Doctor helicopters (D‒Helis) have contributed to improvements in the outcomes of emergency patients, not only due to rapid transport to designated institutions, but also due to the treatment provided by crew doctors and nurses. To evaluate the usefulness of D‒Helis in neurosurgical emergencies, we investigated the characteristics of neurosurgical emergency patients who were transferred by D‒Helis to our hospital and the differences in outcomes between patients transported via D‒Helis and those transported via ground emergency medical services (EMSs). We studied patients with traumatic brain injury, cerebrovascular disease, and consciousness disturbance as neurosurgical emergency patients transferred by D‒Helis between July 2015 and September 2017. We investigated the types of diseases, transfer times, Glasgow Coma Scale (GCS) scores, treatments by doctors and nurses of D‒Helis, hospital stays, and modified Rankin Scale (mRS) scores at discharge. We also compared the outcomes of patients transported via D‒Helis with those of patients transported via ground EMSs using statistical analysis. Thirty‒nine (35%) neurosurgical emergency patients of a total of 113 patients were transferred to our hospital by D‒Helis during this period. No differences between the traumatic brain injury, cerebrovascular disease, and unconsciousness groups were found in transfer times and GCS scores. Patients with traumatic brain injury underwent out‒of‒hospital intubation most frequently among the 3 groups, and patients from all the groups were administered medications. No significant statistical differences between D‒Heli transport and ground EMSs were found on patient hospital stays and mRS scores at discharge. However, two cases demonstrated the usefulness of D‒Helis. In these cases, rapid transport of the patient to an adequate hospital and reduction in in‒hospital procedure times after completing a primary survey on the D‒Heli transport may have contributed to favorable outcomes. We are planning another approach to evaluate the usefulness of D‒Helis in the future.
Air ambulances both shorten the delivery time it takes to get patients to a hospital and contribute to the early initiation of medical treatment by the attending physicians. We have created acute stroke diagnosis/treatment procedures that are specialized for air ambulances together with an emergency department, and herein we examined the efficacy of these procedures. Our hospital, has used air ambulances in acute stroke care since April 2011. In our procedure, the air ambulance's flight staff in contact with the hospital confirms the patient's Cincinnati Prehospital Stroke Scale (CPSS) score and the last known time that the patient was observed to be well; the flight staff also collects blood from a secured venous infusion line and conveys the patient information to our hospital staff. On arrival at the hospital, the waiting staff obtains a detailed neurological evaluation and takes the patient directly to a computed tomography room for a CT examination. Other staff simultaneously transports the blood samples to the specimen laboratory. Stroke physicians select the subsequent treatment based on imaging and neurological findings. We examined the proportions of stroke subtypes and the use of intravenous recombinant tissue plasminogen activator (rt‒PA) treatment observed from April 2011 to March 2017. Of the 3,453 air ambulance transfers during the observation period, 531 patients (～15%) were diagnosed as having 'any' type of acute stroke, and 92 patients were treated with intravenous rt‒PA. Our acute stroke diagnosis and treatment procedures using air ambulances was observed to achieve rapid and adequate treatment for stroke patients.
In neurosurgical emergency, minimizing secondary brain injury is important for improvement of functional outcomes, and evaluation and stabilization of the general condition is important as primary treatment for this purpose. However, educational opportunities are limited for nurses to learn how to deal with a neurosurgical emergency and sudden changes in neurosurgical patients. Here, we report a method for training of new nurses in a neurosurgery ward at our hospital, using a Primary Neurosurgical Life Support (PNLS)‒based guidebook. Training of new nurses in the neurosurgery ward was performed three times using the PNLS guidebook, and the level of achievement (self‒confidence) of responses to sudden changes in condition was surveyed using a questionnaire before the first training and after the third training. The results of the surveys before and after training of 7 new nurses who participated in all three workshops were analyzed. The self‒confidence of a ‘response to a sudden change in condition’ significantly improved after training (p＝0.045). The most frequent ‘cause of difficulty in dealing with sudden changes in neurosurgical patients’ was ‘I do not know what is happening’ (57.1%). Training of new nurses using a PNLS guidebook improved self‒confidence in responses to sudden changes in the condition of neurosurgical patients. The reason for the inability of new nurses to deal with sudden changes in condition with self‒confidence was a lack of understanding of the pathology of diseases and sudden changes in neurosurgical emergency cases. Our results suggest that the PNLS guidebook may be a useful tool for training of new nurses in the pathology of diseases associated with neurosurgical emergency and dealing with sudden changes in the condition of patients with these diseases.
