Paraneoplastic limbic encephalitis associated with cell surface antigens including NMDAR is antibody-mediated and often improves after removing the antibodies and tumors. NMDAR encephalitis sequentially shows prodromal symptoms, psychosis, hypoventilation, severe orofacial dyskinesias, and various autonomic symptoms. NMDAR encephalitis, which is often related with ovarian teratoma, is sometimes related with malignant tumor. Early diagnosis and treatment, including immunotherapy, tumor resection, or both, are important to improve or stabilize limbic encephalitis.

抄録全体を表示

Clinical characteristics and problems of acute traumatic brain injury (TBI) were investigated, in our consecutive 18 cases with chronic hemodialysis (HD) (M:F=9:9, 75±11y.o.). The most frequent cause of trauma was fall (67%), as the second was a traffic accidents (22%). The frequent intracranial lesions were acute subdural hematomas (72%), cerebral contusions (61%), and so on. The most frequent symptom was depression of alertness, as focal neurological deficits were less frequent. Duration to neurosurgical unit hospitalization from TBI was less than 6hrs in 7 cases (39%), 6-24 hrs in 4 (22%), and more than 24 hrs in 7 (39%). In 6 out of 11 cases, which took more than 6 hrs for hospitalization, hemodialysis with heparin had been done before hospitalization without neuroradiological examination of TBI. Neurological status deteriorated during pre-hospitalized hemodialysis in 5 out of these 6 cases. GCS scores were 13-15 in 78%, 9-12 in 6%, and 17% of cases. GOS scores are GR in 33%, MD in 33%, SD in 6%, VS in 11%, and D in 17% of cases. Frequent causes of poor outcome were HD related systemic complications or delay in diagnosis and treatment of TBI. These result suggest that early diagnosis and appropriate management of HD related complications is important for acute TBI in patients with HD.

抄録全体を表示

Cerebral infarction is a neuroemergency disease that requires immediate diagnosis and treatment. We however experienced 3 patients who did not receive immediate treatment for cerebral infarction due to insufficient initial management. Case 1 and 2 had cerebellar symptoms such as vomiting and ataxia; however, because of inadequate initial evaluation for cerebellar symptoms they were not referred to stroke specialists. Case 2 and 3 were initially examined by non-stroke specialist physicians because they were transferred to our hospital by private car, which caused a delay in referral to stroke specialists. Compared to the well-known symptoms of stroke such as abnormality in the face, arm and speech, cerebellar symptoms should also be recognized by the general public and medical staff. Moreover, further improvement in medical systems is warranted to make early diagnosis and treatment for patients with suspected stroke arrived by private car.

抄録全体を表示

We conducted a survey at a public lecture on stroke emergencies. We examined the level of understanding among the public and the problems of the pre-hospital care. The subjects were local residents who participated in the public lecture. The survey was conducted anonymously via multiple-choice questions. The questionnaire was conducted both before the lecture and after the lecture to assess the change of the level of understanding.The number of participants was 68 and their average age was 43.9 years; 100% of the questionnaire sheets were collected. In the questionnaire before the lecture, 86% of the respondents chose "four and a half hours" to the question "therapeutically effective time from the onset of cerebral infarction." However, after the lecture there was some improvement; 100% of the respondents chose that answer. As symptoms where a stroke is suspected, before the lecture, "sudden paralysis of one side of the face," "sudden paralysis of the limbs on one side" and "sudden slurred speech" was chosen by 73.4%, 84.4% and 84.4%, respectively. The rate went up to to 98.5%, 98.5%, and 97.1%, respectively, after the lecture, which indicated improvement. Before the lecture, 38.7% chose the answer "They will call an ambulance when a stroke is suspected," but after the lecture that went up to 86.6%, which indicated improvement.In this study, we found out the following points: people roughly understood that the treatment is required as soon as possible; however, their understanding of symptoms and emergency response was insufficient. It is necessary to continue to educate local residents the right knowledge of the onset of stroke so that they can call an ambulance without hesitation.

