A work‒style reform project for physicians’ will begin at our _ _ ‒bed neurosurgical acute care hospital in April 2024. Neurosurgeons work in high‒stress settings, often conducting long surgeries, emergency medical care, outpatient work, ward management, and more. The managers of neurosurgical facilities must create a working environment that is appropriate and suited to the emergency medical care in the region, medical practice performance, and the available medical staff manpower. The work‒style reform program presented herein is designed to provide improved conditions for physicians, including the regulation of overtime working hours.

  It is clinically important to prevent posttraumatic seizures (PTSs) as they are associated with the development of posttraumatic epilepsy and other poor outcomes. To identify the characteristics of traumatic brain injury (TBI) associated with PTS, we retrospectively analyzed the cases of 56 patients who were admitted to Wakayama Medical University Hospital between January and October 2022 for a TBI, and we excluded the seven patients died within 30 days of admission. Forty‒nine patients were thus included; 11 had PTS (seizure group) and 38 had no PTS (non‒seizure group). The seizure‒group patients were significantly older than the non‒seizure group (81.2 ± 12.4 vs. 63.5 ± 26.4 years, p=0.022, S=363, Z=2.28). The initial Abbreviated Head Injury Score was significantly more severe in the seizure group (p=0.0017, S=397, Z=3.14). All of the seizure‒group patients had an acute subdural hematoma. We also observed that contusions in the primary motor cortex and temporal base‒subdural hematoma might be associated with PTS (Fisher’s exact test, p=0.028 and p=0.021, respectively). Our results suggest that older age, a severe TBI, acute subdural hematoma, TB‒SDH, and/or a contusion in the primary motor cortex might be the risk factors for PTS. A prospective study is necessary to further clarify the risk factors and the significance of the early detection of PTS.

  The indications for extracorporeal membrane oxygenation (ECMO) for multiple trauma cases have not been established. We report the case details of a pediatric patient who experienced multiple trauma with severe head injury and was successfully treated with ECMO. The 13‒year‒old boy was injured in a traffic collision with a passenger car. Severe traumatic brain injury, tension pneumothorax, pulmonary contusion, and open fracture of a tibia were observed. Because of the patient’s poor oxygenation and progressive ventilation impairment, veno‒venous ECMO was introduced and anticoagulants were used. The patients’ respiratory condition gradually improved, but the cerebral contusion worsened. The use of ECMO in trauma has not been established, and intracranial hemorrhage may be exacerbated in patients with head trauma, as in this case. ECMO is an effective means of improving a patient’s respiratory status, but the use of anticoagulants in such cases should be considered carefully.

  As the number of individuals undergoing hemodialysis (HD) increases, there has also been an increase in the number of individuals undergoing HD requiring urgent neurosurgery. Patients on HD are at a very high risk of stroke — especially hemorrhagic stroke — and they are also prone to falls and head injuries due to imbalance syndrome and hypotension, with worse outcomes than the general population. We have determined the indications for urgent neurosurgery for stroke and head injury based on the hematoma volume and neurological severity, regardless of HD status. In this study, we report the clinical outcomes of urgent neurosurgery in patients undergoing HD at our institution based on a retrospective analysis of the 93 cases of urgent craniotomy or burr hole surgery performed in HD patients over a 16‒year period. The primary diseases were intracerebral hemorrhage (ICH), 49 patients (52.7%); subarachnoid hemorrhage (SAH), n=7 (7.5%); acute subdural hematoma (ASDH), n=15 (16.1%); chronic subdural hematoma (CSDH), n=19 patients (20.4%); and others, n=3 (3.2%). Among the total series, the most common perioperative complication was postoperative seizure (12/93, 12.9%), followed by hematoma enlargement and rebleeding (11/93, 11.8%). Thirty‒seven patients (39.8%) had favorable or moderate outcomes at discharge, and 25 patients (26.9%) were discharged after death. The predictors of outcome identified in the ICH group were admission GCS, hematoma volume, and hematoma location. Across all diseases, a significant number of patients (68/93, 73.1%) underwent successful neurosurgery with a life‒saving or favorable outcome. Our analysis results demonstrate that it is reasonable to determine the indication for urgent neurosurgery based on the hematoma volume and neurological severity even in patients on HD. Urgent neurosurgery should be considered for patients with SAH, ASDH, CSDH, or ICH with a Glasgow Coma Scale score ＞9 or hematoma volume ＜63 mL. The postoperative management of patients on HD should be performed based on the consideration of specific risks such as seizures and rebleeding.

