Recent evidence does not support the abnormally high incidence of subarachnoid hemorrhage (SAH) in Finland. A recent meta‒analysis of the worldwide incidence of aneurysmal SAH between January 1960 and March 2017 suggested that the SAH incidence was associated with blood pressure and smoking prevalence. The reported incidence of SAH between 1980 and 2010 declined by 46.2% in Asia, 40.6% in Europe, and 14.0% in North America, but it increased in Japan by 59.1%. However, based on our research, the incidence of SAH in Japan was showing a declining trend. In the Japanese Stroke Databank, Japan’s Diagnosis Procedure Combination (DPC) database, and a meta‒analysis, no significant difference in the rate of poor outcomes among SAH patients at discharge was found between the patients who underwent surgical clipping and those treated with endovascular coiling. Lower in‒hospital mortality was revealed in patients treated with surgical clipping compared to those treated with endovascular coiling by a propensity score‒matched analysis using the DPC database, but the lower rate was not significant by the meta‒analysis. It is important to determine the reason(s) for the high incidence of SAH in Japan, for a better understanding of cerebral aneurysms.

  In Gunma Prefecture, neurosurgeons have led the development of the emergency medical care system, promoting training courses and ensuring tissue plasminogen activator (t‒PA) therapy can be carried out in thirteen different hospitals. Evidence that endovascular therapy is beneficial in large vessel occlusion (LVO) in the brain has been established, and is beginning to be implemented in Japan. The “Basic Act on Cardiovascular Disease Measures” was launched on December 14, 2018 to promote the extension of healthy life expectancy, with Gunma Prefecture’s own policies being designed to enforce the act. We evaluated the quality of paramedic activity by post‒hoc verification in cases diagnosed as stroke, which were transported by ambulance to one of the hospitals using t‒PA therapy between 2015 and 2018. In this paper, we report whether the emergent large vessel occlusion (ELVO) screen can be applied for thrombectomy. Each emergency department carried out primary verification of stroke and the description at time of onset. An integrated medical information system, developed by Gunma prefecture, was utilized from 2017 to record confirmed stroke. The results were verified by the prefecture Medical Control Council. In January 2018, the levels of confirmed strokes, onset time described rate, and strokes determined using the Gunma’s stroke judgment was 81.6%, 75.8% and, 82.5% respectively, with Gunma’s stroke judgment being 97.2% specific and possessing a positive predictive value of 50.8%. These results show that pre‒hospital screens can be introduced to judge LVO. With this in mind, training of paramedics in the ELVO screen has been adopted. Henceforth, it will be necessary to accelerate the development of the emergency medical system with regards to stroke in order to ensure conformation with the Basic Act on Cardiovascular Disease Measurements.

  Our hospital is the only critical care center in an area with a population of 420,000. On weekdays, we operate a physician car in a hospital‒owned rapid response vehicle. Simulation education was introduced because the number of actual on‒site cases is limited to approx. 300 dispatches per year per crew. The simulations include both a real car simulation and a desktop simulation. The real car simulation is for staff who have not yet received any training. Participants in the simulation scenarios (one physician, one nurse, and two emergency room aides) simulate the rapid response process from the dispatch to on‒site activity and finally delivery to the hospital. The participants use both a real physician car and a hospital ambulance. Debriefing and feedback take place after each simulation. The desktop simulation scenarios are for experienced crews. We simulated optimal on‒site activities and gathered the opinions of all participants. During the real car simulations, the participants noted that it was good to experience staffing and treatment procedures in a narrow ambulance. There were also comments that it was good to become acquainted with the equipment. Regarding the desktop simulation, participants said that it was helpful to consider cases they had not yet experienced, in order to be ready for real‒life situations. The real car simulation was necessary for training crews, and the desktop simulation was considered effective for maintaining crew skills. It is important to use both of these simulation methods effectively in order to properly train physician car crews, and to maintain the high quality of medical treatment.

