Critically ill patients in the intensive care unit (ICU) often develop acute onset diffuse limb weakness during the early course of their severe illness. This clinical entity is named as ICU-acquired weakness, and is related toprolonged mechanical ventilation and even increased mortality. The development of generalized weakness may be caused by critical illness polyneuropathy (CIP), critical illness myopathy (CIM), and a combination of both. The basic mechanisms underlying these disorders are complex and poorly understood. Several risk factors, including sepsis, hyperglycemia, steroid use, and multiple organ failure, are implicated, but remain to be clarified.Furthermore, whether each risk factor is associated with the development of CIP, CIM, or both has not been clarified thus far. Typically, the condition of patients is diagnosed on the basis of neurological findings and electrophysiological examinations, including nerve conduction study and needle electromyography. In addition, muscle biopsy and direct muscle stimulation test can be used to distinguish CIP from CIM. To date, no therapeutic approach has been established for ICU-acquired weakness, and potential preventive measures should be implemented in the daily management of the critically ill patients. Further studies are required to clarify the pathogenesis of these disorders and to identify appropriate therapeutic options.Received: December 11, 2014 / Accepted: February 20, 2015

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Recent advance of digital EEG system enables to monitor long term continuous EEG (CEEG) and find non convulsive status epilepticus (NCSE) which has just EEG seizure pattern with no evident clinical manifestation. NCSE should be treated with adequate amount of antiepileptic drugs as soon as possible after diagnosis. The problems of induction of CEEG in nerocritial care are EEG reading, EEG tech and medical remuneration. Firstly most of emergency physician feels weak in reading EEG. Emergent EEG should be read quickly and contribute treatment therefore three points are noted, temporal distribution, spatial distribution and EEG evolution. Second issue is EEG techs resources problem and EEG machine. EEG Technicians and EEG machines are often the rate limiting step to developing a successful program. To avoid this situation, EEG electrodes are fixed the last time of the daytime and taken next morning. Finally, in Japan, this neurocritical CEEG is not economically covered. This is the one of the fence that CEEG does not spread in our country. These situations should be improved by pertinent scientific societies and Japanese Ministry of Health, Labor and Welfare.

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We planned the new training of coma scale using ISLS content for the new face nurses after the revision of the law “Act on Public Health Nurses, Midwives, and Nurses” on 2012. However, using of coma scale by nurses in clinical situation might not be enough in Mitoyo General Hospital. The new training system could be developed by task force using ISLS (Immediately Stroke Life Support) content. The first training course was held for twenty new face nurses on August 2013 at the present hospital. We report the new training course and discuss the development of the present training system.

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Purpose: We evaluated the utility of The Emergency Coma Scale (ECS) which was developed by ECS society in 2003. Method: We planned a multi-center study and tested the agreement and the accuracy of the ECS scoring, from two different aspects, among multiple raters. In regard to a former study, Medical staffs in each ER evaluated the consciousness level of patients by ECS, The Glasgow Coma Scale (GCS) and The Japan Coma Scale (JCS). Then, we compared the weighted agreements among multiple raters by calculating the Kappa coefficient and relationship between scoring and outcome of the patients.Result: We could observe significantly highest agreements at the ECS scoring among cerebrovascular disease including intracerebral hemorrhage and traumatic brain injury. While, the ECS scoring on admission showed stronger relation with outcome of the patients compared with the JCS and GCS. Discussion: We thought the briefness and accuracy of the ECS may bring the benefit for the evaluation of neurological emergency settings.

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We made e-learning as a part of the contents of ISLS workshop. The conyent of e-learning is comprised of the following four parts. 1) Introduction, 2) Explanation of ISLS, 3) Demonstration of the facilitation and 4) Additional demonstration of the facilitation. After having learned by e-learning, the participant attend ISLS workshop. We tried this from the 11th Akita ISLS workshop in May 25, 2014. The participant must take an examinatuion in the e-learning. 27 people participated until August, 2014. The mean value of the test was 6.0 points of seven points of perfect score. The evaluation of e-learning from attendance is almost good.