  Screening for SARS‒CoV‒2 infection at the time of patients’ admission to a healthcare facility is important to prevent the development of COVID‒19 clusters. The ID NOW (NEAR) test is useful as a screening test because its results are available within 13 minutes, but false positive results are concerns. At our neurological hospital, if a patient’s ID NOW result is positive, we thus immediately conduct an polymerase chain reaction (PCR) test to determine whether or not the ID NOW result is false positive result. Herein, we retrospectively analyzed the results of infection control for COVID‒19 using both ID NOW and PCR tests in our hospital. Of the 41 ID NOW‒positive patients admitted in 2022, five patients were PCR‒negative, but one of them was PCR positive 2 days later. In the five cases of ID NOW‒positive and PCR‒negative results, another PCR was conducted the next day or 3 days later to determine whether the patients had an early‒stage infection or their cases were non‒infectious false positives. The results of our analyses demonstrate that false positive results on the ID NOW test may indicate a recent prior infection, and cohort isolation did not cause re‒infection in the present patients.

  As the population ages, the incidence of acute subdural hematoma (ASDH) in elderly individuals has been steadily increasing. Age is a significant factor influencing the prognosis of ASDH, with a particularly poor prognosis observed in the elderly. An emergency craniotomy for the removal of the hematoma in ASDH cases is commonly performed as a large craniotomy to identify bleeding points for effective hemostasis and to address brain swelling, if present. However, this approach is associated with a lengthy skin incision and relatively prolonged surgical times, both of which are highly invasive for elderly patients. At our institution, with the aim of minimizing invasiveness in managing ASDH in the elderly, we have adopted the use of a limited craniotomy for hematoma removal. This approach involves using only a partial skin incision from the large craniotomy when dealing with cases in which minor trauma served as the trigger and bleeding from cerebral arteries and veins on the brain’s surface is suspected. From January 2017 to September 2022, we performed this procedure in 17 elderly patients with ASDH (12 males, 5 females, age 83.8 ± 6.2 years), and in all cases, we successfully removed the hematoma and achieved hemostasis, allowing for the safe completion of the surgical procedure. A limited craniotomy for hematoma removal in elderly ASDH patients is a minimally invasive and safe technique. Adequate preparations for transitioning to a large craniotomy, if necessary, are considered essential.

  [Background and Objectives] Reports on the clinical application of 3D printers are abundant in the field of unruptured intracranial aneurysms, but there are fewer reports concerning cases of rupture in the context of brain artery aneurysms. In this study, we investigated the feasibility of creating 3D aneurysm models in time for emergency surgery related to subarachnoid hemorrhage. [Methods] Our subjects were 19 consecutive cases of ruptured intracranial aneurysm diagnosed with subarachnoid hemorrhage in our hospital between January and December 2022. We assumed the creation of one hollow model and one model without an inner cavity for each case and calculated the required 3D printing time, including data processing time of 20 minutes. We examined the time elapsed from aneurysm identification to entry into the operating room, and retrospectively compared the two. [Results] The average time until the start of surgery was 421 minutes, and the average time required for 3D model creation was 180 minutes. In 17 of the 19 cases, the two models could have been created within 3 hours, and in 11 cases, the models could have been created before the start of surgery. For models that could not have been prepared in time for surgery, the shortfall was less than 90 minutes in 6 cases and exceeded 90 minutes in 2 cases. [Conclusion] Tailor‒made aneurysm models for the preoperative evaluation of ruptured intracranial aneurysms can be created depending on the case. The proper selection of cases can allow for timely preparation before surgery, potentially contributing to the safety of the procedure.

