Mild traumatic brain injury (mTBI) would be the presence of elevated body temperature, i.e. hyperthermia, in the athlete prior to mTBI due to exercise. The aim of this study was to document the histopathological effects of pre- and post-traumatic hyperthermia on mTBI. Adult male rats were divided as follows: pre- and post-traumatic hyperthermia (pre/post-H), post-traumatic hyperthermia (post-H) and normothermia (N). The pre/post-H group was treated with hyperthermia (40℃) starting 15 min before mild parasagittal fluid-percussion brain injury (1.4-1.6atm). The pre/post-H and post-H groups underwent hyperthermia for 2 h after mTBI. The N group was maintained at normothermia (37℃) throughout all surgical procedures. At 72 h after TBI, the rats were perfusion-fixed for quantitative histopathological evaluation. Contusion area and volume were significantly larger in the pre/post-H treatment group as compared to the post-H and N treatment groups. Both pre- and post-traumatic hyperthermia caused a significant loss in the number of NeuN-positive neurons in the dentate hilus as compared to normothermia treatment. These results demonstrate that pre- and post-traumatic hyperthermia exacerbates histopathological damage after mTBI. These results suggest that individuals with hyperthermic temperatures prior to or immediately after mTBI may be predisposed to aggravated brain damage and subsequent neurological impairments.

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Therapeutic hypothermia (TH) has been used in various types of neurologic injury. It is strongly recommended for adult cardiogenic cardiac arrest (CA) presenting with ventricular fibrillation and neonatal hypoxic ischemic encephalopathy, whereas its use is conflicted in traumatic brain injury (TBI) and stroke. We reviewed our experience with 440 TH cases from 1995 to 2011 to identify the TH effect on the clinical outcomes of different types of disorders. The indication criteria were a Glasgow Coma Scale of ≤6 for patients with TBI and stroke and ≤8 for those with CA. Core temperature was maintained at 33–34℃ by surface cooling at least 24 h. The outcomes were assessed using the Glasgow Outcome Scale after 3 months. The types of injuries were: TBI (n=122); stroke (n=170); cardiogenic CA (n=96); and miscellaneous (n=52). Favorable outcomes (good recovery and moderate disability) were: total, 39.1%; TBI, 38.5%; stroke 31.1%; CA 50.0%. A trend of increase in CA cases and decrease in TBI cases was observed. A meta-analysis revealed significant association of fever with a worse outcome in TBI and stroke. Temperature management is crucial for a variety of neurologic injury and post-CA syndrome emerged as an indispensable issue in neurocritical care.

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We reviewed 7 patients with intracranial hemorrhage who were admitted pre- and postpartum to our hospital. The mean age was 31.0 years old (range 24 to 38 years old). Intracerebral hemorrhage occurred in 5 patients, including 2 cases caused by ruptured arteriovenous malformation and 1 by Moyamoya disease. Two patients suffered subarachnoid hemorrhage. Four patients developed hemorrhage in their third trimester and 2 within one week after delivery. Only 1 was known to have had pregnancy-induced hypertension. Two patients suddenly suffered hemorrhage during their hospital stay for delivery, including 1 case diagnosed with subarachnoid hemorrhage more than 10 hours after onset because the condition was not serious. Four of 5 patients developed hemorrhage at home and were admitted within 3 hours after onset. Three patients were treated conservatively and 4 were treated surgically: 2 with hematoma removal, 1 with aneurysm clipping, and 1 with external ventricular drainage. Overall outcomes were good except for 1 patient with severe consciousness disturbance at admission. Prompt diagnosis and treatment are required to improve the clinical outcome of patients with intracranial hemorrhage during pregnancy and puerperium, even in patients with mild symptoms. This will require refinement of the emergency system for these cases.

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Sudden onset of neurological deterioration suggests cardiogenic cerebral embolism (CE) rather than other types of ischemic stroke. Recent advances in diagnostic methods have improved the accuracy of the differentiation betweenartery to artery embolism and CE caused by paroxysmal atrial fibrillation (CEP). The aim of this study is to evaluate whether analysis on the type of onset can contribute to differentiation between CEP and artery to artery embolism due to carotid artery stenosis (AES). The subjects were 15 consecutive patients with AES and 30 consecutive patients with CEP. CEP patients were older and had a lower diastolic blood pressure on the initial examination than AES patients (P<0.05); however, there were no differences in the other background factors. No significant difference in the onset type was observed between the two groups. Acute onset progressive type was the major type of onset in both AES and CEP groups. Our results indicate difficulty in differentiating between AES and CEP based on the difference in characteristics of stroke onset, background factors, and initial examination. We should be cautious about the clinical judgment of stroke subtype according to the onset type of stroke.

