In neuroresuscitation training such as that used to teach primary neurosurgical life support (PNLS), the trainees are physicians, nurses, other medical staff, paramedics, etc. For the implementation of effective training, the concepts used in adult learning are essential. We use a self‒assessment questionnaire that trainees complete immediately before and immediately after attending the training program, with five levels of understanding and feasibility. The results of our last two PNLS courses indicated that it may be necessary when conducting the skill training and discussions to consider the training contents in light of the type of jobs held by the trainees. It is also possible for the course director to adjust the difficulty of the training course based on the trainees’ self‒assessments, and for the trainees to provide constructive feedback and participation by sharing their own knowledge. The trainees can also gauge their own success in the training course and the performance of the course director. The course director can objectively grasp the trainees’ evaluations, and together the questionnaire’s results and the training course evaluations can be used to make the future PNLS training courses more effective.

  Many patients transferred to tertiary critical care centers are due to neurological emergencies. Neurosurgeons are involved in such emergencies, which include not only neurosurgical injuries such as stroke and head/spinal cord trauma but also generalized convulsions and impaired consciousness of various causes. However, in the author’s survey, board‒certified neurosurgeons were found to account for only 3.4％ of staff doctors in emergency medical facilities approved as supervision institutes. The number of specialists in neurological diseases has been decreasing for the last 10 years. Our facility is an independent tertiary critical care center; thus, neurosurgeons work as acute care physicians, unlike in North American‒style emergency room systems. Neurosurgeons are responsible for neurosurgical procedures as well as for the primary care and intensive care unit management of critically ill neurological patients. This role enables prompt decision‒making and definitive treatment in emergencies such as an impending brain herniation or rerupture of a cerebral aneurysm. It is essential to evaluate a neurological patient’s condition using the most advanced monitoring equipment for brain‒oriented intensive care. Therefore, the involvement of neurointensivists, specialists in neurology and intensive care, is warranted. In the United States, the Neurocritical Care Society (NCS) has developed rapidly, and neurointensivists play a central role in the treatment of critically ill neurological patients in conjunction with specialists in related professions. Many researchers have reported the effectiveness of neurocritical care in improving patient outcomes. Double‒boarded physicians in acute care medicine and neurosurgery support the care of patients with neurosurgical emergencies in Japan. With the current decrease in the number of neurosurgeons and emergency physicians, more should be trained in the field of neurological emergencies. Further development of neurocritical care is expected through off‒the‒job training courses in neuroresuscitation simulation training, hands‒on seminars on neurointensive care, seminars on post‒cardiac arrest syndrome, and Emergency Neurological Life Support provided by the NCS.

  It is important for residents in emergency neurosurgical care to experience a variety of common presentations such as trauma or stroke. However, the current postgraduate medical education system in Japan cannot provide sufficient opportunity to educate these residents. A similar phenomenon is also seen in the neurosurgical residency program, especially at some small‒scale hospitals. Our domestic underpopulation crisis will likely worsen this situation. Therefore, an efficient program to educate residents with a smaller number of clinical cases is needed. In order to respond effectively to this situation, the program should not be executed at each institution, but implement measures involving entire districts or the entire country. Medical clinical instructors must attend lectures on effective instruction. Coaching is an effective method of clinical instruction, but may have different effects depending on the skill levels of the residents. Teaching is more appropriate than coaching for trainees with a low skill level. It is crucial that both residents and instructors make every effort to improve their skills and enjoy teaching and learning together in the residency program.

  After two years of neurosurgical training at a university hospital, the author works as a senior resident at a secondary emergency medical facility with 99 beds. Our department primarily treats emergent patients. The total number of emergency cases transported by ambulance is 90.1 patients/month and walk‒in arrivals is 79.1 patients/month after the author’s assignment. Of 389 hospitalized patients, conservative treatment was selected in 322 cases (82.8%), craniotomy was performed in 13 cases (3.3%), endovascular treatment in 18 cases (4.6%), burr hole surgery, in 27 cases (6.9%) and other treatments in 9 cases (2.3%). The rate of surgical intervention before and after the assignment of the author increased from 3.7% of all emergency patients to 4.4%, reaching 5.9% in the latter period after assignment. In addition, 72% of surgeries were performed for emergency patients. We believe that the active acceptance of emergency cases is important in order to increase the number of surgeries. At a small‒scale hospital, even young neurosurgeons can provide consistent medical care from the initial diagnosis of emergency patients to surgery and perioperative management. We believe that working at both large‒ and small‒scale hospitals is effective for young neurosurgeons to master safe and reliable neurosurgical care.

  A helicopter emergency medical service (HEMS) has been widely used for active medical treatment in Japan’s Wakayama prefecture since 2003, but the benefit of this service for individuals with acute ischemic stroke (AIS) transported by the HEMS has not been well examined. Here, we conducted a review of the AIS patients transported to Wakayama Medical University (WMU) from the surrounding rural areas by the HEMS compared with other means of transportation to WMU (i.e., ambulance and walk‒in), between July 2011 and December 2017. The cases of 1,479 patients with AIS were analyzed. Of these, 113 patients (7.6%) were transported by the HEMS, 1,039 (70.3%) were transported by ambulance, and 327 (22.1%) were walk‒ins. The patient age at diagnosis was significantly older in the HEMS group (mean±SD, 79.3±9.34 years). Regarding the cerebral infarction type, the significantly most frequent etiology in the HEMS group was embolic stroke (60.2%). In the walk‒in group, lacunar infarction (51.7%) was the most common etiology. The NIH Stroke Scale value at admission was significantly higher in the HEMS group (mean 15.8±9.01) compared to the other two groups. The HEMS group also had the shortest times from stroke onset to arrival at WMU (mean 210.3±287.1 min) and the highest rates of receiving intravenous recombinant tissue plasminogen activator (17.7%) and endovascular treatment with mechanical thrombectomy (19.5%). With the patients classified based on the seven medical‒care regions in Wakayama prefecture, we investigated the number of AIS patients from each region to WMU by the HEMS. In one region, the majority of patients were transported from a peripheral hospital to undergo high‒quality medical care at WMU via interhospital transfer by the HEMS, at their physician’s discretion. In another region, the majority of the patients were directly transported by the HEMS from the scene of a medical emergency to WMU based on the emergency medical team’s judgement. The reason for requesting the HEMS thus differed markedly depending on the region. Our analyses revealed that the HEMS system in Wakayama prefecture contributed largely to immediate treatment interventions for AIS patients in rural areas. To further improve the treatment systems of the stroke hospitals in Wakayama prefecture, it is important that hospitals maintain flexibility to comply with the needs for the HEMS that differ among communities.