抄録全体を表示

Three-dimensional CT angiography (3D-CTA) is now widely used as the first-line diagnostic modality to identify ruptured aneurysms in patients with subarachnoid hemorrhage (SAH). However, there is a risk of aneurysm rerupture in the hyperacute phase. We sought to clarify the incidence of rerupture and characterize the patients showing extravasation of contrast media during 3D-CTA and digital subtraction angiography (DSA). We examined the records of 391 consecutive patients with non-traumatic SAH between October 2003 and September 2012. After resuscitation, patients with poor grade SAH underwent CT then 3D-CTA while sedated, mechanically ventilated and with a target systolic blood pressure of 120 mmHg. Three hundred sixty six patients underwent 3D-CTA and 112 of them underwent subsequent DSA; 20 died without return of spontaneous circulation. Extravasated contrast medium was seen in 16 (4.4%) at the initial evaluation during CTA and in 7 (6.3%) during DSA. Those patients were in poor-grade and arrived very early phase after SAH onset, presenting extremely high blood pressure, and frequent episodes suggestive of aneurysm rerupture. Continuous or intermittent rebleeding may occur frequently in hyperacute SAH patients. The consequences of rebleeding are devastating; however, favorable results can be obtained with immediate aneurysm repair with decompression and intensive neurocritical care.

抄録全体を表示

Objective: Ruptured vertebral artery dissection (VAD) should be treated promptly because of the high risk of rebleeding. Endovascular treatment (EVT) for the ruptured VAD is thought to be a reliable technique to prevent rebleeding. Therefore, we retrospectively studied the efficacy and outcome of EVT for ruptured VAD.Methods: Twenty patients were diagnosed to have a ruptured VAD in the acute stage at our institute. Fifteen patients received EVT in the acute stage. Of those, twelve were treated by internal trapping of the dissected segment. Stent-assisted coiling was performed for a patient with contralateral hypoplastic VA, and for 2 cases with bilateral VADs. The clinical outcome at discharge from our hospital was analyzed using the Glasgow Outcome Scale (GOS).Results: In the EVT group, 6 patients had good recovery, 3 patients had moderate disability, and 6 patients had severe disability. There was no rebleeding and no procedure-related complication. However, six patients who received EVT developed ischemic complications due to procedure, which were associated with a poor outcome (P<0.05).Conclusion: EVT for ruptured VAD in the acute stage appears to be safe and effective, but care should be paid to post-treatment ischemic complications.

抄録全体を表示

Sudden intense headache commonly develops in subarachnoid hemorrhage. Subarachnoid hemorrhage can be easily diagnosed using head computed tomography (CT) or head magnetic resonance imaging (MRI). We treated two patients with subarachnoid hemorrhage who could not be diagnosed on the basis of imaging findings. We diagnosed them with subarachnoid hemorrhage after performing lumbar puncture. Here, we report the case findings.Case 1: An 82-year-old manHe developed sudden intense headache while going to eat at home. Head CT did not reveal a clear subarachnoid hemorrhage. The iso-intensity mass was seen in basal cistern by head MRI. However, head magnetic resonance angiography (MRA) revealed an aneurysm in the anterior communicating artery. Cerebrospinal fluid extracted after lumbar puncture was clear. We considered the patient to have an unruptured cerebral aneurysm.Case 2: A 38-year-old womanShe developed sudden intense headache and vomited twice while relaxing at home. The iso-intensity mass was seen in basal cistern by head MRI. However, head MRA revealed an aneurysm in the right internal posterior communication artery. Cerebrospinal fluid extracted after lumbar puncture had a light red color. We considered the patient to have subarachnoid hemorrhage due to a ruptured cerebral aneurysm, and performed emergency clipping and craniotomy.Consideration and conclusionWe think that performing an imaging examination in all patients with headache is unnecessary. We performed an imaging examination only when we suspected subarachnoid hemorrhage after analyzing a patient’s medical history. If subarachnoid hemorrhage is suspected in a case with no abnormal imaging findings, lumbar puncture should be considered.

