We reported our experience of the ISLS (Immediate Stroke Life Support) course holding from a state of "zero". Not only the human cooperation but also the financial support is necessary for a course setup. The foundation of the window to coordinate ISLS course holding is expected. It is necessary to increase facilitators in Fukushima prefecture. We would like to plan for facilitator education from nurses and paramedics as well as medical doctors. We would like to contentiously hold Fukushima ISLS course not only in the Fukushima medical university but also various place in Fukushima prefecture.

Cerebral artery dissection is common in ischemic stroke in young adults. In Japan, approximately 1.2% of all ischemic strokes are caused by cerebral artery dissection. In patients aged ≤50 years, cerebral artery dissection accounts for 2.3%-3.8% of all ischemic strokes. Cerebral artery dissection in Japan typically involves the intracranial vertebral artery as opposed to the extracranial carotid artery, which is commonly involved in Western countries. Extracranial artery dissection can theoretically cause either hemodynamic or thromboembolic ischemic stroke. The rate of ischemic recurrence has been estimated to be between 0% and 13.3% at 1 year after the dissection. Furthermore, recurrent ischemic events usually occur between 1 and 2 weeks after the dissection. The usual regimen includes immediate heparin therapy with long-term warfarin between 3 and 6 months; further management is decided based on the results of vascular imaging. However, in our case, recurrent ischemic stroke occurred 15 years after the right extracranial vertebral artery dissection. Therefore, the pathology and etiology of the dissection should be considered for each case. Despite the onset period of 3-6 months, we should decide on further management based on vascular imaging findings.

The purpose of this study was to determine the risk of the intravenous thrombolysis with recombinant tissue-type plasminogen activator (IV-tPA) in the Japanese patients with relative contraindication. 80 patients was performed IV-tPA, unfavorable outcome (modified Rankin Scale 5-6 at discharge) was more common in patients >80 years and administerd antithrombotic drugs. And more, unfavorable outcome was more common in the patients with 2 relative contraindications that contained >80 years or administration antithrombotic drugs than the others. Therefore, IV-tPA for such patients has to administer on reflection.

A 9-year-old girl was involved in an unhelmeted snowmobile-related accident and was transferred to the emergency department. One hour after the accident, she became comatose (Glasgow Coma Scale score, 4) with fixed and dilated pupils. Head computed tomography (CT) demonstrated acute subdural hematoma over the left cerebral hemisphere and transtentorial herniation. The patient underwent irrigation of the hematoma through a small craniotomy incision. CT immediately postoperatively demonstrated a decrease in the hematoma. However, disturbance of consciousness was unimproved, and she died 14 days after the accident. Snowmobile-related legislation is lacking, and snowmobile riders are not legally required to wear a helmet in Japan. Wearing a helmet has been shown to reduce the severity of head injuries due to snowmobile-related accidents, and snowmobile-related legislation should be established in Japan.

Intracranial pressure (ICP) management is one of the most important issues for the treatment of severe traumatic brain injury (TBI). Hyperosmolar agent, such as mannitol, is commonly used for ICP management in TBI. However, decompressive procedures, either surgical and medical, may aggravate cerebral edema/swelling, induce remote intracranial hematomas, or enlarge initial hematomas. Hyperosmolar agents are recommended to use under ICP monitoring, although blind use of it is generally permitted in comatose patients with TBI. In this article, 3 cases with TBI are presented, whose initial intracranial hematomas have been enlarged after transfer between facilities, to worsen their neurological conditions, significantly. Before mannitol use, 1 of 3 cases were comatose, although the other 2 of 3 cases were alert and were not presented with worsening of neurological condition. In all of these 3 cases, mannitol was rapidly infused during transfer without ICP monitoring, suggesting hyperosmolar agents have potential to decrease ICP temporally to lose tamponade effect, leading to intracranial hematoma enlargement and neurological condition worsening. During a transfer between facilities, a certain situation when ICP monitoring cannot be achieved, and/or when emergency surgical procedure cannot be introduced, the use of hyperosmolar agents should be considered carefully.

Acute Vestibular Syndrome (AVS) is defined by its signs and symptoms: vertigo, nystagmus, nausea, head-motion intolerance or gait disorder. HINTS plus (Head Impulse test, Nystagmus, Test of Skew and audiometry) is a set of examination for stroke diagnosis in patients with AVS. A 4-step bedside oculomotor examinations appears more sensitive for stroke than early MRI in AVS. We report a case of cerebellar infarction with vertigo that could not be diagnosed by HINTS plus.

Case: A male in his eighties was brought to our hospital due to vertigo, walking difficulty and vomiting. He had hypertension and interstitial pneumonia. He presented with normal consciousness and slight hypertension. Although HINTS plus test indicated peripheral vertigo, he had cerebellar ataxia. So MRI was performed which revealed cerebellar infarction.

Consideration: This case showed a left vertebral artery occlusion that affected dysfunction of vestibular nuclei. We assume this dysfunction influenced by Posterior inferior cerebellar artery occlusion, then the abnormal vestibular-ocular reflex appeared.

Conclusion: In diagnosing central vertigo, not only HINTS plus examination, but also other neurological findings, should be taken into consideration.

An 82-year-old female was transferred to our hospital due to disturbance of consciousness after infection of influenza B and norovirus. On arrival, she was afebrile and presented with moderate consciousness disturbance (GCS: E2V2M4) and myoclonus. Clinical testing showed slow and sharp waves in an EEG, elevated initial pressure and protein in the CSF, and normal brain MR imaging. We diagnosed influenza encephalopathy, and administration of peramivir, steroid pulse, and IVIg for three days rapidly ameliorated her problems with consciousness and ADL. She became independent indoors 9 days after admission. Further evaluation revealed elevated IL-6 and antiglutamate receptor antibodies in the CSF. It was suggested that autoimmune-mediated encephalitis might be involved with influenza encephalopathy.

A 38-year-old female patient with ulcerative colitis (UC) presented with fever and disturbance of consciousness. At the time of admission, nuchal stiffness and cerebrospinal fluid pleocytosis suggested meningoencephalitis. Brain MR images showed extensive abnormal signals involving the bilateral thalami and basal ganglia. MR venography revealed occlusion of the Galen vein, which led to a diagnosis of cerebral venous thrombosis (CVT). UC and meningoencephalitis were considered as causes of CVT. Anticoagulation therapy was initiated with continuous intravenous infusion of heparin. The antibiotics and steroid therapy were also administered. CVT should be suspected in a patient with UC who developing acute disturbance of consciousness. We suggest that MRI in combination with MR venography is the preferred imaging modality in diagnosing CVT.