稲桝 丈司

Background: Malignant hemispheric infarction is a life-threatening condition with a high mortality rate. Decompressive hemicraniectomy (DHC) is frequently a life-saving procedure that has shown the highest grade of evidence for patients 18 to 60 years of age. However, the efficacy of DHC in patients >60 years of age has rarely been investigated. Methods: A retrospective study was conducted in a single academic institution. Surrogates of patients with clinical signs of impending brain herniation despite standard medical therapy were offered the option of DHC regardless of age or the side of the lesion. The clinical data from 18 patients >60 years of age who underwent DHC for malignant hemispheric infarction in our institution were analyzed. Patients were classified into the following 2 groups: 61-70 and >70 years of age, and their demographics and surgical outcomes were compared. The variables compared included the male: female ratio, side of the lesion, type of stroke, site of vascular occlusion, use of thrombolytic therapy, National Institutes of Health Stroke Scale score, stroke onset-to-DHC interval, duration of hospital stay, infectious complications, and 90-day mortality rate. Results: There were no significant intergroup differences in any of the demographic variables evaluated. However, the 30-day mortality rate was significantly higher in the group that was >70 years of age (0% v 60%; P = .01) than in the group that was 61 to 70 years of age. Conclusions: We suggest that the efficacy of DHC in malignant hemispheric stroke patients between 61 and 70 years of age be further investigated in future randomized trials. By contrast, it appears unlikely that patients >70 years of age would benefit from DHC.

Patients with aneurysmal subarachnoid hemorrhage (SAH) are frequently complicated by acute cardiac dysfunctions, including cardiac wall motion abnormality (WMA). Massive release of catecholamine into the systemic circulation after aneurysmal rupture is believed to result in WMA, and poor-grade SAH seems to be the most important risk factor. However, plasma catecholamine levels have rarely been measured in SAH patients with WMA, and previous studies indicated that the elevated levels might not necessarily predict WMA. The objective of this study is (1) to evaluate relationship between WMA and plasma catecholamine levels in poor-grade SAH patients in the acute phase and (2) to clarify clinical characteristics of SAH patients with WMA. Among 142 poor-grade (World Federation of Neurosurgical Societies grades IV and V) SAH patients, 48 underwent both transthoracic ultrasound and measurement of plasma catecholamine levels within 24 h of SAH onset. They were divided into WMA+ (n = 23) and WMA- (n = 25) groups, and intergroup comparison was made on demographics, plasma catecholamine levels, and outcomes. Plasma norepinephrine levels were significantly higher in WMA+ group than in WMA- group (2,098.4 +/- 1,773.4 vs. 962.9 +/- 838.9 pg/mL, p = 0.02), and the former showed significantly worse outcomes 90 days after admission. There were no intergroup differences in the plasma levels of epinephrine. Plasma norepinephrine levels were inversely correlated with left ventricular ejection fraction. Multivariate logistic regression analysis revealed that increased plasma norepinephrine levels were predictive of WMA, although age, female sex, and grade V SAH were not. This retrospective study highlights the role of norepinephrine in pathogenesis of SAH-induced WMA.

Objectives The great majority of non-traumatic cardiac arrests (CA) occur at home. The toilet is a closed and private room where CA occurs frequently. However, due to the feelings of privacy that are associated with this room, the circumstances and causes of CA in the toilet have rarely been investigated. Methods A retrospective study was conducted to clarify clinical characteristics and resuscitation profiles of patients sustaining CA in the toilet. Results Among 907 CA patients treated during a 4-year period, 101 (11 %) sustained CA in the toilet. While the collapse was witnessed in only 10 % of these patients, return of spontaneous circulation (ROSC) was achieved in 41 %. However, the long-term survival rate was 1 %. Multivariate regression analysis revealed that a history of cardiac diseases was predictive of CA in the toilet (odds ratio 3.045; 95 % confidence interval 1.756-5.282) but that there was no correlation with advanced age. The frequency of CA in the toilet may be influenced moderately by seasonal/circadian variations. The 101 patients were classified into four subgroups according to mode of discovery of CA. The frequency of ROSC was highest in those who collapsed in the presence of caregivers and lowest in those whose collapse were discovered later by family members being worried that the patient stayed in the toilet "too long." Imaging studies revealed life-threatening extra-cardiac lesions responsible for CA, such as subarachnoid hemorrhage and aortic dissection, in 23 % of the patient cohort. Conclusions The rarity of long-term survival among individuals sustaining CA in the toilet is mainly due to the delay in discovering the individual who collapsed. Although a history of cardiac diseases is a risk factor, predicting who may sustain CA in the toilet remains difficult due to etiological heterogeneity.

