Emergency medicine is part of the infrastructure of a social community; therefore, it should function in compliance with social needs. This is also true of neurosurgical emergency medicine, which is most highly developed in the fields of stroke and traumatic brain injury. Here, the authors present the current management at their institution of occlusive cerebrovascular diseases, neurosurgical emergency in pregnant women, abusive head trauma in children and adults, and the brain‒death determination. They describe the contribution of doctors in their forties, who understand the reality and importance of both front‒line work and administrative work in the establishment of the system in the above areas. They also stress the importance of cooperation with a wide variety of health care workers as well as doctors, and of coordination with the community in preparation for upcoming reform of working practices for doctors.

  The Concussion in Sports Group set up by FIFA (Fédération Internationale de Football Association), the IOC (International Olympic Committee), and the IIHF (International Ice Hockey Federation) and joined by World Rugby and the FEI (Fédération Equestre Internationale) has provided international consensuses about sports‒related concussions (SRCs). The newest ‘Berlin Statement’ was published in 2017 with the SCAT (Sports Concussion Assessment Tool) 5, the Child SCAT 5, and the CRT (Concussion Recognition Tool) 5, which suggest methods for the practical on‒field management and follow‒up of SRCs. The Berlin Statement recommends that medical staff at sporting venues take care of sports‒related emergencies including neurological problems as well as musculoskeletal, cardiovascular, pulmonary and/or abdominal events. As neurosurgeons, we are also encouraged to master the prehospital care of SRCs by using the JPTEC (Japan Prehospital Trauma Evaluation and Care) recommendations, the PHICIS (Prehospital Immediate Care in Sports) guidelines, and BLS (basic life support). Before game days, medical staff should repeat simulation trainings based on possible accidents and injuries.

  With the increase in the number of cases of acute cerebral infarction requiring mechanical thrombectomy (MT), overwork and “burn‒out syndrome” of neurointerventionalists (NIs) have become major concerns. We herein report a new stroke care system that takes the work‒life balance of a single NI into consideration. In 2014, the Nagasaki Medical Center launched its stroke hotline (N‒SHOT), through which the emergency department receives the first call and manages initial care. The Departments of Neurosurgery and Neurology work together to treat stroke patients. MT is managed by a single NI and is performed in collaboration with the Departments of Neurology and Radiology. The NI receives MT calls when patients with acute ischemic stroke are found to have large vessel occlusion. Because the number of inpatients under the NI’s charge and the number of MT cases increased, support from nurse practitioners (NPs) was started in 2016. Even in a hospital with only one NI, it is possible to deal with MT cases while maintaining a certain level of clinical outcome by taking advantage of N‒SHOT, collaborating with multiple other departments, and receiving medical support from NPs.

  On December 14, 2018, the “Basic bill on measures for stroke, heart disease and other cardiovascular diseases to extend healthy life expectancy” was promulgated. It came into effect on December 1, 2019 and an obligation to make efforts to formulate policies specific to each prefecture was imposed. In Gunma Prefecture, neurosurgeons have played a central role in developing a stroke emergency medical system. Hospitals, fire departments, and administrative trinity have been working closely together to train human resources and identify 13 hospitals that can always implement tissue plasminogen activator (t‒PA) treatment. A previous qualitative evaluation of stroke judgment in the Gunma Prefecture ambulance team revealed 82.5% sensitivity, 97.2% specificity, and 50.8% positive predictive value. In our study, we confirmed the usefulness of the large vessel occlusion screen. We introduced the domestic emergent large vessel occlusion (ELVO) screen and began training paramedics. For the purposes of this study, of the 348 patients who were suspected of having a stroke in January 2019 and were rushed to 12 of the hospitals where t‒PA can always be carried out, 122 who had been diagnosed with cerebral infarction at the hospital were targeted. We performed post‒testing at the initial stage of ELVO screen evaluation, and obtained 41.4% sensitivity, 93.5% specificity, and a false negativity rate of 16.3%. In the present report, we outline current problems and future challenges. Now that the above‒mentioned bill is in effect, it will be necessary in the future for hospitals, emergency departments, and administrative offices to continue accelerating the establishment of the emergency medical care system for stroke; this is also important as a response to the spread of COVID‒19 infection.

