Our hospital is the only critical care center for a population of 430,000. The annual number of emergency transportation cases increases every year, exceeding 8,000 in 2013, which makes providing emergency transportation in each of these cases difficult. We examined cases of refusal to provide emergency transportation in 2015 and 2016. In 2015, of 7,846 emergency transportation cases, emergency transportation was refused in 191 (2.4%); and in 2016, 538 of 7,161 (7.0%) emergency transportation cases were refused. The percentage of refusal due to unavailability of beds in the emergency room or hospital was 40% in 2015 and 32% in 2016. Emergency transportation requests for patients with severe health problems need to be accepted as soon as possible. By refusing emergency transportation requests for patients with less severe health problems, it might be possible to reduce the unavailability of beds. Therefore, we have asked ambulances to transport patients with less severe health problems to neighboring secondary hospitals and have also asked these hospitals to accept such patients. In 2017, the cases of refusal to provide emergency transportation increased further, as the unavailability of beds in emergency rooms and hospitals increased. Since every establishment is limited by its capacity to accept patients, it is necessary to improve the efficiency of the system by promoting patient discharge and departure from the emergency room.

  A stroke telephone hotline was introduced in our hospital in December, 2014. The purpose of the present study was to investigate stroke telephone hotline data and identify problems with stroke care that need resolution in our community healthcare area. Our hospital telephone hotline directly connected referral doctors to neurosurgeons 24/7/365. We collected and analyzed patient data gathered through the stroke telephone hotline from February of 2016 to January of 2017. During the study period, 54 patients were referred to Osaka Medical College Hospital. Eighteen patients (33%) were referred on Mondays, and most (87%) were transferred in the daytime. One neighboring general hospital that has no neurosurgical department referred 30 patients (56%), the highest number referred from a total of 18 referral medical institutions; this hospital and most of the other referral clinics were located in areas facing a paucity of neurosurgeons. While 37 patients (69%) had cerebrovascular disease, 12 (22%) were diagnosed with a head injury. Of the 37 patients with cerebrovascular disease, 26 had had an ischemic stroke, but only 2 were transferred to our hospital within 8 hours after onset. No patient was treated with the intravenous administration of recombinant tissue plasminogen activator.

  Our stroke telephone hotline did not contribute to an improvement in acute stroke care in our community healthcare area. However, it facilitated the coordination of both stroke care and neurosurgical care with hospitals and clinics in areas facing a shortage of neurosurgeons.

  Cerebral cavernous malformation (CCM) is a hamartomatous vascular malformation that typically presents as a sporadic lesion. A fraction of CCMs are of a familial type, inherited in an autosomal dominant trait. The present study aimed to investigate the correlation between clinical picture and prognosis of familial CCM in a Japanese population. Eighteen Japanese patients with defined familial CCM were analyzed. They comprised 8 (44%) with CCM1 mutations, 6 (33%) with CCM2 mutations, and 1 (6%) with CCM3 mutation; in 3 (17%), none of the CCM mutations was identified. Frequent initial symptoms were headache and seizure, similar to those of non‒familial, conventional‒typed CCMs. Eleven (61%) of the 18 showed a diffuse manifestation of CCMs involving the cerebral and cerebellar hemispheres, and the brainstem. However, types of genomic mutation and CCM appearance on magnetic resonance imaging (MRI) were variable and inconsistent. During a mean follow‒up of 7.5 years, 17 of the patients showed an uneventful clinical course without neurological deterioration or remarkable increase of CCMs on MRI. Most familial CCMs can anticipate a stable clinical course. Further investigation by comprehensive genomic analysis targeted for whole nucleotide sequences is needed for better understanding of familial CCM.

  Contrast extravasation (CE) within spontaneous intracerebral hemorrhage is a well‒described predictor of hemorrhage expansion, poor clinical outcome, and mortality. Our purpose was to evaluate CE as a predictor of hemorrhage expansion in traumatic intracranial hemorrhage including subdural hemorrhage, epidural hemorrhage and intracerebral hemorrhage. We retrospectively reviewed the cases of 43 patients who presented to our emergency department over a 5‒year period with traumatic intracranial hemorrhage and underwent CT Angiography (CTA) at admission and follow‒up CT within 4 hours. The presence of CE was evaluated in the arterial phase and venous phase of CTA, with CE classified as active extravasation or post‒contrast leakage. Hemorrhage expansion of the subdural hemorrhage was detected in 91% of the patients in the CE (＋) group, whereas expansion was only observed in 21% of the CE (－) group (P＜0.001). Hemorrhage expansion of the intracerebral hemorrhage was detected in 100% of the patients in the CE (＋) group, whereas expansion was only observed in 50% of the CE (－) group (P＜0.001). No significant difference in hemorrhage expansion or the hemorrhage expansion rate was found between active extravasation and postcontrast leakage. CE was a predictor of hemorrhage expansion in our series of patients with traumatic intracranial hemorrhage.