  The aim of this article is to report on activities at the Disaster Medical Assistance Team (DMAT) adjustment headquarters of Aomori prefecture in the 2018 Hokkaido Eastern Iburi Earthquake. Aomori prefecture is a neighboring prefecture across the sea from Hokkaido. Therefor, we adjusted the movement of DMAT on the sea route that we have never experienced before. We assisted the movement of 23 DMAT teams (29 vehicles) to Hokkaido by private ferry. In the future, it was considered necessary to prepare and training on the assumption of movement by sea route.

  Furthermore, the operation of the adjustment headquarters has become possible through the cooperation of neurosurgeons. The number of neurosurgeons involved in disaster medicine is increasing. Particularly in rural areas, neurosurgeons are expected to play an important role in disaster medicine.

  Medical disaster relief activities at buildings that have collapsed are anticipated in the scenarios caused by major earthquakes. For such activities, it is desirable that emergency services and medical teams work together using heavy equipment and carry‒out devices. However, the reality is that it is difficult to secure a site that can be used for the training of emergency teams, and this training has not yet been implemented in many municipalities. Herein, we describe an example of the cooperation between emergency services and a medical team in a disaster‒drill training operation conducted to rescue victims from a ‘collapsed’ building; for the training site, the operation was performed at one of our hospital’s buildings that was in the process of being dismantled.

  Survival curve analyses of patients with a traumatic brain injury (TBI) have shown that the mortality rate after the first 48 hr of trauma is high in the elderly, due mainly to delayed deterioration, or the so‒called “talk and deteriorate (T&D)” status. This study investigated the relationship between coagulopathy and T&D in 270 elderly patients with TBI (154 males, 119 females, 79.0±8.3 yrs old). The patients were assigned to the T&D group (n＝94) and non‒T&D group (n＝176). Clinical indicators were retrospectively compared between these groups, including age, gender, mechanism of TBI, Glasgow Coma Scale (GCS), initial appearance on CT, serum parameters of coagulopathy, Glasgow Outcome Scale (GOS), and more. The patients were also divided based on whether they had been preconditioned by antithrombotic agents, i.e., preconditioned (n＝126) and non‒preconditioned (n＝144) groups for a comparison of their T&D rates. There were no significant difference between the T&D and non‒T&D groups in age, gender, TBI mechanism, or initial appearance on CT. Serum D‒dimer was significantly higher in the T&D group (70.0±86.2 μg/mL) compared to the non‒T&D group (28.2±50.4 μg/mL). The prothrombin time and international normalized ratio (PT/INR) was significantly higher in the T&D group (1.39±0.90) versus the non‒T&D group (1.04±0.22). The activated partial thromboplastin time (APTT) was significantly longer in the patients with T&D (32.0±9.4 s) compared to the non‒T&D group (29.3±5.9 s). The platelet count was significantly lower in T&D (16.6±6.5×10⁴/μL) than non‒T&D (19.5±6.5×10⁴/μL). The serum Na was significantly lower in T&D (138.6±5.0 mEq/L) versus non‒T&D group (140.0±4.2 mEq/L). The deterioration rate was significantly higher in the group of patients preconditioned by an antithrombotic agent than in those who were non‒preconditioned. As the cause of T&D, enlargement of intracranial hematomas was most frequent, but other causes (e.g., cerebral edema, epilepsy, cerebral infarction, and hydrocephalus) were not rare. The GOS was significantly worse in the T&D group compared to the non‒T&D group (p ＜ 0.001). These results suggest that coagulopathy or preconditioning with antithrombotic agents is closely associated with the occurrence of T&D.

  A blast wave (BW) is generated by an explosion and is comprised of a lead shock wave followed by a supersonic flow. In addition to civilian traumatic brain injury (TBI) mechanisms, pressure‒induced damage accounts for the occurrence of blast‒induced TBIs (bTBIs). Fracture, hemorrhage, massive and rapid edema progression, and cerebral vasospasm are the characteristic clinical findings of bTBI in the acute phase, and in the chronic period the characteristic clinical findings are cognitive dysfunction and posttraumatic disorder. Since a BW is invisible and impacts the brain within an extremely short period of time (in contrast to direct‒impact and penetrating mechanism injuries), the victim may not immediately realize that s/he has suffered clinically. There have been few animal models that can be examined in the laboratory and validated in terms of shock wave (SW) physics, and this has hampered the understanding of the mechanisms and pathophysiology of bTBIs. At the Institute of Fluid Science, we have successfully formed organized infrastructures and accumulated knowledge concerning SWs and BWs since the 1980s for both engineering issues and medical applications. Here, we describe the pathophysiology and the mechanisms underlying bTBIs and the current research tasks in the field of SW physics. We also describe the diagnoses of blast injury patients and their treatment.

  When concussion is suspected during contact sports such as soccer, the athlete should not return to play the same day in order to prevent serious injury. The purpose of this study was to identify the rate of sport‒related concussion (SRC) injuries among players in the Japan Professional Soccer League (J League). We carried out a questionnaire survey of J League players to ask about SRC history, mechanisms of SRC, and knowledge of SRC. A total of 92 players from four J League clubs participated in the survey. Of these 92 players, 28 reported a history of concussion, with a total number of 35 concussions. Two players had suffered concussion three times, and three others twice; the remaining players had suffered concussion once. The most frequent mechanisms of injury were head‒to‒ball contact, head‒to‒ground surface contact, and head‒to‒head contact. The concussion rate was higher among high school age players. Physical growth, with the resultant increase in the size and weight of players, is considered to contribute to greater impact, and therefore to SRC in soccer. Most players, including those with a history of concussion, had limited knowledge about concussion. It is essential to strongly emphasize knowledge about SRC by providing concussion education to soccer players and coaches.

