To resuscitate acutely ill neurological patients, prompt and accurate diagnosis followed by the professional treatment is desirable. Initial management in neurological emergency, however, carries a significant risk to fall into pitfalls. To avoid unpredictable devastating outcome, possible life-threatening illness should be recognized. We presented our experience to call attention to such misleading critical illness: neurogenic stunned myocardium, neurological symptoms related to acute aortic dissection, intracranial arterial dissection, etc. Lack of reciprocal ST segment depression in electrocardiogram indicates neurogenic stunned myocardium rather than acute myocardial infarction. An elevated level of serum fibrinolytic marker is useful for screening of acute aortic dissection. Above all, history taking with core knowledge of certain life-threatening critical disorders is the clue to correct diagnosis. Collaboration of dedicated physicians and surgeons is warranted to develop sophisticated treatment standards of neurological emergency and critical care.

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Depression and apathy after stroke are very frequent and significant influence on quality of life in stroke patients. Robinson and his colleagues have argued specific relationship during acute period between the left frontal or left basal ganglia stroke and the high frequency and severity of post-stroke depression. This relationship has continued to dispute still remains unproven. Further research needs in this area.
The antidepressant treatment of post-stroke depression has been shown to improve activities of daily living, cognitive function and survival rate. Thus, appropriate diagnosis and treatment of post-stroke depression are very important. The apathy without depressed mood may mean the true apathy, in which cases, it is more effective dopamine agonists than antidepressants such as SSRI. The patients with severe depression need rest, but the patients with non-depressed apathy need behavioral therapy. In the future, it is very important the management by the medical team and to establish a community network to provide care and support for post-stroke patients.

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BACKGROUND: Non-obstructive hydrocephalus sometimes occur after severe head trauma, however, the incidence or mechanism for the development of hydrocephalus is not well understood.
OBJECTIVE: We investigated the risk of hydrocephalus development.
METHODS: We retrospectively investigated the patients with head trauma, who presented severe neurological condition (Glasgow Coma Scale, GCS < 8) or underwent surgical treatments. Patients who were demonstrated the dilated ventricle on head CT scan 4 weeks after the trauma and presented disorientation, urinary incontinence, or gait disturbance are diagnosed as a hydrocephalus. For these patients, ventriculo-peritoneal shunt (VPS) was performed. We entered the patient age, sex, radiographical findings, the cause of trauma, treatment and serum fibrinogen concentration on a computerized data base.
RESULTS: Fifty-five patients were included in this study and 12 underwent VPS. The average of GCS at admission was 5.1 and 9.3 in patients with or without VPS, respectively (p<0.001). Serum fibrinogen concentration was followed in 6 and 7 patients with or without VPS. The average of serum fibrinogen concentration at 4 weeks after the trauma was 536.5 mg/dl in patients with VPS, which was higher than the upper limit of the normal range. On contrary, it was 278.7 mg/dl, which was within the normal range (p=0.002).
CONCLUSION: Low score of GCS at admission and high concentration of serum fibrinogen in chronic phase might possibly indicate the hydrocephalus development in patients with severe head trauma.

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Mihara Memorial Hospital is one of main stroke centers in Gunma prefecture. We have been continuing three medical activities to advance regional stroke emergency medical system. The activities were as follows: (1) develop non-invasive imaging system to improve outcome in patients with acute stroke (Mihara MR stroke protocol), (2) hold stroke simulation training courses such as PSLS and ISLS courses to work for the qualitative improvement in the medical staff, and (3) reinforce prefectural stroke medical system through the activities of Gunma branch of Japan Stroke Association and Gunma Stroke Emergency Network (GSEN: former's task force)
When the above mentioned activities began to go in orbit, the east-Japan great earthquake occurred on March 11. The planned region-specific outage carried out forcibly right immediately after the earthquake.
Most regional stroke centers could not do diagnostic imaging during the outage. It has possibility that regional stroke emergency medical system failed due to the planned region-specific outage. All the relations that it was cultivated through the three medical activities were used, and ambulance transported-patient with acute stroke reception was planned.
We will report the outline of Mihara MRI stroke protocol and the countermeasure against the outage to protect regional stroke emergency medical system.