  Pituitary apoplexy caused by hemorrhage or infarction in the pituitary gland is infrequent, but it requires emergency management. We retrospectively analyzed pituitary adenoma with apoplexy patients who required urgent treatment. Of the 407 patients who underwent pituitary tumor resections from 2006 to 2016 at our department, we examined the 12 pituitary adenoma cases with sudden onset and requiring emergency treatment (seven males, five females; median age 47 years). Symptoms included headache, visual acuity loss, diplopia, and hypopituitarism in five, four, three and two cases, respectively. There were 10 cases of nonfunctioning adenomas and two of prolactin‒secreting adenomas. All patients received initial hormone replacement. Endoscopic trans‒sphenoidal tumor resection was performed in all cases. The average interval from the symptoms’ onset to the consultation was 0.9 day. The average interval until the operation was 9.1 days. Presurgery symptom improvement occurred in five cases, and the symptoms resolved postsurgery in all five cases. The resected tumor specimens showed hemorrhage in 11 cases and infarction in one case. Total tumor removal was performed in 10 cases and subtotal removal in two cases. No post‒operative complications were observed. All patients returned to their daily lives after surgery; hormone replacement was continued in nine cases. Practically no tumor recurrence was observed. In cases of pituitary adenomas with apoplexy, corticosteroid administration is required to manage pituitary dysfunction, allowing symptom amelioration. The functional prognosis of pituitary adenomas with apoplexy is good if adequate tumor resection is possible, but hormone replacement is often required.

  Traumatic brain injury (TBI) is a common health problem worldwide, with significant long‒term mortality and morbidity. A TBI causes diffuse axonal injury at the injured brain, and it can examined by several imaging techniques. An association between outcomes and several abnormal images in TBI patients has been recognized, but the efficacy of serum biomarkers of axonal injury remains unclear. High‒molecular‒weight phosphorylated neurofilament (pNF‒H) is a novel biomarker of axonal injury. Several studies showed that the blood level of pNF‒H is a predictive biomarker for outcomes in patients who have incurred a TBI. Here we investigated the association between the serum level of pNF‒H and the abnormality at diffusion weighted magnetic resonance imaging (DW‒MRI) in TBI. We retrospective analyzed the records of 14 patients who were admitted to our hospital with a TBI between July 2015 and July 2016. All patients in whom brain damage was detected underwent CT scans. Serum samples were collected at Days 0 and 3 post‒TBI. DW‒MRI was performed post‒injury in all patients. The serum level of pNF‒H was detected in five patients and was strongly correlated with an abnormality shown by DW‒MRI (71% sensitivity, 100% specificity). The results of our analyses demonstrated the serum pNF‒H at Day 3 post‒injury is a significant biomarker for detecting brain injury after a TBI.

  Several randomized controlled trials have established that an acute thrombectomy is recommended for acute cerebral infarction within 8 hr of onset. A standard treatment has not been established for resistant and/or ineffective cases after thrombolytic therapy. We herein describe the surgical outcomes of non‒cardiac occlusive patients who underwent an emergent extracranial‒to‒intracranial bypass within 72 hr of onset, and we discuss the advantages of this surgery and its pitfalls. We retrospectively analyzed the medical charts of 14 consecutive non‒cardiac cerebrovascular occlusive stroke patients who underwent emergent bypass surgery at the acute stage at 8‒72 hr post‒stroke onset, and we examined clinical and treatment outcomes. The patients were nine males and six females, mean age 70 years (range 43‒82 years). We determined the surgical indications in consideration of the observed progressive cerebral infarction with National Institutes of Health Stroke Scale (NIHSS) scores ≥ 4 points, occlusion of the main artery (IC, M1), small cortical infarction (≤ 1/3), and perfusion‒diffusion mismatch. The average NIHSS on admission was 9.5. Seven infarctions were in the middle cerebral artery (MCA: M1) and there were seven internal carotid artery occlusion cases. The average time from the stroke onset to surgery was 36 hr (12‒72 hr). The surgical outcome was good recovery in two patients, moderate disability in six, severe disability in five, and one death. The favorable outcome rate was 57.1%; the poor outcome rate was 42.9%. No patient suffered any complication related to surgical intervention, including hemorrhagic complications. Our analyses indicate that in non‒cardiac acute cerebrovascular stroke patients, emergent superficial temporal artery (STA)‒MCA bypass surgery (which can improve clinical outcomes and reduce the risk of morbidity under strict surgical indications) can be an option for acute‒stage revascularization for cases in which thrombolytic therapy was ineffective.