  It has been proposed that using antithrombotic agents (ATAs) to treat patients with a traumatic brain injury (TBI) increases the risk of both an intracranial hematoma and its enlargement, thus worsening outcomes. However, the criteria for the discontinuation and/or reversal of ATA treatment are not well established. We used data from the recently created Think FAST registry to investigate the characteristics of elderly patients with TBI who were treated with an ATA and to examine the criteria for the discontinuation and/or reversal of ATA treatment. In the Think FAST registry, the cases of 780 elderly patients with TBIs were registered with approx. 90 items including age, gender, pre‒trauma modified Rankin scale (mRS) score, Glasgow Coma Scale (GCS) score, platelet count, prothrombin time (PT), activated partial thrombin time (APTT), midline shift on computed tomography (CT), talk and deteriorate (T & D) status, and Glasgow Outcome Scale (GOS) score at discharge. We divided the 780 patients into two groups based on the presence/absence of preconditioning with an ATA in order to examine each item and between‒group differences. We also divided the patients on ATA treatment into two groups to examine the items based on the discontinuation or reversal of ATA treatment. No significant difference in GCS scores was observed in the patients on ATAs compared to those without them. The ATA‒treated patients showed significantly poorer values regarding the mRS, midline shift on CT, the rate of T & D status, and GOS score compared to the patients without ATA treatment. The GCS score, midline shift on CT, and GOS score were more severe in the patients on an antiplatelet with discontinuation compared to those without discontinuation. The GCS and GOS scores were not significantly different among the patients on an anticoagulant between those with and without discontinuation. In the patients on anticoagulants, although the GCS scores were more severe with the reversal of anticoagulant treatment than without reversal, there was no significant difference in the GOS score between them. These results suggest that only the discontinuation of treatment with an ATA has no effect on the outcome in elderly patients with a TBI, although the reversal of anticoagulant treatment may exert a certain effect to improve the outcome.

  The ‘super‒aging’ population in Japan and elsewhere has posed an increase in the number of elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We investigated the prognostic factors of aSAH by retrospectively analyzing the cases of the 491 patients with aSAH admitted to our hospital from April 2013 to December 2021, stratified by age. After excluding patients aged ≤ 59 or ≥ 90 years, we divided the remaining 273 patients into three age groups: 60‒69 years (n=92), 70‒79 years (n=97), and 80‒89 years (n=84). The groups’ respective mean ages±SD were 64.5±2.95, 74.4±2.86, and 84.0±2.71 years, with a higher proportion of women in all three groups. Compared to the patients aged 60‒79 years, those in their 80s had significantly lower proportions of pre‒onset modified Rankin Scale (mRS) scores 0 to 2 (p<0.001), World Federation of Neurosurgical Societies (WFNS) grades I‒III (p=0.027), and a prior history of surgery (p=0.031). The 70‒79 age group had significantly higher proportions of hypertension (p<0.001), ischemic heart disease (p=0.041), and use of antithrombotic medications (p=0.018), and they were significantly more likely to undergo coil embolization than a craniotomy (p<0.001); their rates of therapeutic completion (p=0.001) and mRS scores 0‒2 at discharge (p<0.001) were also significantly lower. A univariate analysis of factors for poor prognosis (defined as mRS scores 0‒2) revealed that age ≥ 80 years, WFNS grade IV‒V, presence of cerebral aneurysms, wide neck, and nonoperative cases were significant factors. The multivariate analysis of these factors revealed that ≥ 80 years and WFNS grades IV‒V were independent factors for poor prognosis. Age >80 years may be an important factor in deciding the treatment strategy for aSAH, in Japan and other countries with aging populations.