  Although subarachnoid hemorrhage (SAH) is associated with high mortality, a missed or delayed diagnosis can sometimes occur. In this study, a group of SAH patients who were not diagnosed at their first visit were analyzed, and their initial status and outcomes were compared with those of a group of correctly diagnosed patients. Between April 2013 and October 2019, 399 patients were diagnosed with SAH at our hospital, and 30 (7.5%) were not diagnosed correctly at the first visit.

  The mean age of these 30 patients was 61 years, and 25 were females (83%). Twelve patients (40%) did not experience headache. Eighteen patients (60%) initially visited a department other than the Department of Neurosurgery because of posterior cervical pain or visual symptoms, which can lead to a delayed diagnosis of SAH. Although misdiagnosed SAH was associated with significantly good World Federation of Neurosurgical Societies (WFNS) grades and modified Rankin scale (mRS) scores at discharge compared with correctly diagnosed SAH, 7 patients (23%) died. All fatalities had experienced rebleeding within 11 days from the onset of SAH.

  Mild or atypical symptoms could be a risk factor for a delayed diagnosis of SAH. It is important to pay attention to these symptoms for an early definitive diagnosis and appropriate therapeutic intervention.

  It is difficult to determine the appropriate treatment for stroke in pregnant women. We aimed to examine and analyze the background, treatment, and outcome of stroke in pregnant women. We retrospectively examined 15 cases of stroke, including 7 cases of intracerebral hemorrhage (ICH), 6 cases of subarachnoid hemorrhage (SAH), and 2 cases of ischemic stroke in pregnant women admitted to our hospital or related facilities. Of the 7 cases of ICH, 2 had cerebral arteriovenous malformation, 1 had cavernous hemangioma, and 1 had hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome. Direct surgery was performed in all 13 patients with either ICH or SAH, and endovascular surgery was performed for the 1 case of ischemic stroke. All of the 5 patients who developed stroke during the third trimester (after 28 weeks) underwent immediate cesarean section prior to neurosurgical treatment. We were able to save the lives of all infants, but two mothers died. The 7 patients who developed stroke before the third trimester (～28 weeks) underwent neurosurgical treatment prior to delivery, consequently saving the lives of all mothers and their infants. Out of the 13 patients with either ICH or SAH, the maternal outcome was good (mRS 0‒2) for 7 (54%). ICH led to poor maternal outcomes. In cooperation with the Department of Obstetrics, we suggest that, in order to achieve good outcomes, neurosurgical treatment is necessary for pregnant women with stroke, taking the method and timing of childbirth into consideration.

  Complex cerebral aneurysms remain difficult to cure even with state‒of‒the‒art cerebral endovascular treatment and craniotomy, and a breakthrough in treatment is awaited. The purpose of this study was to investigate the therapeutic effect and safety of hybrid neurosurgery, which combines direct surgery and endovascular surgery for difficult‒to‒treat aneurysms. Between April 2003 and December 2017, a total of 1140 cases of cerebral aneurysm were treated in our department. Of these patients, the 10 who were treated with hybrid neurosurgery were included in this study. The subjects were 8 women and 2 men with an average age of 59.9 years (27‒72 years). The aneurysms affected the internal carotid artery in 6 cases (the ophthalmic segment in 2 cases, and the cavernous segment in 4), the vertebral artery in 3 cases, and the posterior cerebral artery in 1 case. The average maximum diameter of the aneurysm was 18.2 mm (4.5‒30 mm). In direct surgery, 6 patients underwent high blood flow bypass using the radial artery and 4 underwent low blood flow bypass using the superficial temporal or occipital artery, and internal trapping was then performed by endovascular surgery or aneurysm coil embolization. Complete obliterations were achieved in all cases. Exacerbation of postoperative symptoms was observed in only one case (preoperative modified Rankin Scale [mRS] 0 → postoperative mRS 1). The median follow‒up period was 123.5 months (32 to 184 months). There was no recurrence in any of the 10 cases and mRS scores were 0‒1 in 8 cases, 2 in 1 case, and 3 in 1 case. These results suggest that hybrid neurosurgery is a highly effective and safe treatment for difficult‒to‒treat aneurysms.

  Our institution (Nihon University Itabashi Hospital) is designated as a pediatric emergency center by the Tokyo Metropolitan Government. The incidence of pediatric stroke is rather low. Here, we examined the outcomes of pediatric stroke at our emergency center. Between 2013 and 2018, 13 stroke patients were admitted to our hospital’s Pediatric Emergency Center. The following clinical data were evaluated: age, diagnosis, level of consciousness, intraventricular hemorrhage (IVH) volume, and Pediatric Overall Performance Category (POPC) at discharge. The IVH volume was estimated from the Graeb score. The patients were seven males and six females ranging in age from 0 to 14 years (mean: 9 years). Six patients had a ruptured arteriovenous malformation (four cases with an intracerebral hemorrhage [ICH], and two cases with an ICH and IVH), five patients had ruptured aneurysms, one patient displayed intraventricular hemorrhage of unknown origin, and one patient was diagnosed as having experienced a cerebral infarct. The median score on the Japan Coma Scale was 100. We performed emergency surgery in six hemorrhagic stroke cases; one other patient was transferred to another hospital due to operation room limitations. Four patients were POPC 1, two patients were POPC 3, two patients were POPC 4, two patients were POPC 5, and three patients died from the initial severe IVH or ICH. The median POPC score was 3 at discharge. The patients who had a poor prognosis with a POPC score of 5 or 6 at discharge exhibited severe IVH such as a high Graeb score. Hemorrhagic stroke was evident in the majority of the pediatric patients with stroke at our pediatric emergency center. Our findings suggest that pediatric patients who have a severe IVH tend to show a poor prognosis at discharge.