  Our hospital is the only critical care center in a region with a population of 420,000. In 2013, the number of emergency transfers of patients to our center exceeded 8,000/year, and there were many cases of difficulty receiving the emergency transportation. Herein we sought to improve the demand‒and‒supply imbalance of medical resources based on the number of emergency transfers from a number of firefighting areas in our hospital's region. The total number of emergency transfers in each of four firefighting areas in 2011‒2017 and the number of emergency transfers to our hospital were counted: 7,531 in 2011, 7,698 in 2012, 8,348 in 2013, 8,662 in 2014, 7,847 in 2015, 7,175 in 2016, 7,241 in 2017. The emergency transfers from firefighting areas A, C, and D coincided with this transition of the total number of emergency transfers, but in area B only, the number of emergency transfers gradually decreased. Area B patients were transported not only to our hospital but also to secondary medical facilities in the area. The close cooperation of primary and secondary medical facilities is necessary to resolve the imbalance between the demand and supply of medical resources.

  Five guidebooks for Neuroresuscitation Simulation Training were published by Japanese Society for Neurosurgical Emergency, Japanese Society for Neuromedicine, Japanese Association for Clinical Emergency Medicine, Japanese Association for Acute Medicine and Japanese Society for Emergency Nursing since 2006 and a training course based on the guidebooks was developed. A ‘team dynamics’ model from prehospital to in‒hospital was enabled because the physicians, nurses, and paramedics who participated in the training course then had common team‒based knowledge about neuroresuscitation. We classified the four education contents of the five guidebooks as Knowledge/Disease, Technical Skills, Non‒Technical Skills, and Team Dynamics, and we calculated the ratios of the numbers of pages devoted to these four contents of each guidebook. The characteristics of the contents regarding primary neurosurgical life support (PNLS) were then determined, and we discuss the future development of the guidebooks’ contents. Little was said in the guidebooks about Team Dynamics. PNLS and immediate stroke life support (ISLS) accounted for the balance of the four education contents. The PNLS contents focused on the methods of care or treatment of several training cases for each participant (physician, nurse, or paramedic), and the contents were written in accord with the 2015 Japan Resuscitation Council resuscitation guidelines. Regarding PNLS, the contents were well‒balanced and provided sufficient information about team dynamics for each training attendee. For better team dynamics, the training attendees should learn about knowledge/disease and technical skills by e‒learning before taking the PNLS course and then learn about team Dynamics mainly in the training course.

  We hold Immediate Stroke Life Support (ISLS) courses once or twice a year in each prefecture in the northern part of Tohoku. At the same time, an ISLS workshop (WS) is also held. Due to differences in the experience of the participants, the content of the WS could not be fixed. Therefore, we produced e‒learning materials so that participants could engage in self‒learning before the WS in 2014, and we continue to use these materials. The e‒learning content conforms to ISLS Guidebook 2013. It consists of 4 parts; parts 1 to 3 are required, and part 4 is an optional part. The required part includes 7 questions, and the participant brings his or her answer sheet on the day of the WS. The contents of the e‒learning materials are as follows: Part 1) Introduction to ISLS; Part 2) Explanation of the elements of the 4 booths; and Parts 3 and 4) Demonstrations of the facilitation of evaluations of consciousness disorders. On the day of the ISLS‒WS, we teach a facilitation training for one hour. We have been holding the ISLS‒WS using the Akita system since 2014. The WS has been held 22 times, and has had 181 participants. The participants have included 52 doctors (29%), 100 nurses (55%), and 29 paramedics (16%). The correct answer rate for the e‒learning questions is 86%, and there has been no significant difference among the doctors, nurses, and paramedics. The questions with lower rates of correct answers involve “the rule of NIHSS” and the “relationship between simulated patients/facilitators.” The most frequent portion of the training completed was “required part only,” completed by 46% of participants. The most frequent number of learning days was “2‒3 days” at 49%. All respondents answered that “these contents were EASY to understand” in their evaluations. This e‒learning system is a useful tool for the ISLS‒WS, and there have been no problems in instituting it. We think that this system will be spread to other neuroresuscitation simulation trainings.