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In neurological emergencies, acute neurological dysfunction is a critical condition because it causes cardiopulmonary arrest without appropriate management. Management of a life-threatening neurological dysfunction is defined as “neuroresuscitation” in Japan. The basic concept of neuroresuscitation is assessment and stabilization of “airway (A)”, “breathing (B)”, “circulation (C)”, and “dysfunction of central nervous system (D)”. Several simulation training courses based on this concept have been developed for medical personnel in Japan. However, junior clinical trainees rarely have opportunities to systematically learn the skills of general management in neurological emergencies. Thus, we have provided junior clinical trainees with neuroresuscitation simulation training using the contents of the Immediate Stroke Life Support (ISLS) course, one of the neuroresuscitationassociated simulation training courses. We developed two types of lectures for simulation training. One is “ABCD management of simulated patients according to scenarios” and the other is “evaluation of simulated patients with the Glasgow Coma Scale and NIH Stroke Scale”. Simulated patients and instructors of this training are performed by 2nd grade trainees because teaching is the most effective learning method. The results of questionnaires filled out by clinical trainees participating in the training have shown that this simulation training is useful for them in learning the skills of neuroresuscitation and helpful in their examination of real emergency patients.

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The need for continuous electroencephalograms (cEEGs) monitoring is increasing in neurocritical care; however, cEEG monitoring requires experienced specialists for application and interpretation. Amplitude-integrated EEGs (aEEGs), generated from simplified EEG montage, with a limited number of raw EEG curves, are notably easy to read and has been widely used in neonatal hypoxic ischemic encephalopathy for prognostication. Recently they are also applied for adult patients with post cardiac arrest syndrome (PCAS), especially those under therapeutic hypothermia treatment. We applied aEEG to monitor 59 critically ill neurological patients, including 31 PCAS, 14 subarachnoid hemorrhage (SAH), 4 intracerebral hemorrhage, 3 convulsion, etc., with 31 of them under therapeutic hypothermia. Initial aEEG patterns were: continuous, 18: discontinuous, 14: electrographic status epilepticus (ESE), 7: suppression burst (SB), 7: flat, 9: and artifacts, 4. PCAS patients showing continuous pattern had generally good functional recovery, while SB and flat pattern indicated poor outcome. Real-time monitoring with aEEGs was feasible in various kinds of critical neurological illness and provided useful information for prognostication and administration of antiepileptics.

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Neurologically, consciousness level has been evaluated subjectively by using the non-quantitative expressions such as “somnolence” and “stupor” until the introduction of the semiquantitative scale such as Glasgow Coma Scale. However, pupillary reactions to penlight are still expressed subjectively by using the term “sluggish”and “prompt”. Recently, electrical pupillometer was produced which enabled quantitative analysis of the pupillary findings at the bedside.In this study, we compared the pupillary sizes by both conventional non-quantitative and quantitative evaluations in patients admitted to our general ICU, and also, performed a questionnaire survey for ICU nurses and physicians specializing in neurocritical care in the fields of neurology, neurosurgery, and rehabilitation.We found that pupillometer can identify subtle pupillary changes and minimum anisocoria which could not be detected by penlight in patients with postcardiac arrest syndrome, which enabled early recognition of the changes of critical pathological conditions. Also, a questionnaire survey disclosed the problems to be solved as follows; analysis of the case in which only pupillometer can detect light reflex, evaluation of the effect of the indirect light reflex, appropriateness of simultaneous measurements of both eyes, and standardization of the measurement environment, needs of evaluation in a large number of patients, confirmation of the patients’ comments and so on.Introduction of the electrical pupillometer to the clinical practice is considered to be a critical progress especially in neurocritical care and so, standardization of the measurement and solution of the cost need to be achieved soon.

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The incidence of intracranial hemorrhage during treatment with novel non-vitamin K antagonist oral anticoagulants; (NOACs) such as-dabigatran, rivaroxaban, and apixaban is lower than that during warfarin treatment. The characteristics of intracranial hemorrhage during NOACs therapy, however, remain unclear. Hematomas that arise owing to acute intracranial hemorrhage during NOACs treatment have been reported as small in size. However, we present two cases suggestives of hematoma expansion during NOACs treatment. The propriety and timing of resumption of anticoagulation after anticoagulation-related intracranial hemorrhage remains uncertain. In this article, we review the clinical and, radiological characteristics of NOACs-related intracranial hemorrhage.