  In the treatment of acute ischemic stroke, it is important to start the administration of tissue plasminogen activator (tPA) and mechanical thrombectomy as soon as possible. We created an acute stroke medical treatment algorithm that we named ‘stroke scramble’ which accelerated the pre- and in-hospital cooperation and began using it in February 2015. After the introduction of this algorithm, an ambulance staff, an emergency outpatient nurse, a radiologist, and a nurse in charge of the angiography room each devised a way to further shorten the length of time before the administration of tPA and the start of mechanical thrombectomy. We also began using the GAI₂AA scale in March 2017, and in cases in which the GAI₂AA score was ≥ 3 points, we confirmed that there was no bleeding by CT and then skipped the MRI and took the patient to the angiography room. As a result, it was 27 min before the administration of tPA and 56 min before the start of mechanical thrombectomy. In conclusion, tPA treatment and mechanical thrombectomy can be started sooner by evaluating the patient’s status based on the pre-hospital information obtained from the ambulance team, scoring the GAI₂AA, and preparing the in-hospital cooperation system before patient’s arrival.

  To reduce the interval time from stroke onset to reperfusion, CT perfusion imaging is used at our institution to evaluate the application of reperfusion therapy for ischemic stroke patients within 6 hours from onset. An optimal workflow and process‒based performance is required for successful reperfusion therapy and the reduction of the interval time. In this study, we analyzed the effectiveness of our workflow and process‒based performance for CT‒based thrombectomy. We compared patients who underwent CT‒based thrombectomy using the workflow and those who underwent MRI‒based thrombectomy. We also investigated factors associated with time delay. Compared to MRI‒based thrombectomy, CT‒based thrombectomy using the workflow significantly reduced the door‒to‒puncture (D2P) time (CT: 39 min; MRI: 72.1 min; P＜0.05), door‒to‒recanalization (D2R) time (CT: 64 min; MRI: 79 min; P＜0.05), and puncture‒to‒recanalization (P2R) time (CT: 26 min; MRI: 39 min; P＜0.05). These results demonstrate that our workflow and process‒based performance for CT‒based thrombectomy is effective for reducing the interval time from onset to reperfusion in ischemic stroke patients.

  In our hospital, we retrospectively assessed the effects of using mechanical thrombectomy among the elderly patients (aged 90 years or older) as well as the route of nutrition administration at the time of discharge. From January 2015 to December 2018, we focused on the 18 elderly patients who underwent acute recanalization therapy: 7 males and 11 females (average age, 92.3 years old; mRS3‒5 in 8 cases (44.4%) before onset). The occlusion sites were ICA in 7 cases (38.9%) and MCA in 11 cases (61.1%). In regard to the treatment used, the following were administered: IV‒tPA in 8 cases (44.4%), SR in 9 cases (50%), SR＋Penumbra in 8 cases (44.4%), and SR → PTA in 1 case (5.6%). The recanalization rates were 100% for TICI2b‒3 in 18 cases (100%), 83% for mRS3‒5 in 15 cases, 0% for mRS6 in 0 cases (0%), and 16.7% for mRS0‒2 in 3 cases at discharge. The DTP average was 67.8 minutes and PTR average 81.4 minutes. In 11 cases (61.1%), the nutrition administration was done orally. Among elderly patients who underwent mechanical thrombectomy, the pre‒symptomatic mRS3‒5 and recanalization rates were high. Furthermore, we believe it is necessary to obtain cases of acute cerebral infarction among the elderly patients to judge the indication, although it is important not to limit the indication by age alone.

  The recurrent bleeding rate and mortality rate of ruptured vertebral artery dissecting aneurysms are high. We investigated the surgical outcomes of ruptured vertebral artery dissecting aneurysms treated by direct surgery or endovascular treatment during the period April 2004 to September 2019. In our hospital, craniotomy was the first choice for treatment during the years 2004‒2016, and endovascular treatment has been the first choice since April 2016. In 2004‒2016, direct surgery was performed in eight patients. From April 2016, endovascular treatment was performed in four patients. Almost all patients showed a poor preoperative World Federation of Neurosurgical Societies (WFNS) grade, which made it difficult to compare the patients in prophase and in anaphase. In the anaphase group, we performed proximal occlusion as endovascular treatment for one patient (posterior inferior cerebellar artery [PICA] involved type) and internal trapping for three patients (PICA distal type). One patient experienced a lateral medullary infarction, but there has been no case of recurrent bleeding. We speculate that proximal occlusion as an endovascular treatment for PICA involved ruptured vertebral artery dissecting aneurysms is useful for preventing ischemic complications and re‒rupture.

  The goal of treating acute cerebral large‒vessel occlusions is to rescue the penumbra, and the evaluation of the penumbra is one of the important factors for effective thrombectomy therapy. A penumbra can be assessed using modalities such as MRI and CT, and many facilities in Japan perform MRI as an initial imaging examination for acute cerebral large‒vessel occlusion. Here, we evaluated penumbras by using the diffusion weighted imaging‒fluid attenuated inversion recovery vascular hyperintensity (DWI‒FVH) mismatch. We retrospectively analyzed 41 cases of acute middle cerebral artery (M1) occlusion treated between July 2015 and October 2019. The region of T_max ＞ 6 sec in CT perfusion (CTP) was used as the penumbra. The cases in which the regions of FVH and T_max ＞ 6 sec were outside the DWI high‒intensity area were defined as mismatch positive(+), and we compared the rate of mismatch(+) between the two groups. The cerebral cortex in the M1 region was classified into seven regions (the insula and M1‒M6), and the cases in which there were regions of FVH and T_max ＞ 6 sec were defined as positive. We next investigated whether the positive percentage in each region was the same between the two groups. The degree of recanalization in thrombectomy therapy was evaluated by the Thrombolysis in Cerebral Infarction (TICI) score, and the relationship between DWI‒FVH mismatch and the modified Rankin Scale (mRS) score was evaluated when good recanalization (TICI 2b or 3) was obtained. The relationship between DWI‒FVH mismatch and DWI‒CTP mismatch had 94.3％ sensitivity and 66.7％ specificity. Regarding the relationship between FVH and T_max ＞ 6 sec in each region, no significant difference was found in the percentage of positivity in any region. In the cases with an mRS score of 0‒2 after thrombectomy therapy, the DWI‒FVH mismatch(+) rate was 48.3％ and the DWI‒FVH mismatch negative(‒) rate was 20.0％ , revealing a significant difference. Thus, no significant difference was revealed in the visualization of FVH and T_max ＞ 6 sec regions in acute M1 occlusion. By using the DWI‒FVH mismatch, a penumbra can be evaluated and a good outcome can be predicted.

