Tragic traffic accidents caused by elderly drivers show no sign of ending. The features and trends of current traffic accidents caused by elderly drivers are analyzed and Toyota’s efforts for reducing those accidents are explained with a focus on the latest safety driving assistance system, to which we refer in this article as the “wrong acceleration cancellation system.”

  Mechanical thrombectomy for acute ischemic stroke (AIS) has been established, Shortening the duration from stroke onset to recanalization has become the most important factor for obtaining a good clinical prognosis. A comprehensive stroke center was launched at our institute in October 2017, and a treatment protocol for AIS patients was introduced in April 2018. This study included 149 patients who underwent thrombectomy at our hospital from October 2016 to October 2020. We retrospectively analyzed the recanalization time, treatment prognosis, and other factors before and after the introduction of the protocol in 68 patients with occlusions of the internal carotid artery or the middle cerebral artery within 8 h of stroke onset. The recanalization rate of TICI 2b/3 was significantly increased after the protocol’s introduction (from 75% to 96％). The median time required for each procedure was significantly reduced: the time of admission to MRI imaging (45 min to 34 min), the door‒to needle (D2N) time (95 min to 75 min), the door‒to‒puncture (D2P) time (119 min to 97 min), and the door‒to‒recanalization (D2R) time (163 min to 126 min). The number of patients with a modified Rankin Scale (mRS) score ≤ 2 significantly increased from 40% to 69% at 3 months post‒onset. Our protocol improved the treatment process from the time of arrival at the hospital, shortened the time for each procedure, and improved the prognosis. However, the onset‒to‒recanalization (O2R) time is not sufficiently shortened and remains a challenge.

  We report the outcomes of mechanical thrombectomy (MT) for acute large‒vessel occlusions with a large diffusion‒weighted imaging (DWI) lesion. Of the 127 patients who underwent MT during the 3‒year period from April 2016 to March 2019 at our hospital, the study subjects were 101 patients with an arterial occlusion involving the major arteries of the cerebral anterior circulation. We divided the patients into two groups based on their DWI‒Alberta Stroke Program Early Computed Tomography Score (ASPECTS) ≤ 5 or ＞ 6 and retrospectively analyzed the two groups’ outcomes. A thrombolysis in cerebral infarction (TICI) grade 2b‒3 was achieved in 62% of the patients in the DWI‒ASPECTS ≤ 5 group and 88% of those in the DWI ASPECTS ＞ 6 group (p=0.004). A good functional outcome (modified Rankin Scale [mRS] 0‒2 at 90 days) was achieved in 24% of the patients in the DWI‒ASPECTS ≤ 5 group. In the DWI‒ASPECTS ≤ 5 group, internal carotid artery occlusion was observed in 86% of the patients who achieved a good functional outcome but in significantly fewer, i. e., 36% of the mRS 3‒6 patients (p=0.023). These results of MT for anterior major vessel occlusion in patients with large early ischemic change demonstrated inferiority compared to the patients with a DWI‒ASPECTS ＞ 6. Successful reperfusion may be related to good functional outcome even in patients with a DWI‒ASPECTS ≤ 5.

  Acute subdural hematoma (ASDH) is a severe and sometimes fatal disease. The standard treatment for ASDH is a large craniotomy under general anesthesia, which is invasive and risky for elderly patients with comorbidities. It is also occasionally difficult to determine the indications for an ASDH in elderly patients. The application of neuroendoscopic surgery for ASDH was recently described. Here we report the cases of six elderly patients who underwent an endoscopic surgery via a small‒size craniotomy for ASDH. We analyzed the effectiveness and the problems of this procedure and the related literature.

  At our hospital between 2017 and 2020, six patients (age 70‒87 years old, mean 78 yrs; four males and two females) underwent an endoscopic surgery for ASDH. Three patients had been receiving antithrombotic drugs. The mean preoperative modified Rankin Scale (mRS) and Glasgow Coma Scale (GCS) scores were 2.2 (0‒4) and 7.8 (4‒12), respectively. The choice between general and local anesthesia depended on the patient’s condition. Gross total removal of the hematoma was achieved in five patients; partial removal was achieved in the other patient. The mean operation time of the six endoscopic surgeries was 94 min (67‒110 min), which was significantly shorter than that of 12 elderly patients who underwent a conventional craniotomy (150 min, range 82‒250 min) during the same period as this study (p ＜ 0.05). There was no postoperative bleeding or infection in the present series, and the six patients’ mean GCS score at 3 months post‒surgery was 3.3.