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We investigated the relation between grimace for painful stimulation and best motor response (M) in Glasgow Coma Scale (GCS) in patients with comatose state. We recorded 51 total GCS scores from 43 patients with comatose state from patients transported to the emergency room or admitted to the emergency ward of Shizuoka Red Cross Hospital. We delivered painful stimulation to all of 43 patients (51 records) on sternum and fingernail bed (or inside of the arms). Grimace was observed more frequently along with M5 than with each of M1 – M4 (p<0.01) Both of intracranial and extracranial diseases showed high percentages of grimace positive in M5, however , grimace was also positive at M4 or lower level of best motor response only with extracranial diseases. The results suggested that grimace for painful stimulation might be equivalent to M5 in comatose state, especially in patients with intracranial diseases and might show that grimace is useful as an indicator in assessing the revel of consciousness. We concluded that grimace might be an alternative criterion of M5 level in case of difficult situation to examine due to traumatic injury or fixation with many vital monitors in extremities.

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A 76-year-old woman was transferred to our hospital because of consciousness disturbance. She showed severe anemia, thrombocytopenia with rouleaux formation, and monoclonal IgM-κ paraproteinemia, and a bone marrow biopsy specimen revealed infiltration of lymphoplasmacytic lymphoma cells (CD20+, IgM+). Brain MRI performed on day 1 exhibited spotty high intensity lesions in the cerebral white matter in diffusion-weighted images. Based on a diagnosis of hyperviscosity syndrome associated with Waldenström macroglobulinemia, the patient was treated with cyclophosphamide, methylprednisolone, and rituximab, and her consciousness level was slightly improved. However, brain MRI on day 32 revealed expansion of the high intensity lesions, many of which were enhanced following gadolinium injection. She was diagnosed with Bing-Neel syndrome, which indicates direct lymphoplasmacytoid involvement in the central nervous system. In spite of the application of a systemic chemotherapy, her general condition and consciousness level slowly worsened, and the patient died 3 months later. Bing-Neel syndrome should be considered as one of the causes of consciousness disturbance in neurological emergency cases.

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はじめに：鈍的頸部外傷による椎骨動脈損傷は稀である．また，その主たる病態は椎骨動脈狭窄・閉塞による椎骨脳底動脈循環不全とされる．今回，我々は，頸部過伸展屈曲外傷後に気道狭窄，呼吸不全で発症した椎骨動脈分枝出血の一例を経験したので報告する．症　例：81 歳，男性．転倒による頭部打撲後の意識障害のため当院救命救急センターに搬送された．来院時，意識レベルはGlasgow Coma Scale：E4V2M5，瞳孔径：右3mm/ 左3mm であり，四肢運動麻痺は認めなかった．身体所見では，著明な気道狭窄音を聴取した．気管支鏡にて，咽頭後壁の隆起によると考えられる気道狭窄を確認した．気管挿管困難であり，輪状甲状靱帯穿刺でも有効な換気量が得られなかったため，緊急気管切開術を施行した．頸椎単純CT にて，頸椎骨折を認めなかったが，椎体前面の後咽頭間隙から頸部全面へ広範に進展した血腫を確認した．緊急で行った頸部血管撮影では，椎骨動脈本幹に異常所見は認めないが，第３頸椎レベルで椎骨動脈から分枝し椎体前面に向かう細い動脈からの造影剤血管外漏出を認めた．その後，ICU にて保存的治療を行い，第40 病日に自宅退院した．結　語：鈍的頸部外傷による頸椎骨折を伴わない椎骨動脈分枝出血は稀な病態である．本例では，頸部の過伸展もしくは過屈曲外傷後，構造的に脆弱である椎骨動脈筋枝が牽引損傷され出血し，重篤な気道狭窄を来したものと考えられた．

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