  In Japan, the treatment for ruptured aneurysms is coil embolization in approx. 40% of the cases and clipping in the other － 60%, but this treatment‒selection ratio differs greatly depending on the hospital. Here, we describe our experience treating ruptured aneurysms with the goal of determining the appropriate treatment ratio. We retrospectively analyzed the cases of the total of 107 consecutive patients with ruptured aneurysms treated at our hospital from 2015 to 2018. Aneurysms with a massive intracerebral hemorrhage (ICH) were immediately treated with clipping. Those without a massive ICH were immediately examined by digital subtraction angiography (DSA) under general anesthesia, Endovascular treatment was considered the primary option for all aneurysms without massive ICH. The choice of modality was based mainly on the overall complex architecture of the aneurysm, and not on age or SAH grade. Aneurysms determined to be suitable for either technique were treated with coiling. Clinical variables were compared between the coiling and clipping groups. Coiling was performed in 38 patients (35.5%) and clipping in 69 (64.5%). Despite the high percentage of patients with a World Federation of Neurosurgical Societies (WFNS) grade of 4 or 5 (55.1%), the percentage of favorable outcomes (modified Rankin scale, 0‒2) at 3 months after onset was high (60.7%) in the total patients. In‒hospital re‒rupture occurred in four patients (3.7%), but not during DSA. Our hospital's first‒aid system and our treatment of choice for ruptured aneurysms are acceptable because their re‒rupture rate was low and the overall treatment results were good.

  A 68‒year‒old man was admitted to our Department of Orthopedics for gait disturbance and underwent laminectomy for spinal canal stenosis. However, his symptoms did not improve after surgery, and a computed tomography (CT) scan revealed idiopathic normal pressure hydrocephalus (iNPH). We planned to place a ventriculoperitoneal (VP) shunt but the patient had a fever before the surgery could take place. He was then diagnosed with acute cholecystitis and cholecystectomy was performed. The VP shunt for iNPH was placed after the patient’s cholecystitis improved. A laparoscopic procedure was used because of malabsorption and malposition of the peritoneal tube due to adhesions of the peritoneum. All of the patient’s symptoms resolved and he was discharged without any complications. Laparoscopic assistance is useful for peritoneal tube placement with V‒P shunting in patients with peritoneal adhesions.

  In traumatic brain injury, especially in serious cases, brain perfusion may decline and brain hypoxia may occur immediately after an injury. These symptoms are likely to enhance secondary brain injuries such as cerebral edema and cerebral hemorrhage. Therefore, an estimation of brain perfusion during the patient’s initial scan is crucial to predict his or her outcome. Single‒photon emission computed tomography is a traditional method for assessing perfusion and, more recently, arterial spin labeling (ASL) has been proposed as a non‒invasive perfusion technique using magnetic resonance imaging (MRI). ASL can be applied even in acute stages. In patients with mild or moderate brain injury, we have detected abnormal brain perfusion on initial MRI including ASL. In one of our two patients, ASL findings suggested low brain perfusion derived from traumatic cerebral vasospasm due to a mechanical injury of the vessel wall. Using ASL, we diagnosed the patients rapidly and were able to provide appropriate treatment. 1) We also used ASL in these patients’ follow‒up examinations. 2) ASL has traditionally been used for follow‒up examination.. The MRI protocol including ASL provides not only anatomical imaging but also perfusion imaging. ASL is highly useful in the acute clinical field.

  A transorbital penetrating injury by a foreign body is a rare type of head injury. Here, we report a patient with a transorbital penetrating skull‒base injury caused by the broken blade of a lawn trimmer. A 69‒year‒old male presented to our emergency room with a ruptured right eye globe. A skull X‒ray revealed multiple foreign bodies (metal fragments) in the right orbital region, right buccal cavity, and right frontal lobe. Head computed tomography (CT) revealed an asymptomatic chronic subdural hematoma on the left side and two foreign bodies in the right frontal lobe. Ophthalmologists removed the metal fragments from the orbital cavity, and neurosurgeons then removed the intracranial foreign bodies by right frontotemporal craniotomy. Because the foreign bodies were assumed to be anterior to the insular gyrus, the Sylvian fissure was opened and excised via a retrograde transcortical approach. The intracranial foreign bodies were identified as a bone fragment and a trimmer blade. Fluoroscopy was useful to confirm the location of the intra‒orbital foreign body, and ultrasound helped to identify the location of the intraparenchymal foreign bodies. The patient had an uneventful postoperative course with no sign of meningitis and no seizures. Although transorbital penetrating head injuries are rarely encountered in daily medical practice, it is necessary to have the appropriate system and mindset to treat them promptly when they appear.

  An 89‒year old woman presented with acute onset of right hemiparesis and right arm pain. Although a head MRI examination conducted 2 hr after the onset showed no ischemic lesion, she was suspected to have experienced an acute cerebral infarction. Because serial head MRI showed no ischemic lesion, cervical MRI and CT were performed and revealed calcification of the ligamentum flavum (CLF) at the C3/4 level. She immediately underwent posterior decompression, and her neurological deficits improved. CLF in the cervical spine usually causes a gradual development of myelopathy. However, CLF rarely causes an acute onset of hemiparesis like cerebrovascular decease.

