We reviewed the measures against novel corona virus disease 2019 (COVID-19) infections in Osaka Prefecture and presented two patients who underwent craniotomy in the 6th wave of the COVID pandemic. Case 1 was an 86-year-old man with acute subdural hematoma. He took a talk and deteriorated course and arrived with a Glasgow Coma Scale of 3, requiring 6.5 hours from the time of injury to the start of surgery. He had moderate COVID pneumonia. He underwent evacuation of hematoma but died without recovery. Case 2 was a 73-year-old woman with a subarachnoid hemorrhage. She was conscious, but her consciousness declined to 200 on the Japan Coma Scale during transportation. A COVID screening in the emergency room revealed her positive. She underwent successful clipping for ruptured anterior communicating and unruptured Azygous anterior cerebral artery aneurysms. She was treated prophylactically for COVID pneumonia and had a favorable outcome. Both patients took longer than usual from arrival to the operating room. Case 1 could recover by early surgery, and Case 2 took time to wean from the ventilator. Under strict infection control measures, the craniotomy was performed safely, but the delay in surgery was considered problematic.

The “Japan Guideline for the Management of Traumatic Brain Injury” was established in 2000, to standardize and to improve the management performance, by maintaining systemic circulation, oxygenation, and intracranial pressure. In recent years, the situations of acute TBI management are divided to develop as prehospital, primary, intensive, and professional, requiring cooperation between departments. As going through several editions of the guideline in the last couple of decades, the mortality of TBI has significantly decreased.

As the population aging, the number of the elderly patients with TBI is increasing. The characteristics of them are known as (1) increased risk of trauma, (2) increased risk of intracranial bleeding, and (3) increased risk of aggravation. Those risks are partially explained by ‘talk and deteriorate’ phenomenon, coagulopathy, and antithrombotic drugs use. Thus, efforts to address those risks may be important to improve outcome of the elderly patients with TBI.

In this article, the commitments of the “Japan Guideline for the Management of Traumatic Brain Injury” are reviewed to clarify the forthcoming challenges.

We report a rare case of de novo arteriovenous malformation (AVM) after cerebral infarction (CI) that ruptured after mechanical thrombectomy (MT) at the time of recurrence of CI. A 64-year-old male had a history of left temporal CI 4 years ago. At that time, no shunt disease was demonstrated on magnetic resonance imaging (MRI). Four years later, he was admitted to our hospital with impaired consciousness and right hemiplegia. MRI showed cerebral infarction in the left middle cerebral artery area due to middle cerebral artery first portion occlusion. MT was successfully performed using combined technique. In addition, left temporal AVM was found on angiography but it was not treated at the same time. Sudden headache and nausea appeared 12 hours after MT. Head CT findings showed left temporal subcortical hemorrhage, and emergency operation was performed. Spetzler-Martin Grade II AVM was demonstrated on postoperative angiogram. Surgical resection of AVM was successfully performed 21 days after MT. It has been reported that de novo AVM is caused by various angiogenic factors. This case suggested that de novo AVM developed due to angiogenic changes caused by first CI, leading to rupture due to hemodynamic changes by another CI.

We report a case of chronic encapsulated intracerebral hematoma that was difficult to differentiate from brain abscess. The patient was a 51-year-old man with a history of Marfan syndrome associated with periprosthetic infection after surgery. When he woke up at 8:00 in the morning, he became aware of right hemiparesis, speech disturbance and right homonymous hemianopia. A brain CT revealed a left occipital subcortical hemorrhage. He was admitted to our hospital. His hematoma had no recurrence, but a CT scan after 23 days of hospitalization showed an enlarged edema around the hemorrhage with a ring-shaped enhancement. A brain abscess was strongly suspected based on the course of fever and blood culture. We performed craniotomy after 27 days of hospitalization. However, no abscess was observed within the capsule, the organized hematoma surrounded by a capsule was removed. It has been reported that chronic encapsulated intracerebral hematoma presents similar imaging findings to metastatic brain tumor, glioblastoma and brain abscess, and that the clinical course is also similar. As reported cases are rare, further investigation including the pathology and risk factors are necessary.

We experienced three cases of status epilepticus due to dural arteriovenous fistula, here we report their diagnosis, treatment, and prognosis. As the presenting symptoms varied, the early diagnosis was not straightforward. The early treatment intervention leads to the better prognosis. MRI also seemed to aid in diagnosis.

Introduction: We report the case of a patient transported to emergency outpatient department by ambulance due to cardiopulmonary arrest following a head injury. He underwent systemic management, leading to organ donation.

Case: A 56-year-old man.

Current illness history/course: The patient sustained a head injury after falling from the bed of a truck and then suffered cardiopulmonary arrest. He was transported to the emergency department by ambulance. After his heart resumed beating, his intention to donate his organs was confirmed on the back of his health insurance card. Discussions with the organ donation hospital coordinator reveal that, donating organs after brain death was difficult due to the general condition; still the possibility of organ donation after cardiac arrest was considered. Systemic management was continued in the emergency department, and upon obtaining consent from his family, post-cardiac arrest organ donation was carried out.