  The benefits of the first‒pass effect (FPE) are significant, as it enables complete recanalization with a single thrombectomy device pass. We investigated the factors that may predict the FPE by retrospectively analyzing the cases of intracranial thrombectomy in which a stent retriever or aspiration catheter was used as the first device at our facility since 2015. We investigated four groups: the FPE group (n＝35, 26.1%), the modified FPE group, the multiple passes/Thrombolysis in Cerebral Infarction grade (TICI) ＜ 2b group, and the TICI ＜ 2b group. Of the 144 cases, 134 occurred during the study period. The percentages of cardiogenic embolism were 38.9% in the TICI ＜ 2b group and significantly higher at approx. 70% in the other three groups (p＝0.02). The rate of lesions suggesting a single‒vessel occlusion (i.e., non‒terminus of the internal carotid artery [ICA], ICA/first segment [M1] of the middle cerebral artery [MCA], or M1/basilar artery [BA]) was high in the FPE and modified FPE groups at 71.4% and 65.2%, showing a significant difference between these two groups and the other groups (p＝0.03). After the adjustment for confounders, the independent predictor of FPE was ICA/M1/BA occlusion with an odds ratio of 2.37 (95% confidence interval 1.02‒5.49, p＝0.045). Our results demonstrated that ICA/M1/BA occlusion was an independent factor that increased the FPE.

  An early start to rehabilitation is recommended to improve motor dysfunction caused by cerebrovascular diseases. However, an early start does not adequately restore motor function in all patients. We examined which factors affect the recovery of motor function by early rehabilitation. Our subjects were 149 inpatients with cerebral infarction (CI) and 108 with intracerebral hemorrhage (ICH) admitted to our hospital between 2016 and 2018. After acute treatment, they were admitted to the convalescent rehabilitation ward. The 257 patients were divided into 2 groups: those with good recovery of motor function and those with poor recovery. The criterion for grouping was set at a score of 30 or more (good) or less than 30 (poor) on the achievement index. We examined factors associated with rehabilitation in the 2 groups, including age, number of hospitalization days in the acute care ward, number of days in the rehabilitation ward, and motor and cognitive scores on the Functional Independence Measure (FIM) upon admission to the rehabilitation ward. Multivariate analysis was included in the statistical analysis. A total of 90 CI patients and 60 ICH patients had good recovery of motor function due to early rehabilitation. In the good recovery group of both CI and ICH patients, hospitalization durations during the acute phase were shorter and FIM cognitive scores were higher. Additionally, FIM motor scores were higher in ICH patients with good recovery. There were no significant differences in age or hospitalization days in the rehabilitation ward. According to multivariate analysis, FIM cognitive score was a factor that affected motor function recovery in both patients with CI (odds ratio, OR: 1.07, p ＜ 0.05) and in those with ICH (OR: 1.09, p ＜ 0.05). In conclusion, we found that, in stroke patients with CI or ICH, the factor best correlated with good recovery of motor function by early rehabilitation was a higher FIM cognitive score, rather than age or length of hospitalization.