We present a case of severe lumbar burst fracture treated with percutaneous uniplanar monoaxial pedicle screw fixation.
A 34‒year‒old woman fell from the third floor and was brought to our hospital in an ambulance. Initial computed tomography revealed a T12 spinous process fracture, L1 burst fracture, and sacral fracture at the S3 level. In addition, a right distal radius fracture and fractures in both calcanei were confirmed. Both lower extremities were numbed by the injury but were relieved within a day. The L1 vertebral body injury had a load sharing classification (LSC) score of 7 points.
Minimally invasive percutaneous pedicle screw fixation was performed, one above and one below the L1 burst fracture, using uniplanar monoaxial screws via the posterior approach. This improved the fragment occupancy rate for the spinal canal from 60 to 16%.
The best treatment for thoracolumbar burst fractures remains a matter of debate. The use of percutaneous pedicle screws for posterior spinal stabilization seems to be an effective method for thoracolumbar fractures. However, polyaxial screws can cause difficulties in obtaining a good correction, because the reduction force cannot be directly transmitted to the fractured vertebra. Percutaneous monoaxial screws are being developed to provide satisfactory reduction. Minimally invasive systems enable a severe burst fracture with LSC score of 7 points that requires anterior reconstruction, as in this case, to be treated with a posterior approach alone.
Ruptured blood blister‒like internal carotid artery (ICA) aneurysms have recently been treated with trapping and high‒flow bypass. Although this treatment is very effective and useful to prevent re‒rupture, there are some concerns related to the surgery; it is time‒consuming and accompanied by a risk of ischemic complications. We introduce the wrap‒clipping technique to treat fragile lesions. This technique can preserve the anterograde blood flow of the ICA. However, the possibility of some stenosis caused by wrap‒clipping should be monitored carefully after the surgery.
Although the trans‒sylvian and subtemporal approaches are used for P2A segment aneurysms, these approaches are associated with temporal lobe damage due to retraction. We have thus decided to use the anterior temporal approach, which enables the acquisition of a wide retrocarotid space with minimum temporal retraction. Here we investigated the problems associated with the anterior temporal approach for P2A segment aneurysms. Between 2012 and 2018, two patients underwent surgery using the anterior temporal approach at our institute. In both cases, the operative corridors were changed from lateral to frontal because of the reduced temporal lobe retraction. Moreover, the high position of the aneurysms required an additional lateral orbitectomy after the zygomatic anterior temporal approach. Although one patient developed a small temporal lobe contusion after the surgery, the aneurysms in both patients were completely obliterated without any additional neurological symptoms. The anterior temporal approach was primarily developed for midline disorders (such as upper basilar aneurysms) and has been useful for the acquisition of temporal lobe mobility with no vessel damage. In these two cases involving high‒position P2A segment aneurysms, the approach was feasible, but the surgical corridor had to be changed from lateral to frontal and an orbitectomy had to be used instead of a zygomatectomy.
The examination of cerebral blood flow (CBF) is very important in patients with occlusion of the internal carotid artery on one side. Single photon emission computed tomography (SPECT) and digital subtraction angiography (DSA) have been used to assess CBF. In this study, we performed cerebrovascular examination to investigate the collateral pathway in patients who underwent SPECT with unilateral internal carotid artery occlusion. We observed the ratio between the contralateral side and the ipsilateral side using quantitative resting CBF. Twenty‒eight patients with unilateral internal carotid artery occlusion (mean age: 69.1 years) underwent SPECT. DSA also showed us the collateral pathway. In the SPECT, the brain was classified into 52 areas by 3D automatic region analysis. In 24 cases, DSA revealed that the collateral pathway included in 79% via the posterior communicating artery, in 71% via the anterior communicating artery, in 42% via the external carotid artery, and in 38% via leptomeningeal anastomosis. In the 28 cases that underwent SPECT, the CBF lowering region was found in the angular gyrus.