  As populations worldwide continue to age, the number of fractures in the vulnerable elderly is increasing. We report the case of an elderly patient with atlantoaxial dislocation that we corrected with cage insertion into the lateral atlantoaxial joints. The patient was an 87‒year‒old female who experienced neck pain for 11 months before coming to our department. The previous physician had diagnosed type II odontoid fracture and recommended halo vest fixation, but the patient rejected this option and chose cervical collar fixation. She also had a 2‒month history of skillful movement disorder in both hands, and gait disturbance. The imaging study on admission revealed that the displacement of the odontoid fracture had worsened, and spinal cord compression due to atlantoaxial dislocation was observed at the atlas. We performed surgery for C1‒C2 internal corrective fusion with an intra‒articular cage. The postoperative course was uneventful. The patient’s neurological condition also demonstrated acceptable recovery. In general, posterior correction for atlantoaxial subluxation is performed by the rod‒and‒screw pull‒up method, but in osteoporotic patients that method might cause an unexpected fracture or screw loosening. Our lift‒up method with an intra‒articular cage achieved the correction more safely. A careful image analysis of vertebral arteries should be conducted before surgery in such cases, and the safe exposure of the lateral atlantoaxial joints must be ensured.

  An endodermal cyst (EC) is typically a benign tumor that can affect the craniospinal axis. A 43‒year‒old man presented with sensory disturbance in an upper extremity and occipitalgia. Magnetic resonance imaging (MRI) revealed a multicystic tumor at the C2 level with enhancement along the ventral surface of the spinal cord. Blood tests showed an abnormal elevation of serum carbohydrate antigen 19‒9 (CA 19‒9). Systemic positron emission tomography‒computed tomography showed normal findings. We performed a total tumor resection, and the tumor was diagnosed pathologically as EC. The patient sustained double vision, hearing loss, and swallowing difficulty on postoperative day 70. MRI taken on day 86 revealed extensive leptomeningeal dissemination. The serum CA 19‒9 level elevated continuously and finally reached 1,515.0 U/ml. On day 108, the patient died of respiratory failure. The autopsy did not reveal any abnormalities in the abdominal or chest organs. Microscopic examination of the leptomeningeal disseminated foci revealed an adenocarcinoma. Both the surgical and autopsy specimens stained positively for CA 19‒9. Spinal ECs may lead to malignant transformation and leptomeningeal dissemination that causes an abnormal elevation of the serum CA 19‒9 level.

  The efficacy of a mechanical thrombectomy for acute large‒vessel occlusion has been reported. Rapid revascularization can provide a good outcome, and the time window for the thrombectomy can be extended to 16 or 24 hours. There appears to be no prior report of an emergency anastomosis after an unsuccessful thrombectomy. We report the case of an emergency superficial temporal artery‒middle cerebral artery (STA‒MCA) anastomosis for MCA occlusion, conducted 4 hours 28 minutes after an unsuccessful emergency thrombectomy had been performed in a 49‒year‒old Japanese man with right hemiparesis and aphasia. Endovascular thrombectomy was initiated and reperfusion was obtained in 1 hour 49 minutes after onset. His symptoms improved remarkably. However, re‒occlusion occurred immediately following reperfusion and symptoms worsened again. Subsequently, endovascular treatment was repeated, but recanalization was not achieved. After 6 hours 2 minutes from onset, we decided to transfer performing emergency STA‒MCA anastomosis to prevent irreversible cerebral ischemia. Postoperative angiography confirmed good revascularization. Neurological deficits recovered and remained slight motor aphasia and right upper limb paralysis. This case demonstrates that an emergency anastomosis is an option for unsuccessful thrombectomy cases.

  We report a case of a 44‒year‒old woman, who experienced a sudden loss of consciousness. Upon contact with the ambulance crew, her condition was scored as III‒300 based on the Japan Coma Scale. No pulse was detected in the radial artery due to ventricular fibrillation. She was successfully resuscitated with cardiopulmonary resuscitation, after which she arrived at our hospital by ambulance.

  Head computed tomography revealed a subarachnoid hemorrhage, tapering of the left vertebral artery, with a string‒of‒beads sign, and wall irregularity after the bifurcation of the subclavian artery; the tapering of the intracranial vertebral artery was detected at points both proximal and distal to the posterior inferior cerebellar artery. At admission, she was diagnosed with subarachnoid hemorrhage due to vertebral artery dissection, including posterior inferior cerebellar artery bifurcation associated with fibromuscular dysplasia (FMD). We performed left vertebral artery occlusion using an endovascular procedure.

  She was discharged for home with a modified Rankin scale score of 2. Twenty‒one months after the onset of this event, no new vascular lesions were detected using magnetic resonance angiography in the head or neck.

  Although vertebral artery dissection associated with FMD requires some additional consideration because lesions may be found in the endovascular access route, we believe that vascular occlusion is as effective in these cases as it is in patients without FMD.

  Microsurgical clipping during cerebral vasospasm (CVS) results in poor outcomes; however, treatment by coil embolization (CE) and angioplasty has shown favorable results. We report three cases of ruptured cerebral aneurysm and CVS that were simultaneously treated. Case 1: A 60‒year‒old woman experienced a headache a week prior to admission and, on the day of admission, exhibited weakness in her left and lower limbs as well as dysarthria. Head CT showed subarachnoid hemorrhage (SAH), and 3‒dimention CT angiography (3D CTA) showed a right middle cerebral artery (MCA) aneurysm with a maximum diameter of 8.1 mm and a broad neck, and CVS was found in the horizontal segment of the right MCA (M1). CE of the cerebral aneurysm as well as arterial infusion (I.A.) of fasudil hydrochloride and percutaneous angioplasty (PTA) for CVS was performed on the day of the visit. Due to the remaining neck of the cerebral aneurysm, we performed clipping on day 27, and she was discharged without any neurological deficits. Case 2: A 45‒year‒old woman was admitted to the hospital 5 days after she experienced an occipital headache. 3D CTA showed an aneurysm in the right MCA and CVS in M1. The cerebral aneurysm had a small upper and lower component 4 mm across M1. After performing PTA on stenosis, CE was performed on the lower component that seemed to be ruptured. Since the upper component may have also been ruptured, clipping was performed on day 36, and the patient was discharged without any neurological deficits. Case 3: A 44‒year‒old man was admitted to the hospital 3 days after experiencing a headache and vomiting. 3D CTA showed a bifurcation aneurysm in the left MCA with a maximum diameter of 5.3 mm and CVS in M1. On day 6, CE of the cerebral aneurysm as well as I.A. fasudil hydrochloride and PTA for CVS was performed. The following day, he experienced mild aphasia and right paralysis; however, after receiving I.A. fasudil hydrochloride, his neurological symptoms improved, and he was discharged. We report three patients who underwent CE during CVS. It is often difficult to cure MCA aneurysm by CE. As a result of performing intentional staged treatment in 2 cases, good therapeutic results were obtained.

