Rural‒area health facilities may face many difficulties when a critical patient’s case is encountered. When an emergency room (ER) physician accepts a critical patient whose condition is not within his or her specialty, the physician may experience stress. Toward the goal of decreasing such stress, we have introduced a consultation network of specialists that a physician can access at any time via a tablet based on information and communication technology (ICT). We also began providing an educational system for inexperienced physicians that can be accessed during the daytime. In April 2016, the Minami‒nara General Medical Center was established in the southern region of Japan’s Nara Prefecture, in a rural area where there are no other emergent medical services. In the present study we examined the role of neurosurgeons at the Center’s ER, based on the ER’s acceptance of critical patients. Between April 1, 2016 and December 31, 2017 (a 15‒month period), our ER was able to accept 22,369 patients including 6,929 (31%) who were brought to our facility by ambulance and 272 (1.2%) who were transported by a medical‒emergency helicopter. These numbers are approximately twice as many patients as the numbers of ER patients accepted in the prior 15‒month period. We distributed a five ‒item questionnaire about emergency care issues to our ER staff (n=57), and their responses (from 80.7% of the staff) revealed that when the ER physician on duty accepted a critical patient, neurosurgeons were the most frequently consulted specialists. Our consultation system and the availability of neurosurgeons are clearly necessary to decrease ER physicians’ stress when they accept emergent critical patients.

  Nagasaki prefecture introduced helicopter transportation for the medical treatment of island patients. In 2006, doctor helicopter for the transportation of emergency treatment of rural residents was begun. In this study, we investigated the effect of doctor helicopter on the neurosurgical emergencies. We retrospectively reviewed the cases of patients who were transported by doctor helicopter from 2014 to 2016. Ambulance and doctor helicopter were employed for the transportation of 9440 and 207 patients, respectively. The Department of Neurosurgery treated 58 patients (18 ischemic stroke, 11 intracerebral hemorrhage, 5 subarachnoid hemorrhage, 16 head injury, 3 epilepsy and 5 other patients). Renacalization for the acute ischemic stroke was employed in 7 patients. Approximately 80% patients were brought to our hospital directly. Doctor helicopter was effective for the treatment of the acute ischemic stroke.

  Thrombectomy is an established treatment for acute ischemic stroke. Along with advances in the development of medical devices for thrombectomy, the time from onset to reperfusion has now become one of the most important factors influencing good patient prognosis. Following the establishment of a new Stroke Care Center in Nara Medical University on October 2017, we carried out a retrospective study in an attempt to identify ways to shorten the time to thrombectomy. The study included 26 cases (15 males, 11 females) that we experienced in our hospital between October 2016 and September 2017, prior to the opening of the Stroke Care Center. The variables examined in the retrospective study included the visit style, reperfusion time, and patient prognosis. The mean age was 75.7 ±12.2 years (age range: 40‒91 years). The NIHSS score on arrival was 17.7±6.6, and a reperfusion of TICI 2b or better was achieved in 21 patients (81%). The door‒to‒puncture (D2P) time was 121.7±54.9 min, and the puncture‒to‒reperfusion (P2R) time was 44.8±23.5 min. Patients were divided into two groups: a first group (cases 1‒13) and a second group (cases 14～26). We demonstrated a significant shortening of the P2R time (p＝0.005) in the second group, although the D2P time remained unchanged. In other words, with the increase of thrombectomy, shortening of the P2R time was achieved due to technical factors, although the D2P time remained unchanged due to systemic factors. The establishment of the new Stroke Care Center is expected to further strengthen the in‒hospital system and improve the coordination with doctors and co‒medical staff members such as paramedics leading to a shorter D2P time.