  Carotid web is a fenestrated structure that develops on the posterior wall of the internal carotid artery origin and subtype of fibromuscular dysplasia. Blood stasis occurs in the carotid web, resulting to embolic material that can cause cerebral infarction, especially in young patients with no risk factors for stroke. For treatment, carotid revascularization is considered because of the high risk of recurrence with medical treatment alone. Although carotid endarterectomy has long been reported as a method of carotid revascularization, carotid artery stenting (CAS) has recently been increasingly reported. Here, we report three cases of CAS for symptomatic carotid web induced middle cerebral artery occlusion, which were successfully treated with CAS following mechanical thrombectomy.

  Background: Impalement injury is defined as penetrating trauma caused by a relatively blunt, long object. These injuries are rare, especially in the head and neck region. We describe a cervical impalement injury caused by a pencil impaled in the left neck, treated with parent‒vessel embolization using coils on the vertebral artery damaged by the pencil.

  Case: A 10‒year‒old female with no significant medical history fell while holding a pencil, which became lodged in her left neck. At the scene, the pencil was immobilized with a log made of gauze to prevent any further movement. A cervical collar could not be applied due to interference from the foreign body, so the patient was transported to our hospital with manual head immobilization. Upon arrival, her vital signs were stable, and no loss of consciousness or neurological deficits were observed. The pencil was lodged on the left side of the 7th cervical vertebra. Contrast‒enhanced CT scan revealed a filling defect in the left vertebral artery from the 6th cervical vertebra to the 1st thoracic vertebra level, indicating that the pencil was either penetrating or compressing the vertebral artery. Given the risk of significant bleeding upon pencil removal or the potential for emboli to travel into the intracranial space upon blood flow restoration, we confirmed the good development of the right vertebral artery and decided to occlude the left vertebral artery with coil embolization before pencil removal. The patient underwent general anesthesia and intubation before being transferred to the angiography suite. We first embolized the proximal side of the filling defect in the vertebral artery and confirmed complete occlusion. We removed the pencil in the hybrid ER room. During the removal, there was evidence of what appeared to be retrograde arterial bleeding; however, 30 min of cervical pressure led to successful hemostasis. There were no apparent neurological deficits after treatment. The patient had a stable postoperative course without wound infection or pseudoaneurysm formation. She was discharged home on the 30th day post‒procedure.

   Conclusion: Vertebral artery injuries due to severe neck injury have a high mortality rate. Most of them are blunt injuries with cervical vertebral fractures; the frequency of perforating injuries (including picket wounds) is low because most of the vertebral artery runs are protected by the bony structures. Endovascular treatment is effective in treating perforating vertebral artery injuries, and care should be taken when removing the foreign body to ensure that the forward blood flow is interrupted and to consider techniques to stop the retrograde blood flow. Prior to treatment, it is essential to evaluate the situation accurately using imaging studies, and to provide adequate treatment according to the patient’s background.

  We investigated the clinical characteristics and the current status and issues regarding the initial response of patients who experienced a hospital‒onset cerebral infarction by conducting a retrospective analysis of the cases of the 79 patients admitted to Toho University Medical Center Omori Hospital between January 2009 and June 2019 who had a cerebral infarction during hospitalization. They were 47 males and 32 females aged 72.7±9.8 years (44‒93 yrs). Patients with a modified Rankin Scale (mRS) score of 0‒3 points at discharge were classified as the good‒prognosis group (n=29), and those with an mRS score‒4‒6 points comprised the poor‒prognosis group (n=50). Our analysis results demonstrated that compared to the good‒prognosis group, the poor‒prognosis group had significantly more malignancies as pre‒existing diseases (p=0.003) and more instances of disturbed consciousness (p=0.003). When the comparison was limited to 4.5 hours from the detection of hospital‒onset stroke patients to the first consultation with a stroke specialist, the time of the good‒prognosis group took longer than that of the poor‒prognosis group. To provide prompt responses to patients with hospital‒onset stroke in the future, it is necessary to educate medical staff who are not in the stroke department and to improve the medical care system.