  Several recent reports have described the efficacy of mechanical thrombectomy for patient with acute ischemic stroke. However, the efficacy of mechanical thrombectomy for the elderly has not been analyzed sufficiently. Here, we evaluated outcomes in elderly patients at a regional core hospital. Between February 2017 and August 2019, 30 patients (14 males, 16 females; average age, 81.1±11.4 years) with intracranial acute large vessel occlusion, were treated with mechanical thrombectomy at our institute. We compared outcomes between patients ≧ 85 years old (n＝13) and those＜85 years old (n＝17), and assessed prognostic factors for favorable outcomes (90‒day modified Rankin Scale (mRS) scores of 0‒2) at 90 days in all patients. There was no significant difference in Successful recanalization (Thrombolysis in Cerebral infarction [TICI] score2b/3) (76.5% versus 69.2%) between the 2 gropes. Favorable outcomes (0% versus 52.9%, P＝.003) were achieved more often in those＜85 years old. Univariate regression analysis showed that age, hypertension, NIHSS at onset, pre‒symptomatic mRS, onset to door time, puncture to lesion arrival time, puncture to recanalization time, type of cerebral infarction were significant predictive factors. The clinical outcomes of the elderly in the present study were not as good as those of the non‒elderly. Elderly patients tend to have low pre‒symptomatic mRS scores and many underlying diseases, so not only is prompt and effective recanalization required, but also their rehabilitation and nursing after treatment require more human resources than for non‒elderly people. Conclusion: It is necessary to carefully judge treatment indications based on these issues for regional core hospitals.

  Severe acute basilar artery occlusion (BAO) has a high morbidity and mortality rates. We summarized our clinical experience of mechanical thrombectomy (MT) for severe acute BAO in order to evaluate the surgical indication of MT. From 2018 to 2020, we treated consecutive 9 cases of MT for acute BAO. Of the 9 cases, 7 patients who were severe infarction with over 26 points of National Institutes of Health Stroke Scale (NIHSS) at administration were inclusion in this study. All patients were men. The mean age was 64±13.6 years (range: 43‒78 years) and had a mean NIHSS score of 32.7±4.2 (range: 27‒37). The time from onset to perfusion ranged from 123 to 713 minutes (a median of 342). The time from puncture to perfusion ranged from 29 to 76 minutes (a median of 40). A technical complication was not found. Perfusion was confirmed in all of cases. Their 90 days follow‒up outcomes showed only one case of mRS 0‒2 and 5 cases of mRS 6. Especially, 3 out of 4 patients whom were on a ventilator or were used vasopressor agent was died. Severe acute BAO is a very high fatality rate. However, the mechanical thrombectomy was occasionally effective in patients with severe acute BAO. Severe acute BAO feasible treatment needs more efforts to assure patients better clinical outcomes.

  Stroke is suspected in many patients who are suddenly presented with neurological symptoms. Acute aortic dissection (AAD) is one of the causative diseases that should not be overlooked and requires early treatment. 15 cases of ADD with neurological symptoms will be reported with some review of the literature. 80 cases of AAD patients admitted during the 9 years and 10 months from January 2010 to November 2019, and 15 cases had neurological symptoms. We examined retrospectively the complications of chest and back pain, neurological symptoms, and prognosis. ADD was associated with neurological symptoms in 18.8％ , and half of them did not have chest or back pain. 13 patients (88％) with neurological symptoms of AAD were Stanford A, and 6 patients died (40％). Because the patients were not the chest and back ache, the delay did not occur in the time required for until a diagnosis of AAD. Some patients with AAD suspected of stroke have chest and back pain of AAD, so it is necessary to consider examinations to prevent them from being overlooked.

  We report two cases of severe infectious disease due to poor oral hygiene. The first case was a 53‒year‒old man who was transported to our facility by ambulance due to fever, convulsions, and consciousness disorder. A computed tomography (CT) scan of the head and face revealed a left subdural abscess with extensive pus accumulation from the maxillary sinus to the frontal sinus, and decompressive subdural abscess lavage was performed. Alpha streptococcus was identified in bacterial culture. Intracranial infection subsided with large doses of antibiotics. The patient had untreated diabetes and was thought to have caused dental maxillary sinusitis, the subdural abscess, and a brain abscess due to the combination of poor oral hygiene and diabetes. His right hemiplegia and higher cerebral dysfunction improved gradually, and he is currently in rehabilitation to return to society. The second case was a 63‒year‒old man who was transported to our facility by ambulance due to fever, convulsions, and consciousness disorder. CT and magnetic resonance (MR) scans of the head revealed scattered bleeding and infarcts in the skull. Transthoracic echocardiography showed vegetation on the mitral valve. The patient was diagnosed with cardiogenic cerebral embolism associated with infectious endocarditis, and cerebral hemorrhage associated with ruptured bacterial aneurysm. He had no habit of brushing his teeth. He had recently gone to a dentist to start treating and brushing his teeth. He also had thrombocytopenia and presented with disseminated intravascular syndrome (DIC). Staphylococcus aureus was identified in bacterial culture. The patient died 4 days after admission due to progressing renal failure and intracranial hemorrhage. Systemic infections and central nervous system diseases associated with oral hygiene are rare but can occur in the general public. Caution may be required as such conditions may result in serious consequences.