BACKGROUND: For cardiac arrest (CA) victims, brain computed tomography (CT) may serve as a prognosticator. Loss of gray-white matter discrimination (GWMD) and sulcal edema/effacement are reliable CT signs of hypoxia, and a time window may exist for development of these signs. Most data are derived from CA victims of cardiac etiology, however, and CT signs have rarely been evaluated in victims of CA secondary to subarachnoid hemorrhage (SAH). METHODS: A retrospective study was conducted to clarify the incidence, temporal profile, and prognostic significance of early CT signs in resuscitated SAH-CA patients. RESULTS: During a 6-year period, 35 SAH-CA patients were identified. CT signs were observed in 94 %: loss of GWMD was observed in 94 %, whereas sulcal edema/effacement was observed in 77 %. In 29 patients, the interval between CA and the return of spontaneous circulation (ROSC) was estimated. CT signs developed almost invariably when the CA-ROSC interval exceeded 10 min. Loss of GWMD always preceded sulcal edema/effacement. None of the 35 patients achieved long-term survival, regardless of the presence of the CT signs. CONCLUSION: CT signs may develop earlier in patients with SAH-CA than CA of cardiac origin. Because of a poor prognosis, early CT signs are not useful prognosticators in that population.

The outcomes of patients with traumatic cardiac arrest (TCA) have been dismal. However, imaging modalities are improving rapidly and are expected to play a role in treatment of patients with TCA. In this retrospective study, whether obtaining computed tomography (CT) immediately after resuscitation had any clinical value was evaluated. Among 145 patients with TCA admitted to our institution during 4 years, hemodynamically stable return of spontaneous circulation (ROSC) was achieved in 38 (26%). Brain and cervical spine CT was obtained prospectively, and the frequency and type of traumatic brain injury (TBI)/upper cervical spine injury (UCSI) were investigated. CT was performed uneventfully in all patients with an average door-to-CT time of 51.5 ± 18.6 min. Twenty (53%) had CT evidence of TBI. However, no patients underwent brain surgery because of lack of return of brainstem functions. Among the 18 patients without TBI, CT signs of hypoxia were present in 15 patients (39%), and CT was considered intact in 3 patients (8%). None of the 35 patients with abnormal CT findings survived, and the presence of such findings predicted fatality with high sensitivity and specificity. While 13 of the 38 patients (34%) had CT evidence of UCSI, concomitant TBI and USCI were uncommon. None of the 13 patients with UCSI underwent spine surgery because of lack of return of brainstem functions, and the presence of USCI might also be associated with fatality. Although obtaining CT was useful in the prognostication of TCA patients with ROSC, it did not have much impact in therapeutic decision making. © 2013 by The Japan Neurosurgical Society.

A 62-year-old man with diabetes and a history of ischemic coronary disease visited the emergency department complaining of acute pain and swelling of the tongue. Physical examination found subtle swelling and pallor of the right side of the tongue, and he was initially diagnosed with glossitis. However, his symptoms were progressive, and the tongue had sustained serious tissue damage before the correct diagnosis was established. Digital subtraction angiography of the cervical vessels revealed occlusion of the right external carotid artery (ECA) and lingual artery without collateral circulation to the right side of the tongue from the contralateral ECA or ipsilateral vertebral artery (VA). Endovascular revascularization was performed to restore blood flow to the tongue using balloon angioplasty of the proximal segment of the right ECA followed by deployment of a self-expanding stent. Tongue pain subsided shortly after the procedure, and configuration of the tongue returned to normal 4 months after intervention. Tongue infarction is rare and usually associated with systemic vasculitides. Tongue infarction due to unilateral occlusion of the ECA is extremely rare because of the rich collateral circulation to the tongue from the ipsilateral VA and contralateral ECA. Atherothrombotic unilateral occlusion of the ECA should be included in the differential diagnosis of tongue infarction. Revascularization of the occluded ECA is worth attempting despite substantial tissue damage because of the viability of the tongue muscles and the minimal risk of complications in experienced hands.