  The optimal treatment strategy for internal carotid artery (ICA) stenosis associated with moyamoya disease has not been fully established. There are few reports of endovascular angioplasty for this condition, and the outcomes suggest that this procedure is not recommended. We report a case of endovascular angioplasty for stenosis of the petrous segment of the ICA associated with moyamoya disease and ischemic stroke. The patient was a 78‒year‒old Japanese man who presented with conjugate eye deviation to the left, aphasia, severe right hemiparesis, and left lower extremity paresis after the gradual deterioration of a gait disturbance. Brain magnetic resonance imaging revealed an acute brain infarct in the left internal capsule with no involvement of the cerebral cortex. Magnetic resonance angiography showed poor blood flow in the left ICA, the left middle cerebral artery, and the bilateral anterior cerebral arteries. Angiography revealed a severe stenotic lesion in the petrous segment of the ICA, for which we attempted endovascular angioplasty. Despite repeated percutaneous transluminal angioplasty (PTA), refractory restenosis and dissection developed. However, a favorable angioplasty outcome was obtained using the Neuroform Atlas stent system (Stryker Neurovascular). Although blood flow distal to the stenotic lesion improved, the flow beyond the terminal segment of the ICA remained poor and typical moyamoya vasculature was seen around the basal ganglia. We then suspected moyamoya disease or moyamoya syndrome. The patient’s symptoms improved rapidly after this treatment. Angiography 1 month after the first treatment showed restenosis inside the stent, so we performed a repeat PTA. Restenosis reoccurred 3 months after the second treatment, and it was treated with the placement of a drug‒eluting stent within the Neuroform Atlas. Moderate restenosis was seen on angiography after the final treatment, but there was no recurrence of ischemic attack. In endovascular angioplasty for ICA stenosis associated with moyamoya disease, close observation is required because repeated recurrence after treatment often occurs.

  The optimal strategy for treating tandem lesions with obstruction that is distal and proximal to the ipsilateral vasculature is controversial. We report a case of acute ischemic stroke (AIS) in a 60‒year‒old man who was admitted to our hospital with tandem lesions. Upon his arrival, we observed right‒sided paresis and motor aphasia. His score on the National Institutes of Health Stroke Scale (NIHSS) was 8. An acute cerebral infarction had been caused by occlusion of the M2 segment of the left middle cerebral artery and by an ipsilateral occlusion of the internal carotid arteries. We diagnosed the infarction as tandem lesions. Cerebral angiography was performed, and thrombolytic therapy was given, and the patient’s neurological deficit disappeared the day. Antiplatelet drug therapy was then started. The patient’s medical history included ipsilateral oropharyngeal cancer radiotherapy, and his left internal carotid artery severe stenosis was thought to be a result of this treatment. On the fourth day after the patient’s AIS onset, consciousness disorder, right‒sided complete paralysis, and global aphasia suddenly appeared. Emergency MRI revealed occlusion of the M1 segment of the left middle cerebral artery. The patient’s NIHSS score was 17. Endovascular treatment was selected because the patient could not undergo thrombolytic therapy. First, the occluded blood vessel was expanded to a minimum width; a device was passed through to reopen the proximal occluded blood vessel. After reperfusion of the M1‒2 segment with a mechanical thrombectomy, a stent was placed in the internal carotid artery with a distal protection device, and good patency was obtained. Postoperatively, signal changes were observed in the basal ganglia on diffusion‒weighted imaging, but the neurological symptoms were improved (Modified Rankin Scale score, 1), except for motor aphasia and mild neurological dysfunction. On day 26 after AIS onset, the patient was discharged from our hospital for further rehabilitation. The use of the combination of a mechanical thrombectomy and carotid artery stenting was an effective strategy for this patient’s tandem lesions that were caused by the artery‒to‒artery embolism from arteriosclerotic carotid artery stenosis and the resultant cerebral infarction.

  In treatments for vertebral artery (VA) lesions involving the origin of the posterior inferior cerebellar artery (PICA), known as PICA‒involved lesions, various methods have been attempted to preserve the PICA. We report a case of subarachnoid hemorrhage from an atypical lesion of the VA around the origin of the PICA, which was treated by internal trapping with stent placement. A 62‒year‒old woman with occipital headache and vomiting was admitted to our hospital. A computed tomography (CT) scan revealed a subarachnoid hemorrhage primarily in the posterior fossa. Cerebral angiography showed no apparent bleeding source such as an aneurysm or dissecting lesion, but extravasation of the contrast medium was seen around the right VA with no connection to the subarachnoid space. The extravasation disappeared on left VA angiography with interruption of the right VA blood flow by a balloon catheter placed just proximal to the origin of the PICA. We attempted treatment for this right VA lesion similar to that for a PICA‒involved lesion. The next day, we placed an external ventricular drain and performed endovascular therapy with internal trapping by coil embolization just proximal to the origin of the PICA after placing a stent in the range of the PICA and distal VA across the VA union via the left VA. Post‒treatment left VA angiography showed that the extravasation had disappeared with preservation of the blood flow of the right PICA. The patient was discharged home with a modified Rankin Scale score of 0. We believe that a tiny aneurysm and dissecting lesion had occulted and a pseudoaneurysm had formed through a fistula to the exterior of the artery. We achieved complete cure and control of the bleeding source at the VA with preservation of the PICA by internal trapping and stent placement in the range of the PICA and distal VA via the contralateral VA. We consider this method to be superior to direct surgery with regard to both surgical invasiveness and technical difficulty, although there is some risk of thrombotic complications during the perioperative period.