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Background: Cerebral vasospasm following severe traumatic brain injury contributes to a significant rise in morbidity and mortality rate. Japanese and US guidelines for the management of severe traumatic brain injury do not specify any treatments for post-traumatic vasospasm; therefore, patients with cerebral vasospasm following severe traumatic brain injury are administered endovascular treatment in line with that administered for vasospasm following aneurysmal subarachnoid hemorrhage.
Clinical presentation: Following a fall, a 21-year-old woman presented to us with traumatic subarachnoid hemorrhage, basal skull fracture, multiple trauma with hemorrhagic shock, and an initial Glasgow Coma Scale score of 6.
Intervention: Eight days after the injury, the patient developed left hemiparesis with disturbed consciousness. An angiogram revealed severe vasospasm of basilar artery (BA) and the bilateral internal carotid arteries (ICAs), middle cerebral arteries (MCAs), and anterior cerebral arteries (ACAs). She underwent transluminal balloon angioplasty and intra-arterial infusion of nicardipine in BA, ICAs, MCAs and BA. Significant clinical improvement was observed following this endovascular treatment. A follow-up angiogram did not reveal any sings of vasospasm, and the patient was discharged 53 days after injury for further rehabilitation.
Conclusion: Endovascular treatment, including transluminal balloon angioplasty and intra-arterial infusion of a vasodilator is safe and efficient treatment for symptomatic post-traumatic vasospasm.

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Treatment strategy for traumatic optic nerve injury (TON) is observation, administration of corticosteroids, surgical optic canal decompression or combination of them. However, in the literatures, there is no treatment of TON that can be surely expected to improve visual acuity. So the management of TON has remained controversial. We report a case of TON in which visual acuity improved following optic canal decompression. The patient was a 38-year-old man who suffered a severe hit on the right side of his face when he was playing football. He had impaired visual acuity of the right eye. Radiography demonstrated contusional hematoma and pneumocephalus in the right frontal lobe, depressed fracture of the right temporal bone and fractures of right orbital walls. In order to prevent intracranial infection, repair of the dura with optic canal decompression was carried out 26 hours after injury. His visual acuity improved remarkably, although diplopia and lower nasal quadranopsia of the right eye was remained. This case illustrates that optic canal decompression could bring about a remarkable effect for certain cases.

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An 82-year-old man sustained a severely posteriorly displaced type II odontoid fracture. He had dyspnea with retropharyngeal hematoma and required the ventilator management. Closed reduction was not successfu1 with skeleta1 traction. Posterior atlanto-axial fusion was performed with the Cl lateral mass screw and a C2 pedicle and laminar screw. The patient has been followed with satisfactory results. Careful definition of the bone injury and instability is crucial for correct surgical planning and satisfactory outcome.

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Objiective: We report a rare case of dural arteriovenous fistula (dural AVF) of the left sigmoid and superior petrosal sinus developed after treatment of superior sagittal sinus dural arteriovenous fistula.
Case presentation: A 63-year-old female presented disturbance of consciousness. CT showed intracranial hemorrhage in left frontal and parietal lobes with intraventricular perforation. Angiogram revealed a superior sagittal sinus dural AVF fed by middle meningeal artery (MMA) with cortical venous reflux. Transarterial embolization was performed for reducing flow of feeding artery of MMA. 5 days after TAE, skeletonization was performed and flow control was successful. One year and three months later, angiograph showed recurrence of superior sagittal sinus dural AVF and skeletonization was performed again. Posttreatment angiograph showed obliteration of the dural AVF.
One and a half year later, she presented epilepsy and angiogram showed recurrence of dural AVF of the left sigmoid and superior petrosal sinus. Sinus packing was performed with coils and dural AVF disappeared angiographycally.
Conclusion: Clinical and angiographical follow up for several years are important after treatment of dural AVF.

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[in Japanese]

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