet therapy with cilostazol, and dyslipidemia (odds ratios of 0.616, 0.445, and 0.297, respectively). Hypertension was associated with a worse prognosis for BAD (odds ratio of 1.955). CONCLUSIONS: Our trial showed that clinical progression of BAD was significantly reduced with the administration of ultra-early aggressive combination therapy using cilostazol compared to treatment with antiplatelet monotherapy.

[Evaluation of deep infection of the surgical site after spine surgery].

OBJECTIVE: Surgical site infection(SSI)is commonly seen following spinal surgery, and it can be associated with serious morbidity, mortality, and increased resource utilization. The objective of this study was to identify specific independent risk factors for SSI occurring after spinal surgery. METHODS: We performed a retrospective study of patients who had spinal surgeries performed from January 2007 to July 2012 at our hospital. 10 patients with deep incisional SSI(dSSI)were identified and compared with 304 uninfected control patients. Risk factors for dSSI were determined with Mann-Whitney's U test, univariate analyses, and multivariate logistic regression. RESULTS: The overall rate of dSSI was 3.2%(10 of 314). Mann-Whitney's U test and univariate analyses showed surgery time and duration of postoperative drainage to be significantly higher in patients in whom dSSI developed than in uninfected control patients. Independent risk factors for dSSI that were identified by multivariate analysis were surgery time(odds ratio=9.891, 95% confidence interval=2.434-40.195). CONCLUSION: We identified independent risk factors for dSSI. Surgery time was associated with the highest independent risk of spinal surgical site infection. Duration of postoperative drainage was associated with a significantly increased risk of dSSI in Mann-Whitney's U test and the univariate analysis. However, it did not remain significantly different in multivariate analysis(p value=0.0854, odds ratio=3.227, 95% confidence interval=0.849-12.262).

Choroid plexus papilloma originating in the sella turcica--case report.

A 51-year-old female presented with a rare case of choroid plexus papilloma originating in the sella turcica manifesting as headaches that was not readily distinguishable preoperatively from pituitary adenoma. Head magnetic resonance imaging revealed a tumor extending from the sella turcica to the suprasellar cistern. The tumor was removed via an endonasal transsphenoidal approach. Histological examination indicated a papillary structure covered with a layer of columnar epithelial cells that resembled normal choroid plexus. These findings, together with immunohistochemistry, led to a diagnosis of choroid plexus papilloma.

Surgical removal of chondroma of the petrous apex resulting in hearing improvement--case report.

An 18-year-old male presented with a chondroma in the petrous apex manifesting as major complaints of headaches and sensorineural hearing disturbance on the right. Head computed tomography and magnetic resonance imaging revealed a neoplastic lesion in the right petrous apex, which had bulged to compress the internal auditory meatus. Surgical removal improved his hearing with normalization of the postoperative air conduction threshold by reduction of the pressure of the internal auditory meatus, suggesting that the function of the cochlea was retained and the tumor was compressing the cochleal nerve at the level of the internal auditory meatus. Histological examination showed the tumor consisted of hyaline cartilage tissue without cellular atypia and the diagnosis was chondroma.

Use of bioabsorbable plates for cranial fixation.

LactoSorb fixation plates are made of a bioabsorbable polymer (82% poly-L-lactic acid and 18% polyglycolic acid), and the strength is not inferior to titanium plates. LactoSorb has been used in the fields of pediatric neurosurgery and facial plastic surgery. Cranial fixation in craniotomy is mostly performed using titanium plates and clamps, but there are issues with esthetics and artifacts on postoperative radiographic images. Absorbable plates solve these problems, but are slightly thicker and more expensive. Here, we describe a technique to solve these disadvantages by inserting absorbable plates into the diploe. The present method was employed in 46 patients, and esthetically favorable results were obtained without intraoperative and postoperative complications. Absorbable plates may replace titanium plates as the main device for cranial fixation. The present method is particularly useful for cranial fixation in adults with a thin scalp.