  A man in his 60s was referred to our hospital due to severe (World Federation of Neurological Surgeons grade 5) subarachnoid hemorrhage associated with hematoma in the genu of the corpus callosum and intraventricular hemorrhage due to a ruptured left distal anterior cerebral artery aneurysm. The aneurysm was treated with direct trapping, and external ventricular drainage was performed for acute hydrocephalus. After surgery, the patient required antibiotic therapy for pneumonia and sepsis due to carbapenem‒resistant Enterobacteriaceae. Ventricular drainage catheters were repeatedly replaced for prolonged hydrocephalus. At and after 30 days post‒admission, the patient was diagnosed with meningitis based on increased leukocytes in the cerebrospinal fluid (less than 424/μL). At 40 days post‒admission, diffusion‒weighted magnetic resonance images showed growing high‒intensity masses in the corpus callosum and bilateral lateral ventricles where the hematoma had been, and computed tomography revealed enhancement of the entire wall of ventricles by a contrast medium, leading to a diagnosis of pyogenic ventriculitis. Endoscopic aspiration of isolated and encapsulated empyema was performed and ventricles were irrigated. In spite of repeated ventricular drainage and endoscopic third ventriculostomy, however, the patient died because of uncontrolled hydrocephalus on the 95th hospital day. Considering the high mortality of pyogenic ventriculitis, early diagnosis and treatment are essential, but early diagnosis is sometimes difficult in cases with a limitedly increased number of leukocytes in the cerebrospinal fluid due to isolated and encapsulated intraventricular empyema, as in this case. In cases with prolonged ventricular drainage for hydrocephalus and intraventricular hemorrhage, pyogenic ventriculitis should be kept in mind for early diagnosis based on findings of computed tomography and magnetic resonance imaging.

  A 43‒year‒old Japanese man underwent transsphenoidal surgery for a pituitary adenoma. The onset of upper abdominal pain, nausea, and vomiting occurred 3 hr, 50 min after the surgery. On the first day post‒surgery, laboratory tests revealed a significant elevation of the amylase level, and abdominal echo and computed tomography (CT) showed acute pancreatitis. Postoperative pancreatitis was diagnosed. The patient was fasted and infused with analgesics and antibiotics, and he recovered from the pancreatitis. Although we could not identify the cause of the pancreatitis, we suspected that the circulatory disturbance of the pancreas and/or the propofol and/or glucocorticoids administered during the surgery might have contributed to the patient’s acute pancreatitis. Postoperative pancreatitis can occur even after neurosurgery. Upper abdominal pain is considered to be a finding of acute pancreatitis, and it is necessary to perform laboratory tests, abdominal echo, and abdominal CT immediately in such cases.

  We report three cases of pituitary adenoma associated with pituitary apoplexy (Cases 1 and 2) and infection (Case 3) who underwent emergent endoscopic endonasal transsphenoidal surgery (eTSS).

  Case 1: A 48‒year‒old woman with a pituitary adenoma had been followed up by a nearby doctor. She was admitted to our hospital as an emergency case because of headache, vomiting, and visual field impairment.

  Case 2: A 51‒year‒old woman was admitted to our hospital as an emergency case due to headache, fever, and consciousness disorder.