  With careful attention to hemostasis and brain swelling, this endoscopic surgery could be a safe and effective option for treating ASDHs in elderly patients. This surgical approach is feasible under local anesthesia in some cases. Although further experiences are needed before conclusions can be drawn, the present six cases indicate that endoscopic surgery can be a useful option for treating an ASDH.

  Dissecting cerebral aneurysms of the posterior cerebral artery (PCA) are rare, and it is difficult to treat aneurysms located in the P1 or P2 segment by microsurgery because of the difficulty in confirming the perforating arteries to the brain stem and thalamus. We report the case of a ruptured dissecting cerebral aneurysm of the PCA in which we identified the perforators of the P1 segment adjacent to the dissecting aneurysm using a CT‒like reconstruction from three‒dimensional (3D) rotational angiography (3DRA). Stent‒assisted coil embolization was performed without ischemic complications. A 46‒year‒old Japanese man was admitted to our hospital complaining of loss of consciousness. CT revealed a subarachnoid hemorrhage (SAH), and a cerebral angiogram demonstrated a dissecting aneurysm of the right P1‒2 segment. The patient was selected for conservative treatment in the early stages. Significant aneurysm enlargement was observed at 12 days post‒admission on a cerebral angiogram. Volume rendering and CT‒like reconstructions from 3DRA confirmed that the perforators to the midbrain and thalamus were apart from the dissecting aneurysm, and we thus decided to perform stent‒assisted coil embolization and finished the embolization with the neck remnant. At 6 days after treatment, a cerebral angiogram revealed disappearance of the cerebral aneurysm, and MRI did not reveal an iatrogenic cerebral infarction. The patient did not present any symptoms of SAH following his endovascular treatment. This case demonstrates that the evaluation of the perforators to the brainstem using CT‒like reconstructions from 3DRA is useful for performing an intravascular treatment of dissecting aneurysms of the PCA without ischemic complications.

  We introduce a less‒invasive surgical strategy for elderly patients with a poor‒grade subarachnoid hemorrhage (SAH) with casting intraventricular hemorrhage (IVH) due to a large ruptured aneurysm located in the anterior communicating artery (ACA). In this strategy, a small‒area frontal craniotomy is conducted around Kocher’s point, and a ventricular drainage tube is inserted into the anterior horn of the lateral ventricle. After direct microscope‒guided evacuation of the IVH using the ventricular drainage tube, dome clipping of the aneurysm including the ruptured point is performed by a transventricular approach. Although we have focused on a reliable closure of the rupture point in cases of poor‒grade SAH with casting IVH, the complete clipping of the aneurysm is not considered very important. A prompt improvement of the pathophysiology that provided the conditions for the patient’s deterioration is necessary; i. e., the release of the increased intracranial pressure by removal of the IVH. The patient outcomes depend on the degree of primary brain damage, and thus a favorable functional recovery can be expected only if the primary brain damage was limited and a new secondary injury was avoided. Although an interhemispheric approach has often been used in patients with a large or high‒positioned aneurysm in the ACA, that procedure has a clinical disadvantage (i. e., the invasiveness involved in the opening of the frontal sinus), and the surgical manipulation presents a significant amount of time and difficulty. The surgical approach we describe herein is less invasive and takes less time as it is not necessary to open the frontal sinus and dissect the interhemispheric fissure, making it possible to improve the pathophysiology with direct IVH evacuation and prevent re‒rupture of the aneurysm. It is also important to determine both the relevant surgical indications and whether it is possible to deal with an aneurysm safely using the transventricular approach, by considering the patient’s preoperative neurological images.

  Stanford Type A acute aortic dissection is a devastating condition that can complicate with stroke and commonly needs immediate surgical repair. A 51‒year‒old hypertensive man was transferred to our emergency room with hemiparesis and speech disturbance. At presentation, the patient’s blood pressure was 161/102 mmHg and he showed restless confusion, in addition to motor weakness in the left upper and lower extremities, and dysarthria. His blood examination showed an elevated level of serum D‒dimer, and a chest X‒ray found mild cardiomegaly with a cardiothoracic ratio (CTR) of 0.53. Cranial computed tomography (CT) scans revealed a subcortical hematoma in the right frontal lobe, 38 mm x 34 mm in maximal diameter with less mass effect. The patient complained of chest pain immediately after the CT scans and suffered abrupt cardiopulmonary arrest a few minutes later. Prompt cardiopulmonary resuscitation did not achieve spontaneous circulation. A chest X‒ray taken after endotracheal intubation showed a considerable increase in the CTR to 0.61. Autopsy imaging revealed disruptions of the wall of the ascending aorta and the collection of pericardial effusion. Based on these results, we assumed that the patient died of cardiac tamponade caused by a Stanford Type A acute aortic dissection that developed rapidly following subcortical hemorrhage. Acute aortic dissection should be assumed to be a possible complication of intracerebral hemorrhage.