抄録全体を表示

We here report the clinical features of three patients presenting with isolated cerebellar nodulus infarction. All suddenly developed nausea, vomiting and walking difficulty. Two experienced horizontal, to-and-fro vertigo. On admission, two could not walk. Motion exacerbated nausea and vomiting for three patients. None of them showed typical cerebellar signs, including dysarthria, dysmetria, or decomposition. Nystagmus was lacking in two. For all three patients, diffusion-weighted image of MRI revealed an isolated, small, high-intensity lesion in the cerebellar nodulus. Symptoms spontaneously resolved over a few days with no residual signs. It is now known that isolated vertigo, or “pseudovestibular syndrome”, without limb ataxia or dysarthria can occur following cerebellar infarction, especially those in the PICA region. A number of recent reports rate that the same syndrome can also be caused by infarction localized at the cerebellar nodulus. This suggests that the cerebellar nodulus must be involved with the vestibular system. Horizontal to-and-fro vertigo might be characteristic of nodular infarction. We believe MRI is necessary for every patient who presents with sudden-onset nausea, vomiting and walking difficulty, even without nystagmus, rotatory vertigo, or limb ataxia.

抄録全体を表示

A 68-year-old man undergoing chemotherapy for squamous cell carcinoma of the lung was transferred to our hospital because of coma and hematemesis. CT scanning of the brain performed on the day of admission revealed multiple spotty lesions with air-like density in cerebral white matter and the superior sagittal sinus. The patient was diagnosed with multiple cerebral arterial gas embolisms, and treated with edaravone and glyceol. Hyperbaric oxygen therapy, recommended for treatment of cerebral arterial gas embolism, was not selected because of the high risk of transfer to another institution for that therapy and in consideration of his critical condition. On the second hospital day, brain CT scanning revealed multiple lesions in cerebral edema areas and the patient died the same day. Multiple cerebral arterial gas embolisms should be considered in neurological emergency cases manifested by coma.

抄録全体を表示

A 6-year-old boy was admitted to the emergency department due to a traffic accident. In physical examination, he presented disturbance of consciousness, Glasgow coma scale score 7 (E1,V2, M3), and didn’t present anisocoria and motor paresis. CT examination revealed a contusion and depression fracture in rt frontal lobe. MRI examination, T2*, revealed a dot hemorrhage in splenium of corpus callosum, and diffuse axonal injury was suspected. Operation for depression fracture was performed and intracranial pressure (ICP) monitor was inserted. Initial ICP revealed 17 mmHg. However ICP was rapidly elevated to 80 mmHg after 1 hour following operation, without hypoxia and hypotension. CT examination revealed diffuse cerebral swelling. Decompressive craniectomy was performed for ICP control, but it present a widespread ischemic area and no abnormalities in vessels at 3D-CTA. Brain hypothermia therapy (35˚C, 6 days) was performed with ICP control, below 20 mmHg.Finally he was transferred with vegetative state. In pediatric head injury, an autoregulation in cerebral vessels are immaturity, so that it reveals a specific hemodynamics, and seizure or subclinical seizure can occur. It is important of monitoring on ICP, hypoxia, hypotension and so on, with ICP monitor, continuous electroencephalogram (cEEG).

抄録全体を表示

From 2010 through 2012, we have treated three cases of bacterial meningitis associated with cervical pyogenic spondylitis. Each patients had been diagnosed with underlying disease such as primary splenic malignant lymphoma, mesopharyngeal carcinoma or diabetes mellitus. All presented with neck pain and high fever. This neck pain was also observed during neck rotation, affecting difficulty in differentiation with neck stiffness. Cerebrospinal fluid examination revealed pleocytosis with a low glucose level. T2 weighted images obtained from cervical spine magnetic resonance imaging revealed pyogenic spondylitis in all patients, and a high signal retropharyngeal abscess in two cases. In two cases, blood culture detected Streptococcus pnemoniae (one case each of penicillin-resistant and penicillin-susceptible strains). Antibiotic treatment was administered until the inflammatory reaction resolved on laboratory data. After treatment, neurological symptoms and neck pain gradually improved. When bacterial meningitis presents with atypical neck pain, it is necessary to consider the association with cervical pyogenic spondylitis.

抄録全体を表示