We describe the case of an undocumented adult from the Republic of China who presented at our institution with a basilar artery (BA) occlusion before being deported to China. The 50‒year‒old Chinese man was undocumented in Japan and was found lying down at the Tokyo restaurant where he worked. He was brought to our emergency room, where head MRI showed an acute cerebral infarction in the pons and cerebellum. Magnetic resonance angiography visualized the BA occlusion. Because a DWI/FLAIR mismatch was recognized, a mechanical thrombectomy was successfully performed. Complete recanalization was achieved, but the patient’s postoperative consciousness disturbance persisted. A clearer delineation of the cerebral infarctions in the pons and cerebellum was provided by postoperative imaging, with no evidence of new infarctions compared to the preoperative imaging. He was an unmarried and undocumented migrant worker and had no close relatives who could be contacted. Since the early postsurgical period, we kept in close contact with the metropolitan police department, the immigration bureau, and other related agencies to coordinate his return to China. Six months after the BA occlusion’s onset, he became to be able to communicate with others, but he still suffered hemiparesis of the right side of his body, which required assistance. He was discharged on the 269th day of his hospitalization and deported to China the same day. The significant medical expenses of his treatment remain unpaid. Considering similar future cases, it may be necessary to establish laws ensuring that uninsured foreign residents, including undocumented individuals, can receive appropriate medical care and their burden on medical institutions can be reduced.

  A Japanese man in his 70s who was admitted to an emergency department due to massive otorrhagia and right peripheral facial palsy was found to have a large pseudoaneurysm in the cervical‒petrous region of the right internal carotid artery. Although stent‒assisted coil embolization achieved temporary hemostasis, a covered stent graft (Gore Viabahn^TM, Gore Medical, Newark, DE) was applied to obtain robust hemostasis, since the patient repeatedly experienced massive rebleeding. Covered stents might be an effective treatment for vascular injuries of the internal carotid artery in the cervical‒petrosal region, although insurance coverage and device accessibility might be issues with this treatment.

  Intracranial hemorrhage during anticoagulation therapy has a poor prognosis, and appropriate anticoagulation therapy is important toward the goal of improving the prognosis. We retrospectively analyzed the use of anticoagulant reversal agents at Tokyo Medical and Dental University Hospital and four affiliated facilities. Between January 2017 and September 2023, an anticoagulant reversal agent was used in 72 cases of acute intracranial hemorrhage (hemorrhagic stroke, n=39; traumatic intracranial hemorrhage, n=33). Surgical treatment was selected for 32 cases, six of which were changed from conservative to surgical treatment due to deterioration of conservative therapy. Forty cases were treated conservatively. The time from arrival at the hospital to the administration of the anticoagulant reversal agents was 98 min in the patient group in which surgery was selected from the beginning, 308 min in the group in which the treatment plan was changed to surgery after hospitalization, and 118 min in the conservative treatment group, which was significantly longer compared to the surgery group. In the group that initially chose conservative treatment, 16 patients experienced increased bleeding after hospitalization, and the time until the administration of medication was 101 min in the patients without increased bleeding versus 308 min in those with worsening bleeding, which was significantly longer. Among all of the patients, nine (13%) died in the hospital. These results suggest that effective hemostatic effects may be achieved by administering an anticoagulant Reversal agent soon after admission to the hospital.

  Nocardia brain abscesses are relatively rare, accounting for ～2% of all brain abscesses, but the prognosis is poor with a mortality rate is three times higher than those of other types of brain abscess. There is no established treatment, but based on past case studies, trimethoprim-sulfamethoxazole is often listed as the first choice. We recently used trimethoprim-sulfamethoxazole to treat a 72‒year‒old Japanese man who was diagnosed with a Nocardia brain abscess, but his renal function deteriorated, and the treatment was changed to moxifloxacin hydrochloride, which improved his condition. We provide the patient’s case details together with a brief review of the literature concerning Nocardia brain abscesses.

  We report the case of a ruptured basilar artery (BA)‒left superior cerebellar artery (SCA) bifurcation aneurysm treated by coil embolization and two endoscopic surgery techniques. A 67‒year‒old Japanese woman was admitted to our hospital for the evaluation of a headache followed by coma. Computed tomography (CT) revealed a subarachnoid hemorrhage (SAH) accompanied by an intraventricular hematoma (IVH) and an intracerebral hematoma (ICH). CT angiography showed a ruptured BA‒left SCA aneurysm. After performing coil embolization for the ruptured aneurysm, we conducted an endoscopic evacuation of the intracranial hematomas. The IVH was evacuated with the use of a flexible endoscope, and the ICH was evacuated with a rigid endoscope. Although the surgical procedure was completed without complications, the patient showed persistent consciousness disturbance. In our opinion, a combination of coil embolization and endoscopic surgery is less invasive than a craniotomy, and when performing endoscopic surgery for intracranial hematomas associated with SAH, surgeons should consider the safety of the procedure based on the hematoma distribution.