  Background: Delays in initial treatment or hospitalization have been reported to lead to poor prognoses in patients with a subarachnoid hemorrhage (SAH), and thus the prompt transport of SAH patients to appropriate institutions is required. The stress index (SI, calculated as blood sugar level/potassium level) is thought to correlate with shifts in the catecholamine level of patients with SAH, in whom high SI values have been observed from the early onset period. The SI can be determined from simple examinations such as a blood gas analysis. We examined the usability of the SI in the early diagnosis of SAH.

  Patients and Methods: We retrospectively analyzed the records of 316 patients who were transported to the emergency department of a local core hospital over the 2‒year period from March 2015 through February 2017. Patients were assigned to the SAH group (n＝34) or the non‒SAH group (n＝282), and their background and SI values were compared.

  Results: The SI value was significantly higher in the SAH group than the non‒SAH group (50.8 vs. 38.9, p＜0.001). A receiver operating characteristic curve analysis resulted in moderate accuracy when the SI cut‒off point was set at 44: 70% sensitivity, 73% specificity, and 0.741 area under the curve (95% confidence interval: 0.668‒0.814). A multivariable analysis revealed an SI value that was 9.5‒fold higher in the SAH group.

  Conclusion: Our findings suggest that use of the SI value could contribute to the decision‒making process for SAH at the transfer institution when used in combination with other clinical observations.

  Spontaneous spinal epidural hematoma (SSEH) is a rare disease that presents as an acute onset of myelopathy and back pain without any traumatic event. We retrospectively evaluated the clinical course and treatment outcomes of the cases at our hospital from 2008 to 2019. The average age of the patients (3 males and 9 females) was 70.3 years old (range: 55‒84 years). Ten cases with progressive neurological deterioration underwent emergent surgery the day of admission. The operation resulted in complete recovery in 7 cases, partial recovery in 2 cases, and no improvement in 1 case. The average onset to operation time was 7.8 hours (range: 4‒23 hours). The patients who experienced partial recovery and no improvement were the 3 oldest patients and they showed a wide range of hematomas involving an average of 6 vertebrae. We observed that early operation contributed to neurological improvement, a result that is consistent with previous reports. For SSEH patients, early diagnosis and operation leads to good treatment outcomes.

  ASPECTS+W (Alberta Stroke Program Early Computed Tomography Score, including deep white matter lesions on diffusion‒weighted image) is recognized as a quantitative evaluation index for ischemic lesions before mechanical thrombectomy, and a low ASPECTS+W score indicates a wide ischemic lesion and the likelihood of a poor outcome. However, some cases with low ASPECTS+W scores in which successful recanalization was achieved were reported to show a favorable outcome 90 days after the operation. To determine the factors that make it possible for cases with low ASPECTS+W scores to achieve better outcomes, we retrospectively investigated 27 cases with ASPECTS+W scores of 6 points or less which had acute internal carotid artery or middle cerebral artery occlusion and were treated with mechanical thrombectomy in a single facility. Of these 27 cases, 12 (44.4%) showed a good mRS (modified Ranking Scale) of 0 to 2. None of the factors including age, sex, preoperative NIHSS (National Institutes of Health Stroke Scale), or onset‒to‒recanalization time showed a statistically significant correlation. In 17 cases, an exact onset‒to‒recanalization time was available, and among these cases the median onset‒to‒recanalization time was 166 minutes in cases with good outcomes and 212.5 minutes in cases with worse outcomes (P=0.051). Though the number of cases we investigated was too small to prove which factors lead to better outcomes after mechanical thrombectomy in cases with low ASPECTS+W scores, a short onset‒to‒recanalization time was suggested to be one such factor.