Conclusion: Establishing a system to confirm the intention to donate organs is important. Donor management can be done by performing normal life-saving measures, but certain donor-specific matters require attention.

Intracranial hemorrhage in patients with blood disorders is potentially fatal. Here, we report a case of aplastic anemia complicated by intracranial hemorrhage with a favorable outcome.

A 37-year-old woman was rushed to a hospital with a headache. The patient was conscious and had no neurological findings. However, brain CT revealed a subcortical hemorrhage in the right temporal lobe. Blood tests showed pancytopenia. We suspected blood disorders such as aplastic anemia. The next day, the hematoma enlarged. The patient became drowsy and had left hemiplegia. Evacuation of the hematoma and decompressive craniectomy were performed. Due to severe brain swelling, ventricular drainage, temperature management, and osmotic diuretics were administered. Thrombocytopenia persisted perioperatively, thus platelets were transfused daily. The patient was extubated on the 12th day after brain swelling was relieved, and the hemiparesis improved. Bone marrow biopsy revealed aplastic anemia. Subsequently, immunosuppressive drugs were started.

Patients with aplastic anemia, who developed intracranial hemorrhage tended to have low platelets. Due to their tendency to bleed easily, when surgery is performed, blood transfusions and frequent monitoring of the platelet level during the preoperative to postoperative periods are essential. Early diagnosis and treatment of the underlying disease are important.

A 46-year-old woman with sudden headache admitted to our hospital complaining of left hemi paresis hemiparesis. Magnetic resonance imaging (MRI) revealed acute right middle cerebral artery (MCA) territory infarction. MR angiography (MRA) showed a narrowing of the right MCA and MRA original image showed a double lumen in the right MCA, indicating MCA dissection. TTP (time to peak) map of CT perfusion (CTP) images showed peak time delay with corresponding decrease in blood flow of right MCA territory. Conservative therapy was adopted and her symptom was improved gradually. Follow-up CTP image showed steady improvement compared with on admission in accordance with morphological repair of the right MCA dissection.

Dissection of the MCA dissection in is less frequent compared with dissection of the vertebrobasilar system or carotid artery. The diagnosis of MCA dissection is not easy. With advances in noninvasive angiographic diagnostic procedures, this type of dissection is being increasingly recognized. But the sensitivity of the findings of double lumen and intimal flap is not satisfactory. CTP can be one of the useful tools for recognizing morphologic changes indirectly in MCA dissection by detecting cerebral perfusion changes.

Introduction: We report a case of craniotomy performed in the emergency department (ED) for a non-traumatic acute subdural hematoma.

Case: An 84-year-old man with long-term psychiatric hospitalization independently performed activities of daily living.

History: While watching TV, he vomited and started losing consciousness. Head computed tomography (CT) revealed a left-sided acute subdural hematoma, and he was transferred to our hospital via ambulance. On admission, his Glasgow Coma Scale (GCS) (E1, V1, and M4) showed pupils 2.0 mm/3.0 mm, sluggish light reflexes bilaterally, and right hemiplegia. Following head CT, his consciousness level deteriorated to GCS (E1, V1, M2), pupils 2.0 mm/5.0 mm, and bilateral loss of the light reflex. He developed a non-traumatic acute subdural hematoma without cerebral contusion. The ED performed a craniotomy for hematoma removal. On postoperative day 27, he was transferred to psychiatric care.

Conclusion: Since non-traumatic acute subdural hematoma does not cause brain contusion, an early craniotomy may improve its prognosis. Prompt interprofessional coordination between a neurosurgeon, anesthesiologist, and operating theater nurse for emergency craniotomies and hematoma removal in the ED may be a useful therapeutic strategy in such cases.

In Gunma Prefecture, centering on the Gunma Stroke Emergency Network, we have published the number of hospitals where recanalization therapy is possible and the number of cases of recanalization therapy. We have continued to hold the Prehospital Stroke Life Support course and post-verification of ambulance crew activities using the Gunma Prefecture integrated medical information system (“system”), but due to the spread of COVID-19, we were forced to suspend from the end of 2019. With the formulation of the Basic Plan for Cardiovascular Disease Control, post verification of ambulance crew activities has become an essential item. In 2021, we confirmed that the quality of ambulance crew activities was the same as two years ago through the primary post-verification of cases that were transported directly to our hospital by ambulance. The usefulness of the 7-item evaluation of physical observation of patients suspected of having a stroke was confirmed through secondary post-testing of cerebral infarction cases. However, the description rate of the last known well time was poor. In the future, it will be necessary to strengthen efforts to continue the primary and secondary post-verification using the "system" as the work of the Gunma Medical Control Council.