Neurogenic pulmonary edema (NPE) occurs frequently after aneurysmal subarachnoid hemorrhage (SAH), and excessive release of catecholamines (epinephrine/norepinephrine) has been suggested as its principal cause. The objective of this retrospective study is to evaluate the relative contribution of each catecholamine in the pathogenesis of NPE associated with SAH. Records of 63 SAH patients (20 men/43 women) whose plasma catecholamine levels were measured within 48 h of SAH onset were reviewed, and the clinical characteristics and laboratory data of those who developed early-onset NPE were analyzed thoroughly. Seven patients (11 %) were diagnosed with NPE on admission. Demographic comparison revealed that the NPE+ group sustained more severe SAH than the NPE- group. Cardiac dysfunction was also significantly more profound in the former, and the great majority of the NPE+ group sustained concomitant cardiac wall motion abnormality. There was no significant difference in the plasma epinephrine levels between NPE+ and NPE- group (324.6 +/- 172.8 vs 163.1 +/- 257.2 pg/ml, p = 0.11). By contrast, plasma norepinephrine levels were significantly higher in the NPE+ group (2977.6 +/- 2034.5 vs 847.9 +/- 535.6 pg/ml, p < 0.001). Multivariate regression analysis revealed that increased norepinephrine levels were associated with NPE (OR, 1.003; 95 % CI, 1.002-1.007). Plasma epinephrine and norepinephrine levels were positively correlated (R = 0.48, p < 0.001). According to receiver operating characteristic curve analysis, the threshold value for plasma norepinephrine predictive of NPE was 2,000 pg/ml, with an area under the curve value of 0.85. Elevated plasma norepinephrine may have more active role in the pathogenesis of SAH-induced NPE compared with epinephrine, although both catecholamines may be involved via multiple signaling pathways.

Neurogenic pulmonary edema (NPE) occurs frequently after aneurysmal subarachnoid hemorrhage (SAH), and excessive release of catecholamines (epinephrine/norepinephrine) has been suggested as its principal cause. The objective of this retrospective study is to evaluate the relative contribution of each catecholamine in the pathogenesis of NPE associated with SAH. Records of 63 SAH patients (20 men/43 women) whose plasma catecholamine levels were measured within 48 h of SAH onset were reviewed, and the clinical characteristics and laboratory data of those who developed early-onset NPE were analyzed thoroughly. Seven patients (11 %) were diagnosed with NPE on admission. Demographic comparison revealed that the NPE+ group sustained more severe SAH than the NPE- group. Cardiac dysfunction was also significantly more profound in the former, and the great majority of the NPE+ group sustained concomitant cardiac wall motion abnormality. There was no significant difference in the plasma epinephrine levels between NPE+ and NPE- group (324.6 +/- 172.8 vs 163.1 +/- 257.2 pg/ml, p = 0.11). By contrast, plasma norepinephrine levels were significantly higher in the NPE+ group (2977.6 +/- 2034.5 vs 847.9 +/- 535.6 pg/ml, p < 0.001). Multivariate regression analysis revealed that increased norepinephrine levels were associated with NPE (OR, 1.003; 95 % CI, 1.002-1.007). Plasma epinephrine and norepinephrine levels were positively correlated (R = 0.48, p < 0.001). According to receiver operating characteristic curve analysis, the threshold value for plasma norepinephrine predictive of NPE was 2,000 pg/ml, with an area under the curve value of 0.85. Elevated plasma norepinephrine may have more active role in the pathogenesis of SAH-induced NPE compared with epinephrine, although both catecholamines may be involved via multiple signaling pathways.

Aim: Ground-level fall is the most common cause of traumatic intracranial hemorrhage (TICH) in the elderly, and is a major cause of morbidity and mortality in that population. A retrospective study was carried out to evaluate whether the use of warfarin/low-dose aspirin (LDA) is predictive of unfavorable outcomes in geriatric patients who sustain a fall-induced TICH. Methods: Charts of 76 geriatric patients (=65 years-of-age) with fall-induced TICH were reviewed. The number of patients taking warfarin and LDA was 12 and 21, respectively, whereas the other 43 took neither medication (non-user group). The frequency of patients with unfavorable outcomes (Glasgow Outcome Scale score of 13) at discharge was calculated. Furthermore, variables predictive of unfavorable outcomes were identified by logistic regression analysis. Results: The frequency of patients with unfavorable outcomes was 75% in the warfarin group, 33% in the LDA group and 27% in the non-user group, respectively. The risk of having unfavorable outcomes was significantly higher in the warfarin group compared with the LDA group (P = 0.03) and non-user group (P < 0.01). Logistic regression analysis showed that variables predictive of unfavorable outcomes were: age, initial Glasgow Coma Scale score = 13 and presence of midline shift = 5 mm. Conclusion: The use of warfarin, but not of LDA, might be associated with unfavorable outcomes in elderly with fall-induced TICH. The risk of TICH should be communicated properly to elderly taking warfarin. The information might be important not only to trauma surgeons who take care of injured elderly, but also to geriatric physicians who prescribe warfarin/LDA to them. Geriatr Gerontol Int 2012; 12: 667-672.