  We investigated the treatment outcomes of internal trapping for preservation of the posterior inferior cerebellar artery (PICA) in cases of a ruptured vertebral artery dissecting aneurysm (rVADA) in 19 consecutive patients (11 men, eight women; 43‒82 years; mean age, 54.7 years) who underwent endovascular treatment for an rVADA during the period January 2004 to June 2018. The preoperative Hunt and Kosnik (H&K) grades were grade III in three cases, IV in ten, and V in six. A positional relationship between the dissection site and PICA bifurcation was observed in seven cases in which the dissection site contained the PICA. The dissection site was distal to the PICA in seven cases and proximal to the PICA in two cases; the PICA was unrecognized in three cases. We performed internal trapping to preserve the PICA, and in the cases with hydrocephalus we performed ventricular or spinal drainage. There were no complications or recurrent bleeding associated with the procedure in any patient. Blood flow in the PICA perfusion area was maintained in 16 cases, and PICA flow was maintained in four of the seven PICA‒involved cases. Outcomes were evaluated based on the modified Rankin scale (mRS) scores at 90 days: score 0 (n＝3 cases), 1 (n＝5), 2 (n＝3), 4 (n＝3), and 6 (n＝5). There were 11 cases (58%) with favorable outcomes (mRS0‒2), and in all the cases, the PICA was preserved or the PICA perfusion area was perfused by the anterior inferior cerebellar artery. The five deaths were severe (H&K grade V) cases. Endovascular treatment for rVADA is useful for preventing recurrent bleeding. Blood flow maintenance in the PICA perfusion area is important for achieving a favorable outcome.

  Reversal strategies for anti‒coagulants are important in the urgent treatment of intracranial lesions. Four‒factor prothrombin complex concentrates (4F‒ PCC) were approved as a reversal agent for vitamin K antagonist (VKA) in September 2017. This study aims to analyze the efficacy and safety of 4F‒PCC in order to propose its optimal usage in urgent treatments based on our experience. We retrospectively analyzed 18 patients with intracranial hemorrhage associated with head trauma or stroke (7 female patients, 74.1±17.2 years old). Surgical treatment was performed in 11 patients. As concomitant therapy, fresh frozen plasma was used in one patient and vitamin K in 9 patients. The effect of 4F‒PCC was considered by comparing PT‒INR and the volume of hematoma using computed tomography (CT) before and after the administration of 4F‒PCC. The mean value of PT‒INR before administration was 2.94, which decreased to 1.35 following the administration of 4F‒PCC (p＜0.001). CT scan revealed no post‒operative hemorrhage in patients who underwent surgical treatment and no increase in the volume of hemorrhage in patients who underwent preservation treatment. No adverse events were observed. Effective and safe reversal of VKA with sufficient hemostasis by the administration of 4F‒PCC was confirmed both in patients who underwent surgical treatment and those who underwent preservation treatment. Although 4F‒PCC is effective in reversing VKA, it remains unclear whether concomitant drugs such as vitamin K or fresh frozen plasma provide a further effect in comparison with the administration of 4F‒PCC alone. Further studies with a greater number of patients and the consideration of concomitant drugs are necessary to fully elucidate the optimal usage of 4F‒PCC.

  An 84‒years‒old Japanese woman with non‒valvular atrial fibrillation who had been prescribed warfarin, underwent surgery for a chronic subdural hematoma. Soon after the surgery, anticoagulation therapy was started mainly with warfarin at the patient’s preoperative dose 1.75 mg considering the high risk of a cerebral embolism. Three weeks later, the chronic subdural hematoma recurred and the patient’s international normalized ratio (INR) exceeded the target level. After normalization of the INR with vitamin K, repeat surgery for the chronic subdural hematoma was performed, and a cerebral infarction was caused by compression of the hematoma. After the repeat surgery, a direct oral anticoagulant (DOAC) (a 30 mg dose of edoxaban) continued to be prescribed, and Two months later, the chronic subdural hematoma had disappeared on CT. Although the optimal perioperative anticoagulation therapy is not established, the early resumption of an anticoagulant has been suggested to be safe. Further observations are necessary to determine whether the INR value influences hematoma recurrence. A DOAC may be useful for patients exhibiting difficulty of INR control. Even when neurological symptoms are slight, the rapid correction of coagulation ability and immediate surgery may be required.

