In this study, eleven cases with sports-related traumatic occlusive cerebrovascular accident (OCVA) are investigated to clarify clinical characteristics by reviewing following clinical factors: age, gender, mechanism of trauma, symptom, type of sports, duration between the time of injury and outpatient visit or diagnosis, type and site of vascular injury, co-existent traumatic intracranial lesion, treatment, and outcome. Traumatic OCVAs were accounted for 9.1% of sports-related TBI, as 1.1% of other TBIs than sports-related. It is more common in male than female. Histogram of age distribution demonstrated a peak at the age of 5-14 y.o. Cervical hyperextension and/or hyper-rotation was the most common mechanism of injury. Head and/or neck pain immediately after trauma was the most common initial symptom. The most frequent vascular lesion was an arterial dissection of internal carotid or vertebral artery. Antiplatelets or anticoagulants were introduced for treatment in cases without traumatic intracranial hematoma. Favorable outcomes were obtained in most cases, however, permanent neurological deficits were remained in 3 cases. Since delay in the introduction of treatment results in poor functional outcome, an early visit of outpatient are quite important in patients with sports-related traumatic OCVAs, as well as the standardization of diagnostic algorithm.

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We examined cerebellar infarction cases treated in our department after approval of the recombinant tissue plasminogen activator (rt-PA), and explored indications for rt-PA administration in cerebellar infarction. In 29 patients diagnosed with acute cerebellar infarction by magnetic resonance imaging findings, we examined chief complaints at the initial visit, time from onset to diagnosis, infarction site, acute-phase drug therapy and outcomes at hospital discharge. Most chief complaints at the initial visit were vertigo or staggering gait. The infarction site was in the posterior inferior cerebellar artery (PICA) territory in 26 patients and in the superior cerebellar artery territory in three. Drug therapies used in the acute phase included free radical scavengers (cerebral protective agents), antiplatelet agents and anticoagulant agents. Six patients were diagnosed within the rt-PA therapeutic time window, but none were given rt-PA. While 26 patients had favorable outcomes at discharge, three had poor outcomes, though cerebellar infarction was not a direct cause of these outcomes. Our findings suggest that rt-PA is not necessary for treating cerebellar infarction in the PICA territory. The use of rt-PA should be considered in cerebellar infarction presenting with obvious neurological symptoms, such as cerebellar ataxia.

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Emergency Neurological Life Support (ENLS), an educational program to provide users with a series of protocols regarding management for the first hours of a neurologic emergency, was translated into Japanese and onsite ENLS courses were held in Tokyo and Asakadai. We investigated trainee satisfaction with the ENLS course using a post-course survey. The majority of trainees were physicians with board certification; acute care medicine or intensive care medicine was the most common. Most trainees were satisfied with the course especially related to their interest or specialty. Top scores for usefulness were Pharmacotherapy, Resuscitation Following Cardiac Arrest (RCA), and Acute Non-traumatic Weakness (ANTW) in Tokyo and Status Epilepticus, Intracranial Hypertension and Herniation, and RCA in Asakadai, respectively. Top scores for difficulty were ANTW, Pharmacotherapy, and Coma in Tokyo and Pharmacotherapy, RCA, and Meningitis and Encephalitis in Asakadai, respectively. With improved recognition and understanding of the differences between the medical systems in Japan and the United States, the knowledge gained during ENLS training will help to standardize the management of neurologic emergencies and contribute to obtaining better outcomes globally.

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One of the standardized neuroresuscitations is Immediate Stroke Life Support (ISLS). ISLS is planned for the off-the-job-training course to evaluate and manage patients who had an acute stroke. This course has been conducted by the ISLS-Hamamatsu group since 2008. The ISLS program originally comprised the following four modules: (1) evaluation of consciousness, (2) assessment of neurological symptoms with stroke scale, (3) management of cardiorespiratory condition, and (4) discussion of acute stroke cases. To effectively learn the ISLS algorithm, we upgraded the new module of simulation stroke care consisting of contents in (3) and (4). In this module, the trainees can learn the management of cardiorespiratory condition, discuss acute stroke cases, and clearly understand the ISLS algorithm. According to the post-course questionnaires from trainees, the advanced simulation stroke care module was approved as an easy and effective method to learn the ISLS algorithm, including the management of cardiorespiratory conditions and discussion of acute stroke cases. This advanced simulation stroke care module is useful for understanding the ISLS algorithm in the primary stroke care setting.

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Background: The use of a simulated patient monitor (SPM) influences the educational outcome of simulation-based medical education (SBME) course. However, owing to limited budget, adequate facilities could not be provided for the SBME course.
Object: This project aimed to create an SPM application with sufficient function and low cost for adaptation in SBME for the immediate stroke life support (ISLS) course.
Methods: Medical doctors developed the SPM application with Electron that builds cross-platform desktop applications. The application consists of two operation screens: one for facilitators to design control waveforms in real time and the other for students.
Results: We developed a multiplatform simulated patient monitor application by real-time adaptive control with a two-screen design and published it for free on our website.
Discussion: This is the first report by medical the professionals who developed the SPM application for medical training from scratch. The application was completely usable and enhanced the education effect of the ISLS courses. The future tasks are to make it available to more people for use and to acquire human resources and funding for further development.
Conclusion: The application we developed had sufficient functions for its use in the ISLS course.