  Our subjects were 11 consecutive patients who underwent acute‒phase endovascular thrombectomy for M2 occlusion using a 3‒mm Trevo^® XP 3 between November 2016 and October 2017. We examined the modified Rankin Score (mRS) and the National Institutes of Health Stroke Scale (NIHSS) score upon arrival, thrombolysis in cerebral infarction (TICI) grade upon recanalization, and mRS after 30 days in these cases. The average age of the patients (7 males and 4 females) was 76.6 years old (range, 33‒86 years old). Pathological features included 4 cases with a single M2 occlusion, 1 case with M1 occlusion and M2 occlusion caused by distal migration of blood clots accompanying the procedure, 5 cases with M2 occlusion caused by distal migration due to IC occlusion, and 1 case with P2 occlusion caused by distal migration of blood clots due to basilar artery (BA) occlusion. The average NIHSS score at arrival was 19.3 (7‒30). The numbers of patients with TICI Grade 3, 2b, and 2a at recanalization were 4 (36.3%), 5 (45%), and 2 (18%), respectively. The average mRS after 30 days was 3.0 (1‒6), and the good outcome group, defined as those with an mRS of 2 or better (0‒2), consisted of 5 cases (45%). A small subarachnoid hemorrhage was observed during the procedure in 1 case, but no symptoms were observed. A total of 82% and 36% of patients showed TICI grades 2b/3 and 3, respectively, immediately after surgery, and relatively good recanalization was obtained. After 30 days, mRSs of 0‒2 were seen in 45% of subjects. Safe and effective endovascular thrombectomy was implemented by using a 3‒mm device with excellent operability and guidance control for M2 and P2 occlusion.

  We examined treatment outcomes and problems of thrombectomy at our hospital, the only center that performs them in our medical area. We examined the characteristics of percutaneous cerebrovascular thrombectomy in 56 patients who underwent the procedure for acute cerebral arterial obstruction between January 2015 and May 2017. Patient mean age was 69.0 ± 14.0 years, with a female/male ratio of 20:36. Of the 56 patients, 27 were referred from other hospitals and 29 were direct admissions. We examined the background, vessel subjected to treatment, and treatment outcomes of all patients. We found that the median National Institute of Health Stroke Scale (NIHSS) score was 15.5 (interquartile range: 11‒19.25), and the time from onset to recanalization was 263 min. Successful recanalization for thrombolysis in cerebral infarction (TICI) grade equal to or more than 2b was achieved in 44 patients (78.6%). Symptomatic intracranial hemorrhage was observed in three patients (5.4%). Favorable outcome at 90 days (modified Rankin Scale: mRS ≤ 2) was noted in 28 patients (50.0%). Our univariate analyses revealed that the factors associated with favorable therapeutic outcomes included age, NIHSS score, time from onset to recanalization, and successful recanalization. Our examination showed that we need to refer from other hospitals more quickly, shorten the time from onset to recanalization, and increase successful recanalization.

  In thrombolytic therapy for an acute ischemic stroke, the time of onset is very important. The purpose of this study was to identify unknown onset times in acute ischemic stroke within 4.5 hours using diffusion weighted image (DWI) and fluid‒attenuated inversion recovery (FLAIR) mismatch (DWI‒FLAIR mismatch). We retrospectively examined 56 cases of anterior circulation acute ischemic stroke with known onset times that occurred between January 2015 and August 2017 (28 males, 28 females; average age, 77.9±10.8 years). We categorized signal intensities on DWI and the FLAIR results of the same region into negative, moderate, or positive. We investigated relationships between the time interval from onset to MR scan and the 3 categories of FLAIR as a qualitative evaluation; and relationships between the signal intensity ratio (SIR) calculated using the stroke area (defined by DWI) and the region of interest (ROI) in the same region on the contralateral side on FLAIR images as a quantitative evaluation. We also calculated the SIR cut‒off based on the receiver operating characteristic (ROC) curve. Based on visual evaluation, there were significantly more negatives than moderates or positives in cases within 4.5 hours after onset (p＜0.01). There were significant differences between SIR and FLAIR in all categories (p＜0.05). In ROC curves, the cut‒off was 1.24 and the area under the curve (AUC) was 0.88 (95% CI 0.80‒0.97); sensitivity was 93.2% (95% CI 86.5‒99.9), specificity was 91.7% (95% CI 84.3‒99.1), the positive predictive value was 95.3% (95% CI 89.6‒100), and the negative predictive value was 84.6% (95% CI 75.0‒84.2). Under our method, we were able to identify by visual evaluation cases with a negative categorization at or below SIR 1.24 within 4.5 hours after onset, and thereby determine the best choice of treatment for acute ischemic stroke with an unknown onset time.