A 71-year-old woman presented with a rare case of geriatric ependymoma originating from the fourth ventricle manifesting as progressive gait and memory disturbance. Imaging studies revealed an extraaxial mass in the fourth ventricle protruding into the right cerebellomedullary cistern, with concomitant obstructive hydrocephalus. Surgery achieved subtotal removal since the tumor tightly adhered to the right vestibular area of the fourth ventricular floor. The histological diagnosis was ependymoma, which was also confirmed by comparative genetic hybridization. Although she developed severe laryngeal edema and worsening of the hydrocephalus postoperatively which required additional treatment, she recovered with residual mild gait disturbance, and was transferred to a rehabilitation facility. Fourth ventricle ependymoma in the elderly is rare. Comparative genetic hybridization may be important in the diagnosis of geriatric ependymoma and in the choice for adjuvant therapy as well as in estimating the prognosis for patients with rare types of ependymoma.

Background and Purpose-The majority of patients with ventricular wall motion abnormality (WMA) associated with subarachnoid hemorrhage (SAH) are postmenopausal women. In addition to elevated catecholamine, the role of estrogen in the pathogenesis of WMA has recently been implicated. The objective of this study is to clarify the interrelation among catecholamine, estrogen, and WMA in patients with SAH. Methods-A retrospective analysis was performed on the medical records of 77 patients with SAH (23 men, 54 women) whose plasma levels of epinephrine, norepinephrine, and estradiol had been measured and echocardiograms had been obtained within 48 hours of SAH onset. Results-Twenty-four patients (31%) were found to sustain WMA on admission. Multivariate regression analysis revealed that decreased estradiol (P=0.018; OR, 0.902) and elevated norepinephrine levels (P=0.027; OR, 1.002) were associated with WMA. After quadrichotomization of 77 patients based on sex/WMA, plasma norepinephrine levels were markedly elevated in men with WMA, whereas estradiol levels were markedly decreased in women with WMA. Plasma norepinephrine and estradiol levels were not correlated. Fifty-four female patients with SAH were further quadrichotomized based on norepinephrine/estradiol levels with a threshold value of 1375 pg/mL for norepinephrine and 11 pg/mL for estradiol. The incidence of WMA in the high-norepinephrine/low-estradiol group was significantly higher than the low-norepinephrine/high-estradiol group. Conclusions-To our knowledge, this is the first study to evaluate the interrelation among catecholamine, estrogen, and SAH-induced WMA. Lack of estradiol in postmenopausal women may predispose them to develop WMA after poor-grade SAH. However, the precise role of multiple sex hormones in SAH-induced WMA should be evaluated in future prospective studies. (Stroke. 2012;43:1897-1903.)

A 48-year-old man with a history of a penetrating brain injury was referred with a presumptive diagnosis of bacterial meningitis. Examination revealed a brain abscess in addition to meningitis. Blood and cerebrospinal fluid (CSF) cultures were negative for bacteria, and empirical IV antibiotic therapy with vancomycin (VCM) and meropenem was initiated. Despite initial improvement, however, his condition rapidly deteriorated into coma following intraventricular rupture of the abscess and hydrocephalus. Thereafter, an emergency ventriculostomy was performed and the abscess was evacuated. Bacterial cultures of the pus were negative. To manage the hydrocephalus, 150-200 ml of CSF were drained daily. Intraventricular administration of VCM (20 mg q.d.) was added to the IV antibiotic therapeutic regimen after surgery. Although the primary abscess rapidly decreased in size, ependymitis developed in the fourth ventricle. This new lesion, which resulted from CSF dissemination from the primary abscess, was refractory to treatment, and eventually disappeared after the intraventricular VCM dosage was increased from 20 to 30 mg and continued for 30 days. A possible reason for the development of fulminant ependymitis and why it was refractory to treatment despite the shrinkage of the primary lesion may be that physiological CSF flow from the lateral to the fourth ventricle was lost due to CSF drainage, and the stagnant CSF flow coupled with an insufficient VCM level in the fourth ventricle facilitated the rapid growth of pathogens. Although intraventricular antibiotic administration is efficacious for treating ruptured brain abscesses, it may be associated with the unexpected development of secondary lesions.