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The purpose of this study was to elucidate the effect of learning method using simulation format in medical training for neurological emergency medicine. The objects were 255 students (167 males, 88 females) at the fifth grade in Nagoya City University, who had undergone clinical training of neurological emergency medicine from April 2015 to July 2017. After a short lecture, we performed training of 3 cases for all students in simulation format, such as cerebral infarction, hypoglycemic coma and epileptic patients. During those training, all students played a role of patients. As a result, the number of students dozing during training in simulation format was significantly decreased when compared with that in lecture format. Some student had also assessed simulation format in neurological medical training for emergency medicine as favorable method in questionnaire. These result may suggest the effect of medical training in neurological emergency by using simulation format.

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Along with rapid increase of aged population in Japan, number of patients with iNPH, who are known well to easily tumble and fall, has been increasing. In this study we investigated frequency of preoperative episode of injury by tumbling accident and resultant brain injury in 144 patients who underwent surgical treatment for iNPH. Approximately 70% of the patients suffered tumbling injury, and 45% of them had multiple episode of tumbling. As more than a half of the patients with tumbling injury had associated traumatic brain injury, although the severity of which was mild, it is strongly suggested that elderly patients with iNPH should be carefully diagnosed and properly treated by shunt surgery to improve their gait disturbance, which must reduce the potential risk that they might suffer from a severe brain injury associated with accidental tumbling.

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A 45-year-old man, who encountered sudden loss of consciousness during driving followed by transient defect of his right visual field, was brought to our hospital. He presented no neurological deficits, but diffusion weighed images on magnetic resonance image revealed left cerebellar infarction. Blood tests excluded diabetes, hyperlipidemia, and collagen diseases. He was suffering from habitual headache with scintillating scotoma from 18-year-old, and was diagnosed migraine with aura. Nine days before admission, he noticed non-disable headache followed by behavior abnormality and delirious state. Hence he was delivered to another hospital. He recovered after one-day-sedation using midazolam and dexmedetomidine, and migraine with brainstem aura was suspected in terms of his past visual defects and consciousness disturbance. Since his headache persisted with fluctuation, he was taking rizatriptan, which was prescribed for his typical migraine with aura, for nine days. The usage of triptans is assumed to be contraindication to migraine with brainstem aura because of their vasocontractive effect. Concerning this case, his infarction was distributed as watershed area between anterior and posterior inferior cerebellar artery without cerebrovascular risk factors. Therefore, frequent use of rizatriptan possibly induced cerebral infarction by vasoconstriction. We report the case of a patient suspected migraine with brainstem aura, who experienced cerebellar infarction, presumably triggered by continual administration of rizatriptan.

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A 74-year-old male who had undergone thymectomy for thymoma presented with dysphagia and dyspnea. Because he showed hypotension and dehydration, he was admitted to our hospital. On the following day, he developed respiratory failure and disturbed consciousness with CO₂ accumulation. He was immediately intubated and placed on mechanical ventilation. He did not show diplopia, ptosis, or muscle weakness. Edrophonium and Harvey-Masland tests were also negative. However, we suspected myasthenia gravis (MG) and myasthenic crisis because his anti-acetylcholine receptor (AChR) antibodies before thymectomy had been positive. We began treatment with immunoadsorption plasmapheresis, steroid pulse, intravenous immunoglobulin (IVIg), oral prednisolone, and tacrolimus. The patient’s symptoms gradually improved, and we extubated him on hospital day 17.After treatment, the titer of anti-AChR antibodies when he developed the crisis was revealed to be higher than that before thymectomy. Furthermore, edrophonium testing after extubation showed improvement of his symptoms. Based on these findings, we diagnosed postthymectomy myasthenia gravis (PTMG). This case illustrates the need to consider MG and myasthenic crisis as a diagnosis when patients with positive anti-AChR antibodies before thymectomy develop acute respiratory failure or bulbar symptoms after surgery, even though they showed no preoperative MG symptoms.