  Though the incidence of spinal epidural abscess (SEA) has been increasing, SEA is a rare clinical condition, and remains a challenging problem despite advances in neuroimaging and neurosurgical treatment modalities. SEA usually develops in patients with predisposing factors such as diabetes mellitus and immunodeficiency. We present the case of a patient without such predisposing factors who developed cervical canal stenosis due to inflammatory pseudomembrane around the dura mater, which is associated with cervical epidural abscess.

  We report the case of a 14‒year‒old girl with severe head injury with bilateral intracranial hematomas that occurred repeatedly. Emergency surgery was performed, leading to a favorable outcome. The patient was riding on a motorcycle when she crashed with a car and suffered head injuries. Her consciousness level on arrival was GCS 6, and dilation of the right pupil was noted. During primary care, left hemopneumothorax was observed, and thoracic drainage was performed. Initial computed tomography (CT) of the head revealed right acute subdural hematoma (ASDH) and linear fracture of the left temporal bone. In the emergency room (ER) of the critical care center, craniotomy was performed to remove the right ASDH. Dilation of the left pupil was noted immediately after surgery, and CT revealed left acute epidural hematoma (AEDH), which was then removed in the ER by craniectomy. The patient was transferred to the operating room, and left craniotomy was conducted. Immediately after surgery, dilation of the right pupil was observed, and additional right craniotomy was performed. A third CT scan showed brain contusion in the right frontal lobe, and internal decompression was carried out. The patient’s postoperative course was favorable and after 8 months, she was referred to another hospital for rehabilitation. However, assessment using the Glasgow Outcome Scale (GOS) upon discharge from our hospital suggested moderate disability (MD). Early decompression in the ER and surgery for contralateral hematoma detected on postoperative CT may have led to a more favorable outcome.

  Head injuries, some of which are due to abuse and may cause severe sequelae, are the most common cause of death among children. We report a case of intracranial pressure (ICP) monitoring for head trauma in an abused child. ［Case］ A five‒month‒old girl, who had not been seen by public health nurses as they were not consulted for regular checkups, was referred to the hospital when the mother complained about how “funny” the infant was. At the consultation, we observed that the patient had a poor complexion, upper right lower limb clonic convulsions, and confirmed bilateral subdural hematoma with CT. To treat the convulsions, the infant was sedated with midazolam and administered phenobarbital. She was transfered to our hospital after the child guidance center notice in Hahaji separation purpose, which is the other prefectures. Based on MRI findings suggestive of diffuse axonal injury and bilateral subdural hematomas, an ICP sensor was placed to manage and follow the anterior fontanelle bulging and to treat it with midazolam. While we observed ICP, we were able to administer the drug without increasing the ICP. Therefore, we removed the sensor on the 8 th day. The infant was able to nurse after 3 months, and subsequently left the hospital. Children are less tolerant of increased ICP, and have a particularly poor prognosis, especially abused children with head trauma. Active ICP management using the ICP sensor is considered useful. Here, ICP measurements were carried out on an abused child with head trauma and suspected increased ICP, and ICP monitoring was an effective index for drug treatment.

  Blunt vertebral artery injuries are rare. They are difficult to diagnose initially without diagnostic symptoms. However, they may lead to delayed posterior cerebral circulation strokes and serious sequelae. It is necessary to screen such injuries effectively at the initial clinical examination because a delay in diagnosis and treatment may influence the prognosis unfavorably. We report the case of an 84‒year old woman who presented after a motor vehicle accident. She was diagnosed with rt. C2 transverse process fracture with extension into the transverse foramen and rt. blunt vertebral artery injury by CT angiography. Anticoagulation therapy was initiated immediately, but she demonstrated rt. cerebellar infarctions the next day. We then occluded her rt. vertebral artery with endovascular coil embolization.

  While risk of rebleeding after surgical repair of ruptured cerebral aneurysm is known to be rare, it is associated with significant morbidty/mortality. We experienced 4 patients with early postoperative rebleeding after surgical clipping in 420 consecutive cases. Rebleeding after clipping occurred within 7 days in 2 cases, and at around 23‒26 days in 2 cases. Retrospective investigation suggested reasons for early rebleeding included inappropriate closure line in aneurysmal neck clipping, premature rupture, very small aneurysmal size, and vessel branching from the aneurysmal dome. Our results suggest that such aneurysms need careful attention in operative treatment and postoperative observation.