  We report two cases of an intraventricular hemorrhage due to the rupture of an arteriovenous malformation (AVM). An endoscopic hematoma removal and/or a third ventricular ventriculostomy (ETV) were performed in the acute and subacute stages, and through the combination of these therapies good clinical outcomes were obtained. Case 1: A 15‒year‒old Japanese male was referred to our hospital, unconsciousness and with right hemiparesis. Computed tomography (CT) and magnetic resonance imaging revealed a left thalamic hemorrhage extending to the left lateral ventricle, with acute hydrocephalus. A Spetzler‒Martin grade IV AVM was identified at the left basal ganglia with a nidus measuring 5 cm with multiple feeders from the basilar artery, left posterior cerebral artery, and left middle cerebral artery. An urgent endoscopic hematoma removal and endoscopic ventricular drainage (EVD) insertion were conducted to manage the already increased intracranial pressure, followed by an ETV on the 17th postoperative day and intravascular embolization to the feeders on three different occasions in the chronic stage of the illness. Case 2: A‒25‒year‒old Japanese woman became comatose and was transferred to our hospital. CT showed a bilateral ventricular hemorrhage and acute hydrocephalus with a ruptured AVM of the lateral ventricular trigone. Endoscopic hematoma removal, ETV, and EVD insertion were performed in the same setting. On the 3rd postoperative day, three feeders originating from the left posterior cerebral arteries were embolized, and a reduction of the flow of the arterio‒venous shunt was achieved. The EVD was removed after embolization. One month later, stereotactic radiotherapy was performed. There are few published reports regarding endoscopic removal with ETV for an intraventricular hemorrhage due to a ruptured AVM. Although our sample is just two patients, their outcomes indicate that in addition to acute intracranial pressure control, ETV has the advantage of shortening the EVD insertion procedure and the elimination of the necessity of shunting, which may improve patient outcomes.

  A 75‒year‒old man presented to the emergency department with acute‒onset right upper and lower extremity hemiparesis and global aphasia. Initial non‒contrast computed tomography scan showed no evidence of intracranial hemorrhage. Diffusion‒weighted magnetic resonance imaging showed slightly high‒intensity changes in the left temporal, occipital, and parietal lobes without apparent occlusion of the intracranial cerebral artery on magnetic resonance angiography (MRA). Based on an initial diagnosis of acute ischemic stroke, intravenous tissue plasminogen was administered. Computed tomography after intravenous thrombolysis revealed intracranial hemorrhage with depression of consciousness. A retrospective evaluation of the source image of the MRA showed moderately high‒intensity structures in the transverse/sigmoid sinus, suggesting the presence of a dural arteriovenous fistula (DAVF). Isolated sinus type DAVF in the transverse/sigmoid sinus with cortical venous reflux was demonstrated on subsequent cerebral angiography, and endovascular treatment was performed prior to craniotomy for hematoma removal. Non‒hemorrhagic DAVF with cortical venous reflux has the potential to develop into critical intracranial hemorrhage after intravenous thrombolysis therapy, and thus DAVF should be considered a crucial differential diagnosis of stroke mimics in the setting of acute ischemic stroke therapy. An MRA source image is useful for the diagnosis of DAVF, even though a conventional reconstruction image of the MRA shows no apparent findings of DAVF.

  Endovascular treatment for acute large‒vessel occlusion has been widely used, with favorable results. However, in cases with atherothrombotic cerebral infarction, a stent retriever and an aspiration device may not be able to provide reperfusion. Here we report two cases in which an atherothrombotic cerebral infarction was treated successfully using an intracranial stent. Patient 1: A 52‒year‒old man presented with right‒sided paralysis and aphasia. Magnetic resonance angiography (MRA) showed left middle cerebral artery (MCA) occlusion, and urgent endovascular treatment was then performed. While reperfusion was initially obtained using a stent retriever and an aspiration device, re‒occlusion of the MCA subsequently occurred. Due to this recurrence, an intracranial stent was used to treat the occluded MCA. Patient 2: A 78‒year‒old Japanese man presented with transient right‒sided paralysis. MRA showed left MCA stenosis. During hospitalization, the patient developed right‒sided paralysis and aphasia. Repeat MRA showed left MCA occlusion, and endovascular treatment was initiated. Reperfusion could not be achieved using a stent retriever. Subsequently, percutaneous transluminal angioplasty was repeated, but re‒occlusion occurred. Therefore, to successfully achieve reperfusion, an intracranial stent was placed. In both of our patients, the functional prognosis was good. Thus, intracranial stenting can be considered an effective, acute treatment option for an atherothrombotic cerebral infarction.

