The purpose of this study was to analyze the tendency of patients with subarachnoid hemorrhage in our emergency department and to determine the risk factors to influence an unfavarouble outcome. Two hundred twelve patients with subarachnoid hemorrhage patients, including 73 with out-of-hospital cardiac arrest, were evaluated from November, 2015 to December, 2020. Mean age 64±15, female 133 patients (63%), WFNS grade I (2%), II (6%), III (3%), IV (11%), V (77%). It was more a lot than the frequency that vertebral artery dissociation patients (15.2%) was reported. Age, respiratory disorder, absent pupillary reflex, severe hydrocephalus, severe intraventricular hemorrhage, WFNS grade IV, V were significant unfavarouble prognostic factors (p<0.05). Although patients with subarachnoid hemorrhage in our emergency department were critically ill, our patients were relatively favarouble outcome by treatment interventing from an early stage. All patients with severe hydrocephalus, severe intraventricular hemorrhage were unfavarouble outcome.

Background: Encephalopathy is a common complication of sepsis that may result in worse outcomes. Effective treatment requires an understanding of the underlying mechanisms that cause this complication.

Materials and Methods: We investigated clinical, neurological, and brain MRI findings in five patients with sepsis-associated encephalopathy who were admitted to our hospital between 2016 and 2018.

Results: Age at symptom onset was high (61.6±12.9 years), with three patients having a history of hypertension. The Sequential Organ Failure Assessment score was high (11.6±4.82). Conscious disturbance appeared as a neurological complication in the early stages. The cause of sepsis was gastrointestinal infection in four patients. All five patients recovered from sepsis; however, four patients showed residual symptoms. We found slightly elevated protein levels in the cerebrospinal fluid. Brain MRI revealed multiple cerebral infarctions due to endothelial disturbance and vasogenic edema associated with disruption of the blood brain barrier.

Conclusion: While the underlying sepsis can often be successfully treated, patients with sepsis-associated encephalopathy can retain residual symptoms. Brain MRI revealed that the mechanism of sepsis-associated encephalopathy is endothelial disturbance and disruption of the blood brain barrier.

A 70-year-old man presented with a generalized seizure that persisted for 30 minutes with decreased consciousness. Because he lived alone and had no relatives, his past medical, family, and medication history were unknown. On admission, T2-weighted and fluid-attenuated inversion-recovery magnetic resonance imaging revealed patchy high-intensity areas in the bilateral frontotemporal and parietal lobes. Diffusion-weighted magnetic resonance imaging and apparent diffusion coefficient map revealed that the edema within these lesions was of vasogenic origin. Posterior reversible encephalopathy syndrome with onset seizure was diagnosed. The patient was maintained at normal blood pressure and levetiracetam treatment was initiated. His consciousness level improved temporarily but deteriorated again. T2*-weighted imaging revealed multiple macro- and micro-hemorrhages in the bilateral cortical and subcortical regions, consistent with cerebral amyloid angiopathy. Because a brain biopsy could not be performed, probable cerebral amyloid angiopathy-related inflammation was considered in accordance with Chung’s diagnostic criteria. The patient was started on steroids, with both clinical and radiological improvement. Posterior reversible encephalopathy syndrome involves numerous neurologic emergencies and is not always reversible. Earlystage investigation of the cause of posterior reversible encephalopathy syndrome, such as cerebral amyloid angiopathy-related inflammation, is important. Neurologists should be aware of this clinical association because early treatment can reduce the outcome severity.

Patients with splenic hypoplasia are more susceptible to infections with capsular bacteria such as Streptococcus pneumoniae and are more likely to develop severe infections, including bacterial meningitis. Here, we report the case of a 62-year-old male who was transferred to our hospital by emergency transport due to worsening headache and bilateral deafness. Based on the results of cerebrospinal fluid tests, the patient was diagnosed with pneumococcal meningitis and was started on antibiotic treatment. Computed tomography showed hypoplastic spleen and low levels of IgM and IgG, suggesting that hyposplenism was involved in the patient’s pneumococcal infection. Despite the administration of appropriate antibiotics, the patient developed recurrent fever and back pain; subsequent magnetic resonance imaging scans showed intervertebral discitis, spinal epidural abscess, and paravertebral abscess. After administration of intravenous immunoglobulin and subsequent vancomycin (6 weeks), and oral amoxicillin (3 weeks), symptoms and imaging findings improved and the patient was discharged on day 66. There are several reports in the literature of splenic hypoplasia associated with aggravation of pneumococcal infection and abscess formation. In cases of splenic hypoplasia, active treatment and periodic abscess search are key factors, as is a vaccination to prevent infections.

Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) is a type of mitochondrial disease characterized by stroke-like episodes that occurs before the age of 40 years. During the course of MELAS, patients often develop sensorineural hearing loss. However, few reports have described the stroke-like episodes in post-cochlear implantation patients.

A-25-year-old woman developed left hemiplegia and dysesthesia after suffering from fever and headache for three days and was brought to our hospital in an ambulance. We could not perform magnetic resonance imaging (MRI), since she had undergone cochlear implantation for sensorineural hearing loss 5 years earlier. Her brain computed tomography (CT) revealed low-density areas in the right temporal and occipital lobes that did not match the vascular territories. Therefore, we suspected MELAS and started to treat her with L-arginine, taurine, ubidecarenone, and L-carnitine. Her symptoms improved, and she could walk independently on day 11. Thereafter, her genetic testing revealed the mitochondrial A3243G mutation, which lead to the diagnosis of MELAS.

More than a few patients with acute onset sensorineural hearing loss have the mitochondrial A3243G mutation. Therefore, a test screening for the mitochondrial A3243G mutation in patients with sensorineural hearing loss is expected to benefit MELAS patients by their early diagnosis.

A 41-year-old woman without any history of neurologic disorders presented with fever, chills and joint pain. Nine days later, the patient was admitted to the other hospital with generalized tonic-clonic seizure (GTCS). Three days later, she was transferred to our hospital for treatment of refractory status epilepticus. Despite intensive treatment including antibiotics, catecholamine, antiepileptic agents and sedative agents, she repeated GTCS. Cerebrospinal fluid testing showed pleocytosis (7/µL). Initial brain magnetic resonance imaging (MRI) was unremarkable, but follow-up MRI showed symmetric T2 hyperintensities in the bilateral medial temporal lobes. Considering the possibility of autoimmune-mediated encephalitis, intravenous methylprednisolone pulse therapy was repeatedly given, but no favorable response was observed. After three courses of intravenous immunoglobulin therapy, her clinical symptoms dramatically improved. Anti-neuronal antibodies associated with autoimmune-mediated encephalitis were all negative. The clinical picture of our patient is consistent with cryptogenic new-onset refractory status epilepticus (NORSE). The possibility of NORSE should be considered in refractory epilepsy, and early immunotherapy may improve patient prognosis.

64 years old, female. She had an untreated thoracic aortic aneurysm. She had amnesia from the time she woke up. Since there was no abnormality in the head CT scan at a nearby neurology clinic, she was brought to our hospital on suspicion of acute encephalopathy. When the patient came to our hospital, she had mild abdominal pain. Based on her medical history, amnesia, and abdominal pain, aortic dissection was suspected, and a thoracoabdominal contrastenhanced CT was performed. The CT revealed a false lumen opening acute type A aortic dissection, and it was decided to perform surgery. However, disruption of hemodynamics made the surgery difficult, and eventually the patient died. In patients with acute onset amnesia, it is important to suspect aortic dissection as soon as possible based on physical examination, history, and medical history.

An 80-year-old woman has been pointed out the hyponatremia by her family doctor for 4 years. She was taken to our hospital by the ambulance because she was confused in February. There was no significant lesion in her Brain MRI, and her consciousness came back gradually. She appeared to be drowsy in March. She couldn’t understand how to use the mobile phone and in April. The serum sodium concentration was 125mEq/L, and the EEG showed diffuse slow waves. She was admitted to our hospital in May. Her physical findings showed slight dry mouth, and she was kept alert while the serum sodium concentration exceeding 135mEq/L. We diagnosed her with MRHE from the slight dehydration state, low serum osmotic pressure, low plasma renin activity, and increased excretion of sodium of urine. After taking fludrocortisone, both the normal concentration of sodium and clear consciousness were maintained. The EEG became to be normalized. An elderly patient presenting with consciousness disturbance by mild hyponatremia often tend to be taken by the ambulance. MRHE is difficult to distinguish from SIADH (syndrome of inappropriate secretion of antidiuretic hormone), but the treatment is different. We need to keep MRHE our mind for treating the hyponatremia of elderly.

The diagnosis and treatment of stroke are often difficult, especially while taking measures to prevent coronavirus disease (COVID-19). Herein, we report a relatively rare case of acute cerebral infarction.