  A 59‒year‒old man who presented with severe subarachnoid hemorrhage was found to have a dissecting aneurysm on the right vertebral artery (vertebral artery dissecting aneurysm, VADA) at the junction of the posterior inferior cerebellar artery (PICA). As an initial treatment to prevent re‒rupture of the aneurysm, a stent‒assisted coil embolization (SAC) was performed. The rupture point was successfully embolized and the patency of the parent vessels was preserved. The patient made steady recovery in the acute phase and was discharged with a modified Rankin Scale score of 1. Three months later, however, a recurrence of the aneurysm was found. This time it was treated radically by occipital artery (OA)‒PICA anastomosis and trapping without any trouble. Ruptured VADA should be treated immediately because of the high risk of rebleeding. SAC to prevent rebleeding is thought to be a reasonable technique in the acute phase in patients with this serious condition because it can preserve the patency of the parent vessels. Although long‒term results and the curative role of SAC remain to be investigated, we believe that it is a useful treatment in the acute phase until radical trapping and revascularization can be carried out in the chronic phase.

  Several recent reports have described the efficacy of mechanical thrombectomy (MT) for large vessel occlusion (LVO) in patients aged ≥ 80 years. However, the efficacy MT in those ≥ 90 years has not been analyzed sufficiently. Here, we report 3 cases of MT in patients aged ≥ 90 years and review specific problems in the very elderly. Case 1 was a 97‒year‒old woman (pre‒stroke modified Rankin Scale [mRS] score, 3) with left internal carotid artery occlusion. National Institute of Health Stroke Scale (NIHSS) score was 25 and the Alberta Stroke Programme Early CT Score‒ diffusion‒weighted imaging (ASPECTS‒DWI) score was 7 on admission. MT was performed using the Penumbra ACE^TM 60 reperfusion catheter and Trevo XP ProVue retriever with local infusion of urokinase, and thrombolysis in cerebral infarction (TICI) 2B was achieved (puncture to recanalization (P2R) 178 min). She was transferred to another hospital 17 days after onset; mRS at discharge was 5. Case 2 was a 98‒year‒old woman (pre‒stroke mRS score, 3) with left M2 occlusion. NIHSS score was 11 and ASPECTS‒DWI score was 7 on admission. MT was performed using the Penumbra 4MAX^TM and Trevo XP3, and TICI 2A was achieved (P2R, 66 min). She was transferred to another hospital 25 days after onset; mRS at discharge was 5. Case 3 was a 94‒year‒old woman (pre‒stroke mRS score, 3) with right M1 occlusion. NIHSS score was 22 and ASPECTS‒DWI score was 10 on admission. MT was performed using the Trevo XP4, and TICI 2B was achieved (P2R, 26 min). She was discharged to home 20 days after onset; mRS score at discharge was 3. In treatment for LVO in the very elderly over 90 years old, rapid and reliable MT using various techniques is important, because artery tortuosity due to arteriosclerosis contributes to difficulty in accessing the occlusion site. In addition, prevention of aspiration pneumonia and intensive systemic management, including atrial fibrillation and heart failure, are mandatory to achieve good outcome.

  Pediatric arteriovenous malformations (AVMs) account for approx. 18%‒20% of all AVMs. Compared to adults, the incidence of bleeding in children with an AVM is high, and rebleeding tends to occur. Surgical removal is thus considered effective as the initial treatment in pediatric AVM cases. We report the cases of three pediatric AVM patients successfully treated by surgical removal after transarterial embolization (TAE). Case 1: A 13‒year‒old male developed an intracranial hematoma in the right occipital lobe and was diagnosed with an AVM (Spetzler‒Martin grade [SMG]: 2) in that lobe. TAE was performed using general anesthesia, followed by complete surgical removal. Case 2: A 9‒year‒old male developed an intracranial hematoma in the right occipital lobe and was diagnosed with an AVM (SMG: 2) in that lobe. TAE was performed using general anesthesia, followed by complete surgical removal. Case 3: A 13‒year‒old female in a state of cardiopulmonary arrest was transported by ambulance. Computed tomography (CT) after resuscitation showed cerebellar and intraventricular hemorrhages, and emergency removal of the hematoma was performed. Based on the results of the subsequent close examination, a diagnosis of a cerebellar AVM (SMG: 4) was made. TAE was performed using general anesthesia, followed by complete surgical removal. In each patient, bleeding during the operation was well controlled, confirming the effectiveness of TAE. In pediatric AVM patients, considering the risk of rebleeding affecting the long‒term prognosis and the plasticity of children’s brain tissue, total resection should be performed whenever possible for the prevention of rebleeding. Surgical resection on the day of embolization is recommended because anesthesia is administered only once.