  For asymptomatic lesions of internal carotid artery stenosis, 80% or more of stenosis lesions in the SAPPHIRE study met the carotid artery stenting (CAS) eligibility criteria. Although CAS is well known for thrombosis caused by devices, along with embolisms caused by plaque splashing, acute carotid stent thrombosis (ACST) is a relatively rare complication, and few cases have been reported. Although its incidence rate is 0.5‒0.8%, and there is no established treatment plan, the possibility of CAS causing a distal embolism is high, and must often be dealt with. Stent occlusion can lead to serious complications, especially if the patient is ischemic intolerant. In this case report, we review the treatment results of two cases with stent occlusion that occurred early after CAS, with bibliographical considerations. Both cases involved 75‒year‒old men. They had asymptomatic lesions that progressed to left cervical internal carotid artery stenosis after 6‒9 years, leading to their referral to our department. CAS was conducted under local anesthesia, and the procedures were completed without incident. Case 1: Stent occlusion was observed 5 days after CAS. Although PTA was carried out to reopen the areas of blockage, the patient also experienced a postoperative cerebral infarction, but was discharged with mRS 1. Case 2: Stent occlusion was observed 13 days after CAS. Although PTA was conducted by the Parodi method and reopened, a large amount of the thrombus was found in the internal carotid artery, resulting in thrombus recovery conducted using a Penumbra 5MAX ACE. The patient was discharged with mRS 0, with no postoperative cerebral infarction. Both cases have progressed successfully without restenosis. It is necessary to carefully consider applicable treatments for asymptomatic carotid artery lesions, both for carotid endarterectomy (CEA) and CAS. If surgical therapeutic intervention is conducted with CAS, it is especially necessary to thoroughly carry out intraoperative procedures and perioperative management, paying careful attention to thrombotic complications, while recognizing that rare complications exist, such as stent premature occlusion due to ACST.

  We report the case of a patient with a dumbbell‒shaped malignant lymphoma of the spinal extradural space and a brain lesion; the patient presented with symptoms of spinal cord compression. The patient was a 66‒year‒old Japanese man who had noticed numbness involving the lower extremities and trunk approx. 2 weeks before seeking medical attention. Spinal MRI revealed a dumbbell‒shaped lesion extending from the spinal canal to the paraspinal space at the T4‒5 level. We made the diagnosis of spinal extradural tumor and then scheduled surgery. Three days before the scheduled surgery, the patient became disoriented and aphasic with right upper limb paralysis. Brain MRI revealed a lesion in the left temporoparietal lobe that was diagnosed as a hemorrhagic infarct; he also developed generalized seizure. The surgery was therefore postponed, and we started treatment for stroke and seizure control. The patient’s paraplegia then progressed rapidly and he developed bladder and rectal dysfunction. A spinal tumorectomy was performed 10 days after the detection of the brain lesion. The tumor was confined to the epidural space, and a gross total resection was successfully performed. The pathological diagnosis was diffuse large B‒cell lymphoma. The brain lesion that was initially diagnosed as a hemorrhagic infarction was biopsied, and the same pathological diagnosis was obtained. Positron emission tomography‒CT revealed multiple lesions. After surgery, chemotherapy was started using methotrexate, and the brain lesions gradually disappeared. Although relief of the spinal cord compression was maintained, the paraplegia persisted and thus the patient was transferred to another center for systemic chemotherapy with the R‒CHOP regimen. A dumbbell‒shaped spinal epidural tumor is generally suspected to be a schwannoma, but early surgery is necessary in some cases (such as our patient’s), and the presence of other malignant lesions should be investigated.