  In our hospital, when multiple sinus occlusions and a delay in circulation time are observed in cases of sinus thrombosis, local fibrinolytic therapy (LFT) is used adjunctively with the continuous infusion of heparin, irrespective of disease severity. In this study, we examined the usefulness of LFT in sinus thrombosis. Fifteen consecutive patients (age range: 25‒61 years, mean: 45.3 years; 8 males and 7 females) diagnosed with sinus thrombosis based on CT/MRI findings were included in this study. Of these patients, one had a cerebral infarction, and six experienced cerebral hemorrhage. The superior sagittal/transverse-sigmoid/straight sinuses were affected in five cases, the superior sagittal sinus in three cases, and the transverse-sigmoid sinuses in seven cases. The symptoms observed were as follows: headache in six cases, consciousness disturbance in five cases, aphasia in two cases, and convulsion in two cases. The underlying causes were as follows: contraceptive use in three cases, malignancy in two cases, coagulation disorder in two cases, and infection in two cases. In six cases, the underlying cause was unknown. Local fibrinolysis was used when multiple sinus occlusions and a delay in circulation time were noted. Based on this criterion, six patients were treated with LFT, and nine with only heparin treatment. A maximum of 360,000 units of urokinase (UK) were administered as part of the LFT, and additional mechanical disruption was also performed; heparin was administered such that the activated partial thromboplastin time reached approximately 1.5 times the previous value. If partial recanalization was achieved, LFT was discontinued. In the LFT group, the average quantity of UK administered was 260,000 units. In this group, three out of six patients were treated using a balloon catheter for clot disruption. Partial recanalization was obtained in all cases, and no complications were observed. Outcomes evaluated using the modified Rankin Scale (mRS) 90 days post-treatment revealed that in total, there were eight patients with an mRS score of 0, four with a score of 1, one with a score of 2, one with a score of 3, and one with a score of 4. Thirteen cases (87%) showed a favorable mRS outcome of 0‒2, and the two cases with an mRS result of 3‒4 were in the heparin treatment group. It is useful to combine heparin therapy with early LFT for sinus thrombosis with multiple sinus occlusions, irrespective of disease severity. LFT was considered not to aim for complete recanalization, but to be positioned as an adjuvant therapy and keep safe procedure, and it was concluded that good results were obtained.

  In recent years, the increase in terrorist attacks has come to constitute a widespread menace to the safety of citizens around the world. It is also a matter of considerable concern for Japan, where the Tokyo Olympics and Paralympics will be held in 2020. TEMS (Tactical Emergency Medical Support) is a critical component of the out-of-hospital response to domestic high-threat incidents such as terrorist attacks and other intentional mass casualty-producing acts. TEMS is based on TCCC (Tactical Combat Casualty Care), which is the standard of trauma care in prehospital battlefield medicine created by the U.S. Department of Defense Committee on TCCC (Co‒TCCC). In this paper, we present an outline of TEMS and TCCC, investigate the characteristics of casualties in terrorism and discuss the role of neurosurgeons in mass casualty incidents in terrorist attacks. Given their specifics and skills, neurosurgeons are expected to be called upon to participate actively in TEMS in terrorist attack situations.

  Coil migration occurs in approximately 2‒6% of cases of coil embolization for brain aneurysms. We report our experience of the case of a 75‒year‒old man in whom a coil migrated into the internal carotid artery during embolization for a lingual artery pseudoaneurysm that occurred due to denture aspiration. Given the rarity of distal coil migration, flow control is often not performed in embolization for the external carotid artery using a coil. With giant aneurysms, blood flow may change after embolization, as in the present case. It is worthwhile to consider the risk of coil migration into the internal carotid artery when the branch is near the internal carotid artery.