  We report a case in which bilateral vertebral artery (VA) dissection manifesting as cervical pain became symptomatic due to progressive stenosis. Stenting was performed on the dominant left VA. A 51‒year‒old Japanese woman with the chief complaint of posterior cervical pain was diagnosed with bilateral VA dissection based on magnetic resonance angiography (MRA) and was hospitalized. There were no neurological findings, and conservative therapy was initiated. Cerebral angiography and follow‒up MRA were performed. The patient suffered vertigo on day 10 of admission, and magnetic resonance imaging (MRI) revealed an infarction in the right cerebellar hemisphere. MRA demonstrated an occlusion of the right VA and severe stenosis of the left VA. The patient became somnolent, and her symptoms were attributed to brain ischemia. We speculated that ischemia of the brainstem had caused the symptoms. Cerebral angiography on day 12 showing that the dominant left VA was near occlusion. The cerebral blood flow (CBF) of the brainstem was poor. We considered that improvement of the poor CBF would be difficult even with strong medication. The patient underwent stenting of the left VA. The postoperative course was uneventful. Bilateral VA dissection that manifests clinically with a headache and ischemic features is generally cured by medical treatment. However, medication is not effective in cases in which a bilateral VA dissection is accompanied by stenosis. These obstructive changes unusually occur on both sides simultaneously. This case showing that endovascular revascularization was a viable treatment option for symptomatic VA dissection with stenosis.

  We herein report a patient with idiopathic spontaneous intracranial hypotension (SIH) and a difficult‒to‒treat chronic subdural hematoma (CSDH) who suffered from impending cerebral herniation. A 45‒year‒old Japanese male who was treated in another hospital with chief complaints of headache, dizziness, and tinnitus arrived at our hospital due to the lack of symptomatic improvement. His symptoms worsened when he stood up, and he was admitted to our hospital with suspicious SIH. Computed tomography revealed bilateral subdural hygroma, and magnetic resonance imaging with gadolinium demonstrated diffuse dural enhancement. Cisternal scintigraphy led to the suspicion of cerebrospinal fluid leakage at the level of the upper thoracic spine. Conservative treatment was unsuccessful, but an epidural saline infusion and epidural blood patch led to rapid improvement. However, the patient’s consciousness deteriorated and he developed right oculomotor nerve palsy. Repeat treatment with an epidural saline infusion and epidural blood patch did not improve his symptoms. An additional injection of saline and autologous blood did not improve the level of consciousness, whereas burr‒hole drainage led to the recovery of consciousness. The patient underwent postoperative rehabilitation and was discharged on the 56th day of hospitalization. In this patient’s case, the initial mechanism was a decrease in intracranial pressure due to SIH, which was balanced by the pressure from the CSDH. However, we speculate that the increase in the CSDH led to an increase in intracranial pressure. Therefore, closing the leak site with epidural blood patch might have led to impending cerebral herniation due to a rapid increase in intracranial pressure. As illustrated by this patient’s case, simultaneous treatment should be considered in patients with SIH accompanying CSDH who might rapidly deteriorate, and a meticulous neurological follow‒up is critical for successful outcomes in these patients. The safest treatment is the simultaneous administration of an epidural blood patch and burr‒hole drainage.

  We report a case of carotid stenosis with limb‒shaking treated by staged angioplasty. A 70‒year‒old Japanese man was admitted because of the involuntary movement of his left limb that had lasted for the previous 20 days. Computed tomography, magnetic resonance imaging, and digital subtraction angiography showed a subacute cerebral infarction, severe stenosis of the right cervical internal carotid artery, and a circulation delay in the right middle cerebral artery area. The patient was treated first with antiplatelet therapy. The involuntary movement improved but remained. Percutaneous angioplasty of the carotid artery was performed, and the involuntary movement disappeared. Finally, staged carotid artery stenting was performed, with no sequela. The involuntary movement was suspected to have been caused by the hemodynamic compromise. Similar cases may require aggressive treatment including early surgical intervention.