Emergency Neurological Life Support (ENLS) is a comprehensive educational program designed to help first-line physicians, nurses, and other caregivers of various backgrounds for common neurological emergencies, including basic resuscitative procedures, intracranial pathophysiology, and individual neurological and neurosurgical conditions. Focusing on the first critical hour of neuroemergencies, ENLS demonstrates a collaborative, multidisciplinary approach and provides a consistent set of protocols, practical checklists, decision points, and suggested communication to use during patient management. Thirteen key topics directly relevant to neurocritical care were selected and co-chaired by neurointensivists and emergency physicians. Debuted at 2012 Neurocritical Care Society (NCS) conference, this program was published in Neurocritical Care journal and is hosted on the NCS website, as is the training and certification course. At the 2013 NCS conference, train-the-trainer course was held to facilitate an on-site ENLS class worldwide. Supported by the significant advancement seen in the field of emergency neurology, a new version of ENLS was released in 2015. In the second version, prehospital and pediatric sections were included in each module where appropriate, and a new module, ENLS: Pharmacotherapy was added. The knowledge gained during ENLS training will help to manage neurologic emergencies and to contribute to obtain better outcome.

Endovascular vertebral artery occlusion including dissected site is currently very popular for the treatment of ruptured vertebral artery dissecting aneurysm (VADA). However, among the VADA cases previously treated in our hospital, we encountered two pitfalls in a postoperative course of endovascular treatment. One pitfall is an antegrade recanalization of a completely embolized vertebral artery, in particular cases with VADA distal to the origin of the posterior inferior cerebellar artery (PICA), therefore, we should carefully follow up in case of PICA-end appearance after endovascular treatment. Another pitfall is de novo VADA in an unaffected contralateral vertebral artery due to hemodynamic stress after internal trapping of a dissected vertebral artery. Taken these two pitfalls into consideration, a strict follow up angiography of bilateral vertebral arteries is necessary at the postoperative appropriate time such as 1 day, 2 weeks, 1, 3, 6, and 12 months following endovascular treatment for ruptured VADA.

Our hospital is a comprehensive stroke center in Hachinohe, Aomori Prefecture, one of the prefectures where stroke mortality is the highest in Japan. Here we introduce five actions for neuroresuscitation, especially treatment of acute stroke. Our comprehensive stroke center has a 24-hour medical care system providing stroke hot-line. We have ward rehabilitation specialists for rehabilitation from acute stroke. We hold campaign for public education called “Stroke Fair,” and skill-up seminar courses about medical care of acute stroke for healthcare staff members called “ISLS/PSLS course.” In addition, we have been proactively performing endovascular therapy for the treatment of acute cerebral infarction, demonstrating favorite outcomes.

Purpose: We evaluated clinical background and outcome of ischemic stroke patients with mild symptoms treated with intravenous recombinant tissue plasminogen activator (rt-PA). Methods: We analysed clinical and radiological data of 159 ischemic stroke patients treated with intravenous rt-PA therapy in our stroke center from Jun. 2006 to Mar. 2015. Among them, 14 patients had National Institute of Health Stroke Scale (NIHSS) score ≤4 points (mild group) before rt-PA and 145 patients had NIHSS score >4 (severe group). Results: There were no differences in the sex or age between both groups.Cardioembolic stroke were more frequent in the severe group, and atrial fibrillation was significantly frequent in the severe group. NIHSS score 24 hours after the rt-PA treatment was significantly good in the mild group. The cases which NIHSS 24 hours later improved to point zero were significantly frequent in the mild group. Compared to patients in the severe group, patients in the mild group more often had good outcome at discharge [Modified Rankin Scale (mRS): 0-1]. Six patients had hemorrhagic complications in the severe group while no patient had in the mild group. Conclusion: Intravenous rt-PA treatment is beneficial for patients with mild deficit.

Objective: We report a case which conservative treatment was performed for spontaneous dissection of the cervical internal carotid artery (CICA) and the prognosis was good.

Case: A-37-year old male developed sensory disturbance of the left side and the weakness of left lower limb and came to us 3 day later. Brain magnetic resonance imaging on diffusion-weighted image showed acute ischemic lesions in the right frontal lobe, and magnetic resonance angiography (MRA) of the cervical lesion demonstrated the stenosis and intramural hematoma in the lower portion of right CICA. After hospitalization, we started conservative therapy, including received antiplatelet drug and blood pressure control. Six days later, cerebral angiography revealed irregularities and stenosis of the carotid wall, stasis of the contrast agent in the lower portion of right CICA. After that, the neurological deficit of the patient improved gradually, and the patient was discharged on Day 20. Three weeks later after discharge, MRA showed an almost normalized condition. Based on these observations, we had a diagnosis of spontaneous CICA dissection, and MRA demonstrated complete recovery of the carotid artery dissection on 180 day.