  A blunt traumatic carotid artery injury is often associated with multiple traumas, and can cause a brain infarctions in the delayed phase, and it is crycial to diagnose and treat this injury without delay. We report four cases of blunt carotid artery injury, including descriptions of the carotid artery dissection. The effectiveness of antithrombotic therapy, and the period of carotid artery stenting (CAS) in each case are addressed. (1)A 44‒year‒old male suffered systematic injuries at traffic accident. On hospitalization day 12, computed tomography revealed a left internal carotid artery dissection. (2)A 56‒year‒old male suffered a right common carotid artery dissection due to a traffic accident. (3)A 37 year‒old male with systematic injury suffered left internal carotid artery dissection. (4)A left carotid artery dissection was detected 6 months after an injury in a 53‒year‒old female. In the acute phase when there was a risk of hemorrhage from an accompanying injury, anticoagulant therapy with intravenous heparin was administered for stroke prevention. We started antiplatelet therapy when the hemorrhage risk became sufficiently negligible, and CAS was planned. In all four cases, no brain infarction was observed after the CAS. For patients with a blunt carotid artery injury, early treatment by CAS is effective to prevent brain infarction.

  The origin of the posterior inferior cerebellar artery (PICA) varies, and it is possible for the PICA to share a common origin with the anterior spinal artery (ASA). Double origin of the PICA (DOPICA) is an extremely rare variation and is closely associated with aneurysm and dissection. We report a case involving an ASA aneurysm associated with DOPICA treated by coil embolization. An 83‒year‒old Japanese woman with severe occipital headache and nuchal rigidity was admitted to our hospital. A computed tomography (CT) scan demonstrated a mild supratentorial subarachnoid hemorrhage. Cerebral angiography had shown no apparent bleeding source, and we thus initiated conservative therapy. At 14 days after admission, the patient developed a severe consciousness disturbance with a Glasgow Coma Scale score of 3; further CT revealed a severe subarachnoid hemorrhage mainly in the posterior fossa, with hydrocephalus. An external ventricular drain was placed, and the subsequent angiography of the left vertebral artery (VA) revealed an aneurysm below the VA union. The PICA and ASA were seen to bifurcate from the neck of the aneurysm. Another branch of the PICA was seen as the terminal branch of the right VA, and there was no connection between the distal end of the right VA and the VA union. These two anomalous branches of the PICA were confluent and together supplied the right inferior aspect of the cerebellar hemisphere. These anatomical structural findings were highly suggestive of DOPICA. We opted to perform endovascular coil embolization of the ruptured aneurysm. Briefly, the left brachial artery was punctured, the aneurysm was approached through the VA union via the left VA, and the coil embolization was performed. A ventriculoperitoneal shunt was inserted, and the patient was transferred to another hospital; her modified Rankin Scale score at discharge was 5. We presume that the occlusion of the section of the right VA between the two bifurcations of the DOPICA had induced the formation of the aneurysm in the region of the ASA communicating with the one branch of the PICA.

  An 80‒year‒old Japanese man developed consciousness disorder and right hemiplegia and was brought to our hospital. An examination by 3D‒CTA revealed left internal carotid artery occlusion. Intravenous recombinant tissue plasminogen activator (rt‒PA) therapy and mechanical thrombectomy were performed, and during the intracranial mechanical thrombectomy the patient’s left upper arm blood pressure could suddenly not be measured. Priority was given to the intracranial mechanical thrombectomy. The door‒to‒reperfusion time was 148 min, and the thrombolysis in cerebral infarction (TICI) grade of 2b was obtained. A mechanical thrombectomy was performed using an intracranial mechanical thrombectomy device for a left brachial artery embolism. The onset‒to‒reperfusion time of 103 min was necessary to reopen the artery. This patient’s case emphasizes that brain artery occlusion and acute limb artery occlusion can be combined, and stroke care with limb artery occlusion in mind is important. Brain tissue is vulnerable to acute limb artery occlusion combined with acute limb artery occlusion, and thus immediate treatment for limb artery occlusion should be performed after a thrombectomy for the brain artery. An intracranial mechanical thrombectomy device may be useful for limb artery occlusion, and its use should be considered in emergency situations.

  A 76‒year‒old Japanese woman with a history of schizophrenia presented with disturbed consciousness and a Japan Coma Scale (JCS) grade of 200. Computed tomography (CT) showed an intraventricular hemorrhage and ventricular enlargement, diagnosed as obstructive hydrocephalus due to intraventricular hemorrhage. Ventricular drainage was performed, and her consciousness improved to JCS grade 3. On the fourth day of hospitalization, CT revealed a new intraventricular hemorrhage from the lateral to the third ventricle; cranial angiography revealed a nidus in the corpus callosum (CC) draining into the feeder and galenic veins from the left and right posterior cerebral arteries (PCAs). Spetzler‒Martin grade III arteriovenous malformation (AVM) of the corpus callosum (CC arteriovenous malformation; CCAVM) with drainage was observed. As the patient was elderly, high‒risk craniotomy was judged inappropriate; instead, trans‒arterial embolization (TAE) combined with gamma knife treatment was selected. Left and right PCA feeders were embolized using N‒butyl‒2‒cyanoacrylate. There was mild ataxia after the operation but no new neurological abnormalities. The day after the embolization, gamma knife (irradiation 17 Gy 70%) radiosurgery was performed. Magnetic resonance images taken on the 15th day after admission showed that the size of abnormal blood vessels had decreased. Subsequently, the patient was transferred to rehabilitation with the modified Rankin scale score 3.

  Corpus callosum arteriovenous malformation is a rare disease that has been reported as a cause of intraventricular hemorrhage in young people. Here, we present a case of corpus callosum arteriovenous malformation in an elderly patient; trans‒arterial embolization and gamma knife radiosurgery were chosen as low‒risk treatments and resulted in a good outcome. Our observations can help to better manage the treatment of this rare condition.