  In Case 1, the patient’s pituitary adenoma including hematoma was entirely removed by emergent eTSS. In Case 2, the pituitary adenoma was associated with meningitis and sinus abscess, and the patient underwent emergency abscess drainage and partial removal of the adenoma. Gross total removal was performed 36 days later.

  In pituitary diseases, pituitary apoplexy and infectious diseases may require immediate treatment, and neuroradiological imaging examination is required in each case.

  von Willebrand disease (VWD) is a rare hematologic disease comprised of six subtypes. It occasionally presents hemorrhagic diathesis. A 46‒year‒old Japanese man diagnosed with type 2A VWD was emergently transported to the hospital. At presentation, he exhibited sustained amnesia but no other neurological deficits, scoring 14 points on the Glasgow Coma Scale. Cranial computed tomography scans revealed a thin acute subdural hematoma, cerebral contusion, and traumatic subarachnoid hemorrhage. The patient underwent conservative treatment with intranasally administered 1‒desamno‒8‒D‒arginine vasopressin (DDAVP) and an intravenous infusion of tranexamic acid. During his hospitalization, no electrolyte imbalance or other adverse events were noted. DDAVP may be effective for the treatment of patients with traumatic intracranial hemorrhages complicated by VWD.

  The endovascular treatment of ruptured vertebrobasilar artery dissecting aneurysms preserving the parent artery has not yet been established. Several treatments have been proposed and overlapping stent‒assisted coil embolization seems to prevent rerupture of dissecting aneurysms. We performed overlapping stent‒assisted coil embolization using low‒profile visualized intraluminal support (LVIS) stents in two cases of ruptured vertebrobasilar artery dissecting aneurysm. Complete occlusion of the dissecting aneurysms and good clinical outcomes were achieved in both cases. This treatment can be effective in preventing rerupture of dissecting aneurysms. Further study is needed on antithrombotic therapy to avoid perioperative ischemic complications with this treatment.

  Cases of medial longitudinal fasciculus (MLF) syndrome caused by head trauma are occasionally reported. Cases that are classified as mild may be caused by falls or traffic accidents, and they are often accompanied by temporary loss of consciousness. We report a case of MLF syndrome caused by a trivial head trauma. A 61-year-old man was admitted to our hospital because of nausea, unsteady gait, and diplopia that appeared after he sustained a bruise on the forehead after accidently walking into a pillar. Based on head computed tomography (CT) and magnetic resonance imaging (MRI) findings, a diagnosis of acute infarction of the left pons and traumatic subarachnoid hemorrhage in the interpeduncular cistern was established. The patient was conservatively treated. The bleeding did not spread and the symptoms were relieved. Eventually, there was only a slight adduction disorder and he was discharged 15 days after the injury. In this case, the impact of the head injury caused traction of the perforator branch of the basilar artery, resulting in a subarachnoid hemorrhage in the interpeduncular cistern; the MLF syndrome was thus considered to be ischemic.

  Occlusion of the parent artery for a vertebral artery dissecting aneurysm (VADA) with the posterior inferior cerebellar artery (PICA)‒end on the contralateral side causes a cerebral infarction (CI). We present the case details of two patients treated with stent‒assisted coiling (SAC) of a VADA with the PICA‒end on the contralateral side. Case 1: A 57‒year‒old man presented with dizziness. MRI showed a lateral medullary infarction, and digital subtraction angiography (DSA) demonstrated a VADA with the PICA‒end on the contralateral side. Because the VADA was growing, SAC of the VADA with the PICA‒end on the contralateral side was performed. No CI or subarachnoid hemorrhage (SAH) occurred. Case 2: A 41‒year‒old man presented with left occipital pain and decreased consciousness. CT showed SAH, and DSA demonstrated a ruptured VADA. SAC of the VADA with the PICA‒end on the contralateral side was performed. No CI or SAH occurred. SAC of a VADA with the PICA‒end on the contralateral side is useful because it preserves the parent artery and prevents VADA rupture.