Among the ruptured cerebral aneurysms that were embolized by the same surgeon between May 2015 and February 2018 at our hospital, we retrospectively analyzed the 12 consecutive cases with a small ruptured cerebral aneurysm measuring＜3 mm in maximum dimension. The five male and seven female patients’ mean age was 58.7 years. The aneurysms were classified into four types by location: anterior communicating aneurysm in six patients, anterior cerebral artery aneurysm in one, internal carotid aneurysm in two, and vertebrobasilar aneurysm in three. The grades according to the Hunt & Kosnik classification at the onset of aneurysm rupture were Grade I for three patients, Grade II for four, Grade III for two, Grade IV for two, and Grade V for one. Coil embolization was feasible in all patients. Post‒operative angiography revealed complete occlusion in nine patients, neck remnant in two, and dome filling in one. There were no complications related to procedures such as intraoperative rupture. One patient with a basilar tip aneurysm showed recanalization after 1.5 months. One patient with an internal carotid posterior communicating aneurysm showed recanalization after 16 months. Additional coil embolization were therefore performed in these two patients. At 90 days, the mean modified Rankin Score (mRS) was 1.57 (0‒6). However, one patient classified as Grade IV and one classified as Grade V had after‒treatment mRS values of 6 due to pneumonia and initial brain damage, respectively. At follow‒up (mean 19.3 months), no patients required retreatment other than the above‒mentioned embolizations, and no patients had rebleeding or other complications. The use of coil embolization for a small ruptured cerebral aneurysm measuring＜3 mm has become widespread as the development of devices has advanced and small‒diameter coils have become available. More intricate intravascular treatment techniques are now feasible for smaller aneurysms that previously were clipped. Small ruptured cerebral aneurysms rupture more frequently during surgery, and it is therefore advisable to individualize the treatment when coil embolization is used.
Endovascular thrombectomy using a stent‒retriever or aspiration catheter has become the standard treatment for ischemic stroke due to large‒vessel occlusion in the anterior circulation excluding the middle cerebral artery M2 segment. Although some techniques simultaneously using a stent‒retriever and aspiration catheter have been reported, few studies have compared this combined technique with the conventional technique. The present study compared the efficacy of the combined and conventional techniques by occlusion site. The cases of the 51 consecutive patients with occlusion of the anterior circulation treated with endovascular thrombectomy at our institute from August 2014 to December 2018 were evaluated. A stent‒retriever had been used as the first‒line device until August 2017 (n＝31), and then the combined technique was used since September 2017 (n＝20). The clinical outcomes and successful reperfusion rates were compared between the two groups overall and by occlusion site. Overall, the successful reperfusion rate (80% vs. 81%) and favorable outcomes (50% vs. 42%) were similar between the two groups. Although the favorable outcome rate and the reperfusion rate were similar between the two groups for M2 occlusion and other occlusion sites, the procedure time was significantly longer (83 vs. 59 min, p＝0.025) for M2 occlusion and tended to be shorter (58 vs. 68 min, p＝0.078) for other occlusion sites. The combination technique may thus be a promising treatment for acute ischemic stroke due to proximal artery occlusion and may be somewhat inferior for distal artery occlusion.
We retrospectively analyzed the cases of 34 patients (20 males, 14 females; mean age 73.5 years) who were transferred from our hospital to other institutes in an acute phase between January 2017 and September 2018. Thirteen of our 15 acute ischemic stroke patients were transferred as mechanical thrombectomy candidates. Another patient harbored severe carotid artery stenosis with severe bradycardia due to complete atrial‒ventricular block, and was then transferred for emergency pacemaker implantation and carotid artery stenting. Six of the eight intracerebral hemorrhage patients and three of the five patients with moderate to severe head injury were transferred due to the absence of a neurosurgeon, computed tomography, or operating room. Two subarachnoid hemorrhage patients and one arteriovenous malformation patient were transferred for endovascular surgery. The mean duration of transfer was 1 hr 50 min (range 40 min to 2 hr 50 min) when the patient was directly transferred from an emergency room. Two patients were transferred to institutes near their residences and in consideration of their sociological background. After intravascular intervention was introduced at our institute, the number of transferred patients decreased greatly, to five patients. Even though multimodal therapeutic methods decrease the burden of transfer of critically ill patients, rural areas still face low numbers of neurosurgeons and imaging facilities and their stability, and these factors affect the transfer of patients in rural areas with few medical doctors. The local emergency rotation system and patient refusal at some institutes also affected these results.
The understanding of head injuries in various types of sports has progressed in recent years, and the rules for several sports have been revised accordingly. The precise conditions of head injuries in Japanese rhythmic gymnastics have not been clear. We conducted a survey of the concussions experienced by males and females who participated in the SASAKI CUP, a rhythmic gymnastics event. We distributed our survey to 478 individuals who participated in SASAKI CUP 2018, and we received 147 valid responses (30.8%: 72 males, 93 females). The overall average age was 16.4 years (SD = 1.2). Ninety‒three individuals had a medical history of sports injuries, and concussion was reported in four males (five cases) and one female (one case). Three of the males were injured due to landing incorrectly after a somersault, and the fourth male suffered a concussion after an apparatus fell on his head. The single female had hit her head on the floor. After suffering a concussion, all athletes had some symptoms, including headache and dizziness. As with other sports, it is necessary to create a response method after athletes suffer from a concussion during rhythmic gymnastics performance or training, and to create an environment which prevents serious accidents.