Conclusion: Compared with western countries, in Japan, spontaneous CICA dissection is rare. Spontaneous CICA dissection should be considered as a differential diagnosis of young stroke patients.

A 65-years-old man was admitted to our hospital because of sudden-onset unconsciousness and left hemiparesis. On arrival, he showed consciousness disturbance, left hemiparesis, and left hemispatial neglect. These symptoms resulted in National Institutes of Health (NIH) stroke scale score of 17. Brain diffusion weighted MR imaging showed hyper-intense lesions at the right insula, putamen, and cortex of right frontal lobe. MR angiography revealed occlusions of the right internal carotid artery (ICA) and middle cerebral artery (MCA). Thrombolytic therapy with intravenous recombinant tissue plasminogen activator (IV-rtPA) was started 135 min. after onset, and cerebral angiography was performed immediately after IV-rtPA. Angiography of the right common carotid artery (CCA) showed that the ICA was nealy occluded. Thus, we performed percutaneous transluminal angioplasty (PTA) to the lesion. Then, we performed angiography of the ICA, it revealed MCA occlusion in the M1 proximal portion, so thrombectomy was performed. MCA was recanalized completely as Thrombolysis in Cerebral Infarction (TICI) Grade 3. Subsequently, we performed carotid artery stenting (CAS), and all procedure was finished uneventfully. On postoperative DWI, new lesions were not observed. Clinically, neurological status was gradually improved, and his discharge modified Rankin Scale (mRS) was 2 on the 36th hospital day.

A 49-year-old man with progressive dysarthria and weakness of the lower extremities was brought to our hospital. He had been diagnosed previously with myasthenia gravis (MG) and was awaiting treatment. Clinical features supported the diagnosis of MG exacerbation, and we started oral prednisolone and pyridostigmine. Although his symptoms responded well to the initial treatment, abnormally agitated behavior appeared on the seventh day after admission. He developed a high fever, generalized weakness, and respiratory disturbance that required intubation. He was diagnosed as having an MG crisis and was treated with plasma exchange therapy and methyl-prednisolone pulse therapy (1 g/day), along with intravenous immunoglobulin therapy. His symptoms improved, and he was extubated on day 21. During the crisis episode, it was revealed that he was dependent on antipsychotics and was abusing large quantities of various drugs from multiple hospitals.

We report the case of a patient with MG, along with drug dependence, who experienced a crisis, presumably triggered by symptoms of withdrawal from antipsychotics. A careful review of a patient’s medication history is crucial, especially in drug-dependent patients, considering their underlying risks.

Cerebral Fat Embolism (CFE) is known as potentially fatal complication of bone fracture. Patients with CFE develop variable and nonspecific clinical manifestations like a headache and disturbance of consciousness. Brain MRI has been reported to be the most sensitive method for diagnosing CFE, but conventional MR sequence is not sufficient for detecting CFE because some kind of pathological changes shows similar findings. We report a 74-year-old female with unstable pelvic fractures and diffuse axonal injury from traffic accident subsequently associated with cerebral fat embolism successfully diagnosed using susceptibility-weighted imaging (SWI). Brain MRI performed on day 6 revealed multiple high intensity lesions on diffusion-weighted imaging (DWI) in gray-white matter interface which may indicate cytotoxic edema due to DAI. We confirmed the diagnosis of CFE to find the presence of numerous petechial hemorrhages located predominantly in the white matter on SWI.

We herein report on the current and future approaches regarding the MC system for strokes in Gifu Prefecture. In regions within the prefecture, where MC systems in the Neurosurgical Department are indeterminate and CPSS is the only assessment available, it is not easy to transport patients to more distant hospitals that can handle these patients, and in this situation requiring more accurate screening with sufficient medical facilities, we are considering the introduction of LAPSS to patient transportation protocols which will be shared within the prefecture. To clarify “endogenous load & go” and “patients requiring stroke special treatment,” we are following the Tokyo Metropolitan Stroke Patient Emergency Transportation System and considering naming the latter patients as “stroke patients in the acute stage,” then reflecting it in the verification system and regarding them as key words, and sharing this information.