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Background: The mortality of bacterial meningitis is still high even in modern era, even if antimicrobial therapy has been developed. We report a case of Streptococcus pneumoniae meningitis followed by intracranial hemorrhage which craniotomy was performed. Clinical presentation: A 69-year-old man suffered fever and loss of consciousness. With cerebrospinal fluid examinations, antibiotic and steroid therapy was started with diagnosis of Streptococcus pneumoniae meningitis. The initial head CT scan revealed a cerebral hemorrhage. CT scan taken at the day 4 showed exacerbation of hemorrhage in frontal lobe and brain herniation. Intervention: The operation of hematoma removal was performed. During the operation, the brain tissue was easily bleeding and difficult to stop bleeding. Pathologically, microscopic examinations showed vasculitis and microvascular embolisms. It was considered that vasculitis due to meningitis and abnormal blood coagulation promoted hemorrhage. Conclusion: We experienced a craniotomy for cerebral hemorrhage due to Streptococcus pneumoniae meningitis. We also learned the importance of careful haemostasis and frequent imaging in surgery for hemorrhage with coagulopathy following meningitis.

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Spinal cord infarction is uncommon. The infarction of conus medullaris is even rarer among them. We report a patient with sudden onset paraplegia of lower extremities.
Case: A male in his seventies was brought to our hospital due to sudden onset bilateral leg weakness after defecation. He manifested paraplegia and urinary retention, but brain and lumbar spinal cord MRI revealed no abnormalities. We consulted neurology given the high likelihood of spinal cord pathology. MRI with contrast focused on conus medullaris was obtained which revealed infarction in the cauda equina, which led to the diagnosis of the infarction of the conus medullaris.
Discussion: Contrast effect on MRI on cauda equina isn't apparent in acute phase of infarction. It is observed in several spinal cord diseases other than infarction. Therefore the contrast enhanced MRI doesn’t have high sensitivity nor specificity. However, when clinical suspicion of spinal cord infarction is high, it could severe as a useful modality for diagnosis.
Conclusion: The infarction of conus medullaris is rare, but clinicians need to keep this condition in mind as one of the important differential diagnosis in emergency medicine.

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Clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) is diagnosed using imaging and is characterized by a favorable prognosis, which often improves without treatment. Here, we report three adult patients with MERS who were treated with a different course each; all of them required immunotherapy to some extent. The first case was a 67-year-old male who experienced gastrointestinal symptoms for 3 months prior to hospitalization. The second was a 38-year-old male who experienced a headache and fever, followed by urinary retention. The third was a 36-year-old male who experienced a fever and headache, followed by dysuria, impaired orientation, and upper limb tremor; he was transported to our hospital on the same day. All patients had lesions in the splenium of the corpus callosum. While two patients responded well to steroid pulse therapy, one demonstrated poor response and required immunoadsorption therapy. While some patients with adult-onset MERS require aggressive immunotherapy, this condition covers a broader range of diseases in adults with varying premonitory and clinical symptoms. Although pediatric MERS is often accompanied with a benign condition, this is not always the case for adults. Thus, considering immunotheraphy may be essential.

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Objective: We report a case in which urgent carotid artery stenting was performed for spontaneous dissection of the extracranial internal carotid artery (ICA).
Case: A 46-year-old male presented to our hospital with the weakness of left upper limb and dysarthria. Cerebral angiography revealed irregularities of the carotid wall and severe stenosis of ICA, stasis of the contrast agent, and delayed cerebral blood flow in the right extracranial ICA. Based on these observations, ICA dissection was diagnosed. Although our intensive medical treatment, including blood pressure control and administration of antiplatelet drug, thirteen days after onset, his neurological symptoms were suddenly worsened and increased cerebral infarctions on magnetic resonance imaging (MRI). We performed urgent carotid artery stenting. ICA morphology and cerebral blood flow were improved. The patient was transferred to a rehabilitation hospital on day 33.
Conclusion: Percutaneous carotid artery stenting is useful for dissection of the extracranial ICA that exhibit resistance to medical treatment.

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A 48-year-old man with chills was admitted to our hospital. He was initially diagnosed as fever of unknown origin, which was suspected to be caused by an unidentified virus. He acutely developed disturbance of consciousness, quadriparesis and urinary disturbance. Magnetic resonance imaging of the brain showed multiple hyperintense lesions in the basal ganglia and longitudinally extended transverse myelitis on fluid-attenuated inversion recovery imaging. These lesions were without gadolinium enhancement. We finally made a diagnosis of anti-aquaporin 4 antibody positive neuromyelitis optica. His symptoms did not improve after three courses of intravenous methylpredonisolone pulse therapy (1g/day). After seven courses of double filtration plasmapheresis and successive oral predonisolone (60mg/day) therapy, his expanded disability status scale score improved from 9.5 to 6.5. Our patient developed severe neuromyelitis optica with infection-like signs as initial symptoms. Surveying autoantibodies in the early stage of leukoencephalopathies is important for the diagnosis of neuromyelitis optica because the symptoms of neuromyelitis optica vary in the acute phase, which can mimic disorders associated with acute disseminated encephalomyelitis, posterior reversible encephalopathy syndrome and multiple sclerosis. Brain magnetic resonance imaging findings also showed many patterns with or without gadolinium enhancement, which cannot always differentiate neuromyelitis optica from other leukoencephalopathies.

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