Several guidelines recommend carotid endarterectomy and percutaneous transluminal angioplasty with stenting for patients with carotid artery stenosis. However, considering that such evidence was established around 20 years ago and medical therapy (pharmacotherapy) has made great strides since then, it is essential to perform the best medical treatment for carotid stenosis patients. Statins are often used to treat carotid stenosis to suppress intima-media complex thickening and stabilize carotid plaque. High-dose statins were proven to be protective against recurrent stroke. Antiplatelet therapy is important for protecting against microemboli embolization from the rupture and erosion of the carotid plaque to the brain. Although a single antiplatelet agent is routinely recommended for the prevention of recurrent stroke, the effects of dual therapy were reported during the subacute stage (ex. the initial 3 months after onset) for carotid stenosis patients.

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  Carotid endarterectomy (CEA) is an established surgical treatment for carotid stenosis. Recently, carotid artery stenting (CAS) has become aveilable as an alternative for treating the disease. However, which surgical method is the better choice is still controversial. Recent developments in medical treatment have brought remarkable improvement in the outcome of carotid stenosis. It is therefore time to reconsider the guidelines for carotid stenosis treatment based on the updated clinical evidence.

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  The J-ASPECT Study, a nationwide Japanese study was conducted regarding the acute stroke care capacities of professional training institutions and the prevalence of burnout and quality of life amongst board-certified neurosurgeons and neurologists in Japan. We found that significant disparities existed in the fulfillment of the recommended items for comprehensive stroke centers, and a high prevalence of burnout among those professionals who worked for stroke care. The study group also analyzed the risk of in-hospital mortality for 53,170 acute stroke cases using nationwide administrative data based on the Diagnosis Procedure Combination (DPC) payment system.

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  The introduction of intravenous recombinant tissue plasminogen activator (IV rt-PA) has had an impact on acute stroke therapy. However, IV rt-PA ineligible/failed patients are still at issue. The Merci retriever and Penumbra system were approved and their use is gradually spreading in Japan, but the results of randomized controlled trials were negative in terms of endovascular treatment superiority or non-inferiority to IV rt-PA or standard care. Next generation devices such as stent-like retrievers are expected to show superiority to other treatments.
  On the other hand, acute surgical therapies such as the acute bypass or endarterectomy are also performed, but there are arguments concerning their usefulness and safety. Therefore, randomized trials are warranted to compare acute surgical treatments versus the best medical treatment.

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  Moyamoya disease is a chronic occlusive cerebrovascular disease with unknown etiology characterized by bilateral steno-occlusive changes at the terminal portion of the internal carotid artery (ICA), associated with abnormal vascular networks at the base of the brain. Recent genetic research suggests that the RNF213 gene located at chromosome 17q25 may be the susceptibility gene for moyamoya disease. RNF213 mutation predicts both early-onset and the severe form of moyamoya disease. As secondary insults in addition to the genetic abnormality, autoimmune response, inflammation/infection, radiation, and endothelial progenitor cells may together be implicated in the etiology of moyamoya disease. Finally, the dynamic nature of moyamoya disease, which is the self-compensatory reorganization system demonstrating the conversion of the blood flow supply from ICA system to the external carotid artery system, should be clarified to understand the pathophysiology of moyamoya disease.

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  The authors compared the utility of the International Prostate Symptom Score (IPSS) and Japan Orthopaedic Association (JOA) score for evaluating lower urinary tract symptoms (LUTS) associated with lumbar degenerative diseases.
  A total of 178 patients with lumbar degenerative diseases were assessed according to the IPSS and JOA score. These included 32 females (F-group), 80 males without urinary tract lesions (Mn-group), and 66 males with urinary tract lesions (Mu-group). Patients with ≥8 points on the IPSS and ≤−3 points on the JOA score were classified as LUTS (+). Additionally, we investigated both storage and voiding symptoms using IPSS. Patients with ≥4 points from a possible maximum of 15 across 3 questions relating to storage and voiding symptoms on the IPSS were defined as symptom (+).
  Among all 178 patients, LUTS positivity was detected in 85 patients (48%) by the IPSS and in 81 patients (46%) by the JOA score. In the F-group, 10 patients (31%) were LUTS (+) on both scoring systems. In the Mn-group, 33 (41%) and 39 patients (49%) were LUTS (+) on the IPSS and JOA score, respectively. Thus, there was good statistical correlation between the IPSS and JOA score.
  However, a more detailed analysis of the findings revealed that the group defined as normal by JOA score had worse symptoms on the IPSS : 25% of the 178 patients, including 14% in the F-group and 22% in the Mn-group.
  Moreover, IPSS clearly identified many cases with storage symptoms and many mixed cases with both voiding and storage symptoms associated with lumbar degenerative disease.
  In conclusion, IPSS was considered to be a more sensitive and useful scoring system than the JOA score for evaluating LUTS associated with lumbar degenerative diseases.

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  We experienced a rare case with conus medullaris syndrome caused by an intraspinal cystic mass derived from compressed vertebra.
  A 68-year-old man suffered an L1 compressed fracture from falling. Two months later, he experienced severe lumbago after lifting something heavy. Then, he felt numbness in his buttocks and thighs after a few days, and this symptom became aggravated before he was finally referred to our center. On admission, he was also suffering intermittent claudication and had difficulty urinating. Plain radiographs showed a vertebral collapse at the L1 spine. MRI represented a large cystic lesion antero-medial in the spinal canal strongly compressing the spinal cord at that level, of which the intensity was identical with that of fluid. A Myelogram showed the complete obstruction of contrast medium adjacent to the collapsed body of L1. The patient underwent laminectomy at the L1 level and microscopic resection of the cyst. The cyst wall had a surface covered with smooth and whitish tissue, but it didn't adhere to the dura. The fluid in the cyst was serous and yellowish. The cyst was reduced in size, followed by Th11-L3 transpedicular fixation combined with transpedicular focal bone and HA granule grafts at the L1 vertebra. The postoperative course was uneventful and the patient's neurological impairment soon disappeared completely.
  In this case, the sudden vertical load caused a comminuted burst of the L1 vertebral body. We suspect that the fluid inside the vertebral body extended posterior and formed a large intraspinal cystic mass, resulting in conus medullaris syndrome.

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  Iatrogenic carotid pseudoaneurysms are rare, but they can cause serious complications. We present a case of an extracranial cervical carotid artery pseudoaneurysm caused by central venous catheterization treated by surgical interposition using a synthetic graft.
  A 73-year-old man had an emergency abdominal operation during which his left internal carotid artery was injured by central venous catheterization. He presented hoarseness 1 month after the operation and a left internal carotid artery pseudoaneurysm (18×16×16 mm) was revealed. Direct surgery was performed. The pseudoaneurysm and the internal carotid artery were repaired using a synthetic graft (Gore-tex ePTFE graft). The postoperative course was uneventful and MRI showed no new intracranial lesion. A follow-up MRA and echogram showed the patency of the graft.
  We showed that surgical treatment with a synthetic graft (Gore-tex ePTFE graft) can be considered the treatment of choice for carotid pseudoaneurysms.

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