The brain dock is a kind of screening assessment of brain health started in Japan in 1988 for the detection of unruptured cerebral aneurysms and to search for the etiology and risk factors of silent brain infarction and cerebral white matter lesions. At present, early prevention of stroke and dementia is the main aim of the Japanese Brain Dock Society. In the future, we believe that artificial intelligence (AI) -based diagnostic technology will enable progress by using the large amount of accumulated brain dock data and will continue its development toward the establishment of further proper guidance.

  Several randomized controlled trials have reported the effectiveness of endovascular thrombectomy for acute large-vessel occlusion, and this procedure is increasingly being used worldwide. However, the effects of this treatment are significantly associated with the recanalization rate (thrombolysis in cerebral infarction grade ＞ 2b) and the interval between onset and recanalization. Moreover, the uneven distribution of endovascular therapists and healthcare services between urban and regional city settings remains unaddressed, although research is underway to reduce the prehospital time. Further studies are warranted to investigate the current status across geographical regions to address this issue through a multidisciplinary approach and effective information sharing.

  Telemedicine refers to the provision of clinical services to patients in remote geographical locations via real-time bidirectional communication. Considering a sustainability based approach, telemedicine is important in Japan for effective delivery of health care services to local cities and remote regions. Optimization of treatment for acute cerebral stroke is an important component of neurosurgical services. Following advances in communication technology, real-time information sharing may become possible, particularly with regard to therapeutic procedures. This development would facilitate healthcare delivery at nighttime and during holidays when limited medical resources are available even in urban areas. Telemedicine would play an important role in the treatment of conditions that require a high level of diagnostic and therapeutic expertise. However, telemedicine also has the inherent shortcomings of medicine itself. When introducing and operating telemedicine, it is important to discuss the problems such as the scope of responsibility.

  Since the evidence regarding the efficacy of intravenous alteplase infusion and mechanical thrombectomy in acute ischemic stroke was reported, rapid treatment for acute stroke gathered importance. The concept of primary stroke centers (PSCs) was established in 1990s in Western countries, and more than 1,000 PSCs were certified in the US. The concept of comprehensive stroke centers (CSCs) that provide advanced stroke care including neurosurgical and endovascular treatment and advanced imaging for ischemic and hemorrhagic stroke was proposed and increasing number of CSCs have been designated worldwide.

  In 2010, the J-ASPECT Study was started to examine the geographical disparity of stroke care in Japan, and the effect of stroke center capabilities on outcomes of ischemic and hemorrhagic stroke using the Diagnosis Procedure Combination database. The CSC score, a structural indicator of stroke care, was shown to be associated with better outcomes in acute stroke patients, and higher availability of recombinant tissue-type plasminogen activator infusion and mechanical thrombectomy. In Japan, certification of the PSC was started only in 2019. Further studies are necessary to improve the acute stroke care in Japan using clinical indicators.

  Functional motor recovery after stroke is based on the brain and spinal reorganization. Functional reorganization in the brain and spinal interneurons are induced by the disinhibition of the intracortical interneurons and the change in spinal reciprocal inhibition. Brain machine interface, hybrid assistive neuromuscular dynamic stimulation (HANDS) protocol, and spinal stimulation were developed for functional recovery after stroke in the field of neurorehabilitation. This article reviews the mechanism and effects of the brain machine interface, HANDS protocol, and spinal stimulation in the functional motor recovery of patients with stroke.

  A wide field of view and minimal surgical trauma serve as advantages of endoscopic surgery. Endoscopic endonasal surgery and endoscopic hematoma removal are currently being performed, and the development of sophisticated equipment, novel techniques, and education/training in this field have led to improved surgical outcomes and wide acceptance of this approach in clinical practice. Neuroendoscopic cylinder surgery for intraventricular/intraparenchymal tumors and minimally invasive transcranial endoscopic surgery for extra-axial tumors are alternative endoscopic approaches used in neurosurgery. Currently, endoscopy guided dissection of nerves and blood vessels can be performed to ensure meticulous manipulation of these delicate structures.

  Most benign brain tumors are extra-axial lesions. We are presently investigating an endoscopic keyhole approach that enables observation of the anatomy beyond bony protrusions and nerves through a limited access site. The introduction of high-resolution endoscopes and three-dimensional exoscopes has led to improved visualization of the endoscopic field and also provided a choice of viewpoints. The operation is performed by viewing a monitor, and the holder can be shared ; therefore, procedures can be performed by appropriately switching between the endoscope and exoscope based on the demands of the operation. An endoscope facilitates multi-view surgery, and can also be used for team surgery during which different approaches, such as a transnasal and transcranial approach can be combined. Minimal invasiveness is a known advantage of endoscopic procedures ; other advantages include a greater likelihood of radical cure owing to a wide viewing angle and/or multiple viewpoints to aid in better visualization of the operative field. In a rapidly aging society, it is reasonable not to expect cure but symptom relief for benign lesions. In our view, endoscopic surgery is a useful approach for procedures such as coagulation of feeding vessels and decompression surgery. The endoscopic approach is expected to play a significant role in both radical and minimally invasive surgery performed as palliative treatment.

  A carotid web is a rare condition that causes vascular stenosis secondary to localized fibromuscular dysplasia of the internal carotid artery (ICA). We report a case of a symptomatic carotid web successfully treated with carotid endarterectomy (CEA). A 70-year-old woman presented with sudden onset of left hemiparesis. Mechanical thrombectomy performed after tissue plasminogen activator administration achieved successful recanalization of the occluded right middle cerebral artery. Digital subtraction angiography revealed mild stenosis at the origin of the right ICA. Ultrasonography performed on the 6th day of hospitalization revealed a mobile thrombus, and we performed emergency CEA, and the carotid web and soft and mobile thrombus were removed. The patient's postoperative course was uneventful, and she showed no recurrent thrombosis of the right ICA. Owing to the structural abnormality and consequent blood flow stasis associated with a carotid web, this condition predisposes patients to thrombosis and embolism. Although standardized treatment has not been established for carotid webs, studies have reported that pharmacological treatment alone is associated with a high risk of recurrent cerebral infarction, and surgical treatment should be considered at an early stage.