  Intravenous alteplase administration is limited to acute cerebral ischemic disease and acute myocardial infarction in Japan. However, it is approved for use for retinal artery occlusion in Western Europe and the United States. Blindness caused by retinal artery occlusion must be considered a serious hazard. On the other hand, some reports have revealed intraocular hemorrhage as an adverse event after alteplase administration. In this report, we present two cases and discuss the advantages and disadvantages of alteplase administration for visual function. Case 1 was a 76‒year‒old male referred to our hospital for a visual field defect. MRI revealed multiple infarctions on the left frontal and occipital lobes. Under the diagnosis of cerebral infarction and retinal artery occlusion, alteplase was administered, resulting in recovery of the visual field defect. Case 2 was a 66‒year‒old male referred to our hospital for aphasia, dysarthria, and facial palsy. Alteplase was administered under the diagnosis of left frontal cerebral infarction; on the following day, he was experienced intraocular hemorrhage with sudden onset of right blindness. Intraocular hemorrhage is a rare adverse event associated with alteplase treatment. The effect of alteplase administration for acute retinal artery occlusion is a topic of serious debate. With increasing numbers of elderly people in Japan, cases requiring alteplase treatment will increase. We must consider additional indications for alteplase treatment and weigh the benefits are risks related to visual function.

  Surgical treatment of organized chronic subdural hematoma often requires craniotomy to remove the hematoma, but subsequent postoperative regrowth may occur due to hemorrhage from the outer membrane of the hematoma or dura mater. Middle meningeal artery embolization is known to be effective for preventing the recurrence of refractory chronic subdural hematoma. We report 3 cases of organized chronic subdural hematoma which were successfully treated by middle meningeal artery embolization prior to hematoma removal by craniotomy, resulting in good outcomes. Case 1 was an 81‒year‒old female. Left chronic subdural hematoma was suspected based on CT findings, and burr hole drainage was performed twice, but the hematoma reaccumulated. Middle meningeal artery embolization was performed followed by a third burr hole drainage the following day, but the drainage was not effective, and the hematoma was therefore diagnosed as an organized chronic subdural hematoma. One month later, the hematoma was removed through a craniotomy. Case 2 was an 81‒year‒old male taking aspirin and clopidogrel for ischemic cardiac disease. Bilateral organized chronic subdural hematomas were suspected based on CT findings but, due to the patient’s advanced age, only the left hematoma was treated by burr hole drainage to confirm the diagnosis. The patient was discharged from the hospital, but his symptoms deteriorated. Bilateral middle meningeal artery embolization was performed, and the left hematoma was removed through a craniotomy 5 days later. Case 3 was a 77‒year‒old male. Left organized chronic subdural hematoma was suspected based on CT findings, and burr hole drainage was performed to confirm the diagnosis. One week later, regrowth occurred, and middle meningeal artery embolization was performed followed the next day by craniotomy to remove the hematoma. None of these 3 patients developed recurrence after craniotomy. Middle meningeal artery embolization followed by hematoma removal by craniotomy can prevent postoperative reaccumulation of organized chronic subdural hematoma.

  Lesions that mimic subdural hematomas have been reported and may be difficult to diagnose. We report a case in which treatment was initiated based on a diagnosis of chronic subdural hematoma resulting from head trauma; however, in reality, it was a metastatic malignant lymphoma. The patient was a 61‒year‒old woman with a medical history of rheumatoid arthritis, hypertension, and malignant lymphoma (tonsil). The patient had hit her head on an iron pipe when she stood up. Eighteen days after the injury, she developed numbness of the right upper and lower limbs, and visited a neurosurgeon. Magnetic resonance imaging (MRI) of her head revealed a subdural hematoma. Although her symptoms gradually improved, computed tomography (CT) of her head 32 days after the injury showed an increase in the left subdural hematoma. This resulted in a visit to the neurosurgery department in our hospital. We diagnosed it as a chronic subdural hematoma based on the patient’s clinical course and images, and treated it conservatively. We initially treated the patient as an outpatient, however, because of the appearance of headache and nausea, she underwent burr hole surgery on Day 37 after injury; it was not successful because the subdural hematoma was stiff. A craniotomy was then performed, during which the subdural hematoma was partially removed. As the patient’s symptoms improved, she was discharged from the hospital. She then developed an articulation disorder on Day 97 after the injury, and again visited our neurosurgery department. Tumorous lesions were suspected after performing CT and MRI scans of her head, and craniotomy was performed. She was then diagnosed with malignant lymphoma and chemotherapy was initiated. Malignant lymphoma may be difficult to distinguish from subdural hematoma by CT and MRI of the head alone. In this case, the patient was erroneously diagnosed with chronic subdural hematoma thought to have resulted from a head injury, and was treated for this condition. We recommend pathological diagnosis in cases in which a chronic subdural hematoma has an unusual appearance during burr hole surgery.