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We report two elderly cases of NCSE manifested by coma. Case 1: A 91-year-old man was admitted for impaired consciousness. Then he fell into coma four days later. Hippus and facial myoclonus-like movement were noted in the emergency room (ER). Following head MRI and EEG, he was diagnosed with limbic encephalitis with NCSE. Despite treatment with AEDs, his symptoms did not improve. Subsequent MRI revealed marked gyriform cortical hyperintensity throughout the brain. Case 2: A 77-year-old woman was admitted to Toyooka hospital 10 hours after onset of coma. Facial myoclonus-like movement and nystagmoid eye movement were noted while she was in ER. Following head MRI and EEG, she was diagnosed with NCSE. Her symptoms rapidly improved after treatment with AEDs. As in GCSE, the longer NCSE persists, the more difficult it is to treat and the higher the mortality rate. Therefore, it is important that NSCE is diagnosed and treated as soon as possible. For this to occur, it is necessary to note involuntary facial movements and ocular abnormalities in comatose patient without convulsion, especially in the elderly. EEG is required to confirm the diagnosis.

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We report an 87-year-old female hemodialysis case who suffered epilepsy with higher brain dysfunction (E-HBD) associated with non-convulsive status epilepticus (NCSE). Focal brain edema caused by excess fluid and uncontrolled blood pressure due to insufficient hemodialysis was a possible cause of NCSE. The patient was successfully treated by early anti-epileptic therapy. NCSE is a heterogeneous disorder with multiple subtypes. Therefore it is often difficult to diagnosis and delayed diagnosis sometimes leads to poor prognosis. Thus, early electroencephalography is essential for hemodialysis patients presenting impaired consciousness and/or higher brain dysfunction of unknown cause, under suspicion of NCSE.

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Chronic subdural hematoma is one of the most common conditions encountered in neurosurgical practice, and it is typically treated with burr-hole evacuation. We describe seven cases in which contralateral chronic subdural hematoma size increased after burr-hole evacuation. We show the representative cases.Case 1: An 85-year-old man who had regularly taken antiplatelets and anticoagulants presented to our hospital due to a headache and difficulty walking. He was diagnosed with a left chronic subdural hematoma as a result of the inspection and underwent a burr-hole evacuation. The next day, a head computed tomography scan showed that a new right subdural hematoma, and a second burr-hole evacuation was performed.Case 2: A 73-year-old man who had regularly taken antiplatelets and anticoagulants presented to our hospital due to a headache. He had a diagnosis of a right chronic subdural hematoma as a result of the inspection. A burr-hole evacuation was performed, but a head computed tomography scan the next day showed a left chronic subdural hematoma that was treated with a second burr-hole evacuation.Case 3: A 79-year-old man with hepatic cirrhosis and hepatic cell carcinoma presented with right hemiparesis. He had a diagnosis of a left chronic subdural hematoma as a result of the inspection, and burr-hole evacuation was performed. A right chronic subdural hematoma was found on a head computed tomography scan taken the day after surgery, and a second burr-hole evacuation was performed.Case 4: A 90-year-old man presented to the hospital reporting decreased activity. He had a diagnosis of a right chronic subdural hematoma as a result of the inspection. Although burr-hole evacuation was performed, a left chronic subdural hematoma was observed on a head computed tomography scan taken the next day. A second burrhole evacuation was carried out to treat the left chronic subdural hematoma.All seven cases were of elderly persons. Five were prone to bleeding because they were taking antiplatelets and anticoagulants, one had a chronic liver disorder, and the last case had a previous history of subdural hematoma. Although small contralateral chronic subdural hematomas were observed on preoperative head CT scans, they were not large enough to warrant surgery. It was only on the day after the first burr-hole evacuation that they increased in size and required treatment. Neurosurgeons should be aware that contralateral chronic subdural hematomas may increase in size after burr-hole evacuations performed in elderly patients with comorbidities, who use blood-thinning drugs, or have a history of subdural hematoma.

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