An 84-year-old man visited our hospital with a complaint of impaired consciousness. Physical examination revealed constricted pupils and loss of light reflexes, which suggested cerebral infarction. However, simple computed tomography (CT) of the head revealed normal findings. Since COVID-19 pneumonia was suspected on chest CT, vascular evaluation was performed via head CT angiography without magnetic resonance imaging (MRI) of the head; thrombolysis with intravenous recombinant tissue plasminogen activator was performed. On the second day of hospitalization, reverse transcription-polymerase chain reaction assay for COVID-19 was confirmed to be negative, and brain MRI findings led to the diagnosis of bilateral thalamic infarction. Postoperatively, the patient’s impaired consciousness was resolved, and he was transferred to a rehabilitation hospital on the 58th day of hospitalization because of residual dysphagia and gait disturbance. Bilateral thalamic infarction is a relatively rare type of stroke and should be considered in the differential diagnoses in patients with sudden-onset severe consciousness impairment.

A 46-year-old man fallen down on the floor after the faint signs was brought to our hospital. On admission he complained of chest discomfort and left neck pain No deficits were noticed on complete neurologic examination. Electrocardiogram revealed ST segment depression in II III aVF. He was diagnosed with acute coronary syndrome, then performed primary percutaneous coronary intervention (PCI). After PCI, computed tomography scan (CT) of the cervical spine was performed. It revealed a displaced avulsion fracture of the left occipital condyle (Anderson and Montesano classification type III). No other fractures was present. Isolated occipital condyle fracture (OCF) was diagnosed. The stability of occipito-atlantal and atlanto-axial joint was maintained, so the fracture was managed conservatively.

An isolated OCF is considered extremely rare, but OCFs are may be often overlooked in both clinical and autopsy settings. According to the currently available medical literatures, CT scans are considered superior to conventional radiography for diagnosis of OCFs, especially isolated OCFs. A multiplanar reconstruction CT image is essential in diagnosing these fractures; coronal reconstructions together with axial scans are particularly helpful. Three-dimensional reconstruction did not prove essential in diagnosing these fractures. In any case, the diagnosis of OCF requires a high index of suspicion.

We report a 79-year-old man with leucine-rich glioma-inactivated 1 (LGI1) antibody-associated autoimmune encephalitis following faciobrachial dystonic seizure (FBDS). 4 months before his admission, he developed partial seizures manifesting very brief and frequent dystonia in his right side of face and right hand. In addition, he started to wake suddenly from sleep with a loud scream and experience hallucination. On admission, he showed loss of consciousness and hyponatremia, and developed generalized convulsive status epilepticus. Brain MRI demonstrated high T2/FLAIR signal changes in the bilateral amygdala and chronic subdural hematoma. After removal of subdural hematoma and anti-epileptic drugs therapy, however seizures were not controlled. Treatment with high dose intravenous methylprednisolone and oral prednisolone was highly effective against his symptoms. Our findings collectively suggested that detection of FBDS is important for early diagnosis of anti-LGI1 antibody-associated autoimmune encephalitis and appropriate treatment selection.

Objective: Most of the case reports regarding relations between persistent primitive trigeminal artery (PPTA) and ischemic stroke indicate that the existence of the PPTA can lead to posterior circulation ischemia in the internal carotid artery (ICA) occlusion. We report a case of ICA occlusion due to the dissection in which PPTA played an important role as a collateral pathway.

Case report: A 47-year-old male presented with a sudden left hemiparesis and dysarthria. Magnetic resonance imaging (MRI) showed acute ischemic lesions in the right cerebral hemisphere and the right ICA occlusion. We started intravenous infusion of recombinant tissue-type plasminogen activator and performed digital subtraction angiography. Right common carotid artery angiography showed the right ICA occlusion in the cervical portion. Vertebral artery angiography demonstrated a collateral flow to the right ICA via PPTA. The neurological deficit of the patient improved gradually. After days, right ICA recanalized but it remained severe stenosis and was diagnosed ICA dissection. We performed carotid artery stenting and he was discharged from our hospital with no neurological deficit.

Conclusion: The existence of the PPTA is not only harmful in the ICA occlusion. It may play an important role as a collateral pathway in certain instance.

Traumatic subarachnoid hemorrhage (tSAH) is known to occur in about 10% of cases of severe head trauma. We report a case of non-severe and relatively localized tSAH with moderate head trauma treated conservatively, who had symptomatic cerebral vasospasm. A 48-year-old man fell from the stairs and came to our hospital. He showed impaired consciousness with a Glasgow Coma Scale score of 9 (eye-opening: 4 best verbal response: 1, and best motor response: 4). Head computed tomography revealed SAH in the left Sylvian fissure. After the impairment of consciousness improved, he was discharged. Wernicke's aphasia appeared the next day, and he was readmitted to our hospital. Magnetic resonance image revealed vasospasm of the left middle cerebral artery with cerebral infarction on the left genu of the internal capsule. After standard treatment in accordance with cerebral vasospasm caused by a ruptured aneurysm, it disappeared, and he recovered without any neurological deficit. There are various theories of the cause of cerebral vasospasm. In this case, the distribution of subarachnoid hemorrhage was consistent with the site of vasospasm, and we considered that hematoma causing vasospasm. This case serves to remind this fairly rare condition associated with patients with moderate head trauma.