The effects of the infusion of prothrombin complex concentrates (PCCs) on warfarin‒related intracranial hemorrhages were evaluated. Over a 10‒year period at our hospital, PCCs were administered for a warfarin‒related intracranial hemorrhage to 38 patients (cerebrovascular disease, n＝21; head injury, n＝17). The following were examined: changes in the prothrombin time‒international normalized ratio (PT‒INR) from before to after the PCC infusion; the correlation between body weight and the PT‒INR reduction rate; hemostasis and rebleeding in emergency surgery cases; hematoma enlargement in conservatively treated cases; and any adverse events. In nine (23.6%) of the patients, the PT‒INR decreased from 2.17±0.54 to 1.37±0.17 at 10‒15 min after PCC infusion. In 10 (23.6%) of the patients, the PT‒INR decreased from 2.97±1.03 to 1.59±0.26 at 1‒3 hr post‒infusion. Sixteen of the 19 emergency surgery cases were completed with no difficulties involving hemostasis or postoperative bleeding. Problems involving intraoperative hemostasis or postoperative bleeding occurred in three patients who had been on antiplatelet drugs. There was no hematoma enlargement in 17 of the 19 conservatively treated cases. The hematoma increased by ＞5 mL in two patients who were taking antiplatelet drugs. A left frontal embolic infarction occurred in one patient (2.6%) at 3 days post‒infusion. The administration of a PCC thus corrected the PT‒INR values of the patients with warfarin‒related intracranial hemorrhages quickly and provided prompt hemostasis. PCCs thus appear to be useful for treating warfarin‒related intracranial hemorrhages.
A 63‒year‒old Japanese man presented to our hospital with left homonymous hemianopia. Initial cranial magnetic resonance imaging (MRI) showed a subacute cerebral infarction in the right temporoparietal lobe. Electrocardiography revealed atrial fibrillation, but a transthoracic echocardiogram did not show any abnormalities. We diagnosed a cardioembolic stroke due to non‒valvular atrial fibrillation, and we initiated direct oral anticoagulant (DOAC) therapy. At 38 days after his first visit to our hospital, the patient experienced right motor weakness, and cranial MRI showed an acute cerebral infarction in the left frontal lobe. A transesophageal echocardiogram showed a mobile mass in the left atrium, suggesting a mobile thrombus. A transesophageal echocardiogram performed 1 month later did not reveal any reduction in the size of the mobile mass. The patient was eventually diagnosed with repeated cerebral embolisms due to a left atrial myxoma. A cardiac myxoma excision was performed, and the patient did not experience any further neurological deterioration post‒surgery. DOAC is increasingly used to prevent embolisms. In patients experiencing repeated cerebral embolisms despite DOAC treatment, drug adherence should be confirmed, and additional assessments including transesophageal echocardiography should be performed.
Anticoagulant therapy for nonvalvular atrial fibrillation in the form of direct oral anticoagulants (DOACs) has been increasingly chosen over warfarin. However, the risk of fatal bleeding in unexpected situations, such as trauma, remains, even with DOACs, which typically have fewer hemorrhagic complications. In this study, we experienced intracranial hemorrhagic complications due to trauma during the oral administration of dabigatran for nonvalvular atrial fibrillation. Because I experienced a corresponding case with the administration of idarucizumab, which is a specific neutralizing agent for dabigatran, we examined the cases of 2 patients who received idarucizumab, and also report on the relevant literature. Case 1: a 86‒year‒old man with bilateral chronic subdural hematoma was treated with dabigatran (220 mg) for atrial fibrillation. After bilateral burr hole drainage surgery was performed, an intracranial hemorrhage was found on CT, and idarucizumab was administered. Case 2: a 76‒year‒old man taking dabigatran (300 mg) for atrial fibrillation was injured in a fall and was transported to the hospital by ambulance. He suffered a brain contusion and CT showed a traumatic subarachnoid hemorrhage, for which he received idarucizumab. The neutralizing effect of idarucizumab on dabigatran is almost 100%, but correct timing of its administration is essential to avoid a high risk of a poor outcome. According to the guidelines, prompt administration of idarucizumab is recommended for fatal bleeding, and in clinical practice, it is necessary to make prompt decisions in order not to miss the critical window of time.
