In Japan, there has been a decrease in head injuries due to traffic accidents, but an increase in these injuries in the elderly due to a fall or a slip. This increase is associated with the rapid aging of society. Thus, diffuse brain injury has decreased, while focal brain injury has increased.
  More effective surgical interventions have reduced mortality, but other outcomes have not changed. Intracranial pressure (ICP) monitoring is required in intensive treatment of severe head injury, but the Japan Neurotrauma Data Bank showed a reduced rate of ICP monitoring from 36.0% of cases in 1998 to 28.0% in 2009. Patients who underwent ICP monitoring tended to be younger and had cerebral edema based on head CT. Good outcomes were significantly more common in patients with an ICP ≤20 mmHg, whereas mortality was significantly higher in patients with an ICP >40 mmHg. Procedures for ICP monitoring varied in terms of measurement sites and devices. The normal recommendation is to measure ICP using a ventricular catheter, but ICP in Japan is more frequently measured in the brain parenchyma, followed by the subdural space and ventricle.
  Treatment of intracranial hypertension starts with noninvasive pharmacotherapy. Decompressive craniectomy is used as the final option. The Japan Neurotrauma Data Bank showed that these therapies were used in patients who underwent ICP monitoring and led to a significant decrease in mortality, but did not improve functional outcomes. A mutual understanding of treatment policies between neurosurgeons and neurointensivists leading to an integrated therapeutic approach is likely to improve the treatment outcomes of head injury.

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  The use of neuromonitoring is spreading in the field of neurological emergency treatment, i. e., treatment for traumatic brain injury (TBI), stroke, and post cardiac arrest syndrome (PCAS) patients. For example, continuous EEG (cEEG) and regional brain tissue oxygen saturation (rSO₂) are now widely used in PCAS patients for predicting neurological outcome and assuring quality of resuscitation.
  Several biomarkers such as ubiquitin carboxyl hydrolase-L1 (UCH-L1), and glial fibrillary acidic protein (GFAP) are also now widely accepted as neuronal and glial cell marker in brain and spinal cord injury (SCI).
  In this review, we first mention the differentiation of neuromonitoring, generally divided as regional and global monitors. We then show our clinical data and research data for several neuromonitoring cases in PCAS and SCI patients. We hope this review will help further your understanding and help inform you in the decision making process in neurocritical care.

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  Recently, nonconvulsive status epilepticus (NCSE) has been recognized as the disease type with the highest frequency. The outcome of NCSE is generally not satisfactory and its mortality is still high. Many kinds of neurological and metabolic diseases can cause NCSE. Although NCSE is diagnosed with its clinical symptoms and features presented by electroencephalograph, the diagnosis guideline and definitions have not been established yet. In this report, we explain the current outline for NCSE and present one typical case of NCSE that can be frequently consulted by the general clinicians and neurosurgeons.

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  In the treatment of paraclinoid aneurysms (PCAs), a correct understanding of the microsurgical anatomy is of primary importance, i. e., the site and shape of the aneurysmal neck and the projection of the fundus in relation to the surrounding structures. However, in large or giant PCAs, the aneurysms are often too large to permit accurate anatomical analysis. We therefore retrospectively analyzed 102 normal-sized and directly operated PCAs, exclusive of the carotid ophthalmic and anterior wall aneurysms, and classified them on the basis of precise 3D angiographical and intraoperative findings.
  The proposed classification system is composed of 1) carotid cave aneurysms (descending type, in situ type, ascending type), 2) posterior PCAs (posteromedial type, posterolateral type), and 3) anterolateral PCAs (ring proximal type, ring straddling type, ring distal type). We also argue that in PCA treatment, craniotomy surgery is more advisable than intravascular surgery because the former is the only method that allows the surgeon to precisely trace all of the perforators, to identify visual acuity-related perforators such as the superior hypophyseal artery, and to spare them when clipping the aneurysmal neck. In order to undertake the above-mentioned procedures safely and efficiently, we have found that using an air drill and the fine-tipped microsonocurette that we have improved for refined microsurgical use have proven to be most helpful. Especially in the operation of anterolateral PCAs, this microsonocurette is a “real must” for the safe removal of the anterior clinoid process which tightly covers the whole aneurysm.

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  A 38-year-old woman presented with right trigeminal neuralgia in the second and third division of the trigeminal nerve. She had received conservative medical treatment for several years, but the pain could not be controlled adequately. MRI and CT angiography revealed a venous angioma in the brainstem and an enlarged transpontine vein, which compressed the trigeminal nerve. Microvascular decompression (MVD) for the trigeminal nerve was performed employing a right lateral suboccipital craniotomy. The transpontine vein penetrated the midportion of the trigeminal nerve, compressed it toward the ventral side, and drained into the petrosal vein. We did not sacrifice the transpontine vein and nerve. The trigeminal nerve was released by separating the vein from the nerve. A prosthesis was placed at the compressed portion of the nerve. The patient experienced complete relief of facial pain immediately after MVD, and no relapse was detected in the 1-year follow-up.

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  Distal lenticulostriate artery (LSA) aneurysms are extremely rare with only 52 case reports in the published literature. When LSAs rupture, they are often associated with deep intraparenchymal hemorrhages. It is difficult to treat LSAs with either endovascular or microsurgical techniques, because they are located near the pyramidal tract. The optimal strategy for treatment of aneurysms involving small perforating arteries is controversial. This report describes a case of ruptured distal LSA aneurysm in a 59-year-old female who was treated conservatively. There was no recurrence of hemorrhage, and follow-up angiography demonstrated spontaneous thrombosis. The case report is followed by a review of the literature and a discussion of the treatment of this rare aneurysm.

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