In this study, we report two infants who had skull fractures due to inappropriate use of baby slings. Although accidents related to baby slings are not serious, some of those lead to skull fractures as shown in our report. Since we encountered these two patients within 2 months, we decided to draw parents’ attention to inappropriate use and overestimating the safety of baby slings. Several organizations have already alerted parents on accidents related to baby slings; however, further awareness needs to be provided via social networking services and child health handbooks.

The patient was a 79-year-old man who staggered, fell, and bruised his head when he attempted to get up after defecation in the bathroom. He managed to contact his family, who rushed in and requested for an ambulance. At the time of admission, he was conscious and had no obvious signs of cranial nerve injury, but had a subcutaneous hematoma on his head and persistent dizziness, nausea, and headache. His head CT showed no obvious abnormalities, and it was judged that his head bruise resulted from a fall due to the vagal reflex, leading to a concussion. The following day, the dizziness, nausea, and vomiting continued, and he was transported by emergency. His head CT showed a left cerebellar infarction, and a head MRI was performed. A diagnosis of cerebellar infarction in the region of the left posterior inferior cerebellar artery was judged; he admitted to be the hospital, and treatment was started. Infarction in the posterior inferior cerebellar artery region may be difficult to diagnose because the main symptom are dizziness, nausea and vomiting, while other symptoms are scarce. Distinguishing between cerebellar infarction and concussion is important because of their similar symptoms.

A 59-year-old male, who complained of episodic nausea and chest discomfort, was taken to the emergency room. ECG showed extensive ST-segment elevation, and blood tests revealed elevated myocardial enzymes with extremely high creatine kinase levels. We attempted cardiac catheterization but did not observe artery stenosis. The detailed history-taking unveiled that he had an epileptic seizure three days ago, and afterward he posted incoherent tweets on social networking service. Head MRI revealed a hemangioma in the right temporal lobe, and a FLAIR hyperintensity in the right hippocampus and pulvinar, suggesting of the recent occurrence of epileptic status and convulsive seizures most likely originating from the right temporal lobe. It probably caused takotsubo cardiomyopathy and rhabdomyolysis. EEG suggested focal seizure arising from the right fronto-temporal region because of the continuous delta slow and ill-defined sharp transients in the same region. He was treated with high volume fluid replacement, antiseizure drugs and beta blocker, and was discharged three weeks later. Epileptic focal status or frequent seizures could be one of the important causes of takotsubo cardiomyopathy. Therefore, appropriate historytaking based on the past medical history can lead to early diagnosis even in its acute phase, and to a timely treatment by consulting neurologists.

Subacute tetraparesis is an important chief complaint in neurological emergency care. If a cervical spine lesion is found on MRI, a thorough examination is needed to determine if it is the primary cause of the symptoms. We analyzed four patients who were diagnosed with cervical spondylotic myelopathy or retro-odontoid pseudo- tumor for one year. Two of them had mild pyramidal signs on neurological examination and spinal cord was mildly compressed by cervical spine lesions on MRI images, but these findings were not pronounced. Nerve conduction studies (NCS) were performed to rule out polyneuritis. Sensory nerve action potentials from the upper limbs were marked reduced in two patients without history of diabetes mellitus, making it difficult to distinguish from neuropathy other than compressive myelopathy.

In Gunma Prefecture, the Gunma PSLS course has been continuously conducted to develop human resources for emergency medical services. To confirm PSLS results, a post-verification review of stroke cases transported by ambulance is conducted to qualitatively evaluate activities of emergency medical services. Based on the review results, we have been working on recent treatment methods such as the introduction of a screen for occlusion of the main artery of the anterior cerebral circulation. We have continued to revise the PSLS course in response to latest advances in resuscitation education science and the enactment of the Stroke and Cardiovascular Disease Control Act; however, the effect of the COVID-19 pandemic has been enormous, forcing us to make changes such as delaying the publication of the JRC Resuscitation Guidelines 2020, canceling the Gunma PSLS course, and suspending the post- verification review. To cope with these changes, we have been revising the Gunma PSLS course so that it can be conducted continuously by changing from massed learning to spaced learning. An overview of the revised course will be reported.