Traumatic true anterior choroidal artery aneurysms are extremely rare, and their treatment strategy remains unknown. We describe the case of a patient with a nondisplaced left‒sided anterior clinoid fracture that was due to a motor vehicle accident. The patient was a 20 ‒year‒old male. The patient's traumatic aneurysm of the left anterior choroidal artery was identified during the examination conducted immediately after his admission to our hospital. The aneurysm was successfully treated with endovascular coil embolization. Careful and repetitive follow‒up imaging should be done in cases with a skull base fracture even if the initial image evaluations are unrevealing. The endovascular approach can be the most minimally invasive option for protecting the aneurysm.
I Ruptured paraclinoid aneurysms can be treated by a microsurgical approach or an endovascular approach. We report here two cases of the successful treatment of a ruptured paraclinoid aneurysm by a planned combined microsurgical and endovascular approach. Patient 1 had a wide‒necked ruptured paraclinoid aneurysm and was successfully treated with neck plasty followed by coiling on the first hospital day. Patient 2 had a poor‒grade ruptured paraclinoid aneurysm and was treated by minimally invasive coiling on the first hospital day, followed by clipping on the 17th hospital day when she recovered from the initial brain damage. Both microsurgical and endovascular approaches have their own advantages and disadvantages. A combined microsurgical and endovascular strategy may reduce the potential risks of each treatment. Our two patients with ruptured paraclinoid aneurysms were successfully treated by a combined microsurgical and endovascular approach.
Pyogenic ventriculitis is a rare but severe cerebral infection. We report a case of severe ventriculitis cured with continuous intraventricular irrigation (CIVI) in an elderly patient. An originally healthy 88‒year‒old male presented with fever, seizure, and consciousness disturbance. Computed tomography of the brain revealed hydrocephalus and ventriculitis, and a systemic examination revealed a pyogenic liver abscess. We performed emergency liver abscess drainage and external ventricular drainage; the drained ventricular fluid was suppurative pus. These findings led us to make a diagnosis of secondary pyogenic ventriculitis following liver abscess. We performed CIVI until postoperative day 8. Culture tests of blood and cerebrospinal fluid samples revealed Klebsiella pneumoniae, and ceftriaxone was administered for 6 weeks. The antibacterial agent had favorable effects against the infection, and a ventriculo‒peritoneal shunt was performed 2 months later. These treatments improved the patient's initial condition. In carefully selected cases, CIVI followed by adequate antibiotic therapy can be effective against severe ventriculitis even in elderly patients.
We report two cases of patients who were first diagnosed as heat stroke and later found out to be subarachnoid hemorrhage. The symptoms of heat stroke and subarachnoid hemorrhage are similar in that they both present with headache and nausea, so it is important to take a detailed medical history and quickly screen for stroke in these cases. For subarachnoid hemorrhage, preventing rebleeding greatly affects the prognosis, so it has to be achieved as fast as possible in primary care. In patients in whom the symptoms are not typical of heat stroke, or if the medical history suggests a subarachnoid hemorrhage, intracranial scrutiny and a consultation with a stroke‒specialized facility should also be considered.
Although the computed tomography (CT) findings of encapsulated acute subdural hematoma (EASDH) are similar to those of chronic subdural hematoma (CSDH), the treatment of EASDH differs from the treatment of CSDH. CSDHs are usually treated by burr‒hole irrigation and drainage, whereas a craniotomy is necessary for the radical cure of an EASDH. Here we report the case of a patient with EASDH, and we describe the difficulties in differentiating his EASDH from CSDH. At 1 week before his admission, a 92‒year‒old Japanese male was suffering from gait disturbance and somnolence. CT revealed a crescent‒shaped subdural hematoma which indicated high density within isodensity. We diagnosed CSDH and performed burr‒hole irrigation and drainage, but the post‒operative CT showed a residual hematoma. We then performed a craniotomy to evacuate the hematoma. The operative findings indicated a jellylike hematoma with a thick outer membrane, similar to a CSDH. His consciousness disturbance was improved, and the postoperative course was uneventful. The characteristics of an EASDH in operative findings would be a thick outer membrane similar to that observed in CSDHs and jellylike hematomas. In such cases, a craniotomy should be considered for the evacuation of the hematoma.