Brain CT obtained from cardiac arrest (CA) victims immediately after resuscitation may be useful in predicting their outcomes. Most data have been derived from CA victims of cardiac etiology, however, CT signs of brain ischemia/hypoxia have rarely been studied in victims of asphyxial CA. Loss of gray-white matter discrimination (GWMD) at the basal ganglia seems to be the most reliable early CT sign of brain ischemia/hypoxia a retrospective study was conducted to clarify its incidence, prognostic significance, and temporal profile in resuscitated victims of CA by food asphyxiation. Brain CT scans of each victim were interpreted by two blinded observers. During a 5-year period, 39 resuscitated victims of CA by food asphyxiation underwent brain CT. Thirty-one (79%) showed loss of GWMD, none of whom survived to discharge. Among the other eight victims with seemingly intact brain CT, five (63%) survived to discharge. Loss of GWMD predicted fatality with sensitivity of 100% and specificity of 63%. The interobserver concordance was 82% with kappa coefficient of 0.56. Loss of GWMD developed almost invariably when the asphyxiation-return of spontaneous circulation (ROSC) interval exceeded 10 min. There were five victims with asphyxiation-ROSC interval≤10 min, all of whom survived to discharge. In contrast, none of the 34 victims with the interval &gt 10 min survived to discharge. Loss of GWMD may develop in a relatively time-dependent manner and may be a reliable radiographic indicator of poor outcome in resuscitated victims of asphyxial CA. © Am Soc Emergency Radiol 2011.

Background Sudden loss of consciousness (LOC) and chest pain are common manifestations of out-of-hospital cardiac arrest (OHCA). History of acute pain may be helpful in estimating aetiology and prognosis of OHCA victims. The objective of this study was to evaluate the relationship between acute pain at various locations preceding collapse and outcome. Methods Clinical data of 250 witnessed, non-traumatic OHCA victims were reviewed, and the incidence of pain based on anatomical distribution was documented. The focus was on identifying the difference between those collapsing with LOC alone and those collapsing with chest pain (CP). Clinical variables predictive of survival were identified using a logistic regression model. Results Among the 250 victims, 55.2% collapsed with LOC alone. The incidence of acute pain was: 28.0% for CP, 3.2% for headache, 2.8% for abdominal pain and 2.4% for back pain. The overall 6-month survival rate was 7.2%. The LOC group had a significantly higher return of spontaneous circulation (ROSC) rate compared with the CP group (48.6% vs 31.4%, p < 0.05). The rate was elevated in the LOC group; however, only when the initial rhythm was non-shockable. There was no significant intergroup difference in the survival rate. Initial shockable rhythm positively and history of cardiovascular diseases negatively predicted survival. None of the victims in the headache, abdominal pain or back pain groups survived. Conclusion The LOC group's seemingly higher ROSC rate may be due to its aetiological heterogeneity. Complaint of a headache, abdominal pain or back pain in OHCA victims carries a poor prognosis.

A case of reversible pontine ischemia following diagnostic cerebral angiography performed to evaluate vertebral artery dissection (VAD) of ischemic onset is reported. A 40-year-old man presented with sudden neck pain, dizziness, difficulty in swallowing, and numbness in the left arm. Neurologically, his symptoms were compatible with incomplete Wallenberg syndrome. Diffusion-weighted magnetic resonance imaging (DWI) revealed a small infarction in the medulla oblongata, and the right VA was irregularly stenotic on magnetic resonance angiography (MRA). We suspected that the right VAD was the cause of the medullary infarction. Following conservative treatment, his deficits resolved quickly despite progression of the VAD as revealed by follow-up MRA. Subsequently, diagnostic cerebral angiography was performed with the purpose of evaluating the patency of the right VA and possibility of a dissecting aneurysm. Despite a seemingly uneventful procedure, however, the patient developed altered mental status and right-sided hemiparesis shortly after the placement of an angiographic catheter into the intact left VA. DWI obtained two hours after the procedure revealed a high-intensity signal in the paramedian pons. Following administration of IV heparin and edaravone, the neurological deficits as well as the high-intensity signal disappeared within 24 h. The patient was discharged without deficits 4 weeks after onset. Although cerebral angiography has been considered the gold standard for the diagnosis of VAD, its role in VAD of ischemic onset has recently been questioned, in light of its relatively benign natural history, improved quality of less invasive imaging modalities, and risks of cerebral angiography. From the perspective of avoiding complications, the common practice of obtaining diagnostic cerebral angiography from every patient with VAD of ischemic onset may have to be reviewed, and decision to perform cerebral angiography for those who have already been diagnosed with less invasive imaging modalities should be made cautiously and on case-by-case basis.

Ground-level fall is the most common cause of traumatic intracranial hemorrhage (TICH) in the elderly. Many studies on geriatric TICH have regarded patients aged a >= 65 years as a single group, but substantial heterogeneity is likely to exist within this population. Eighty-two elderly patients with fall-related TICH treated in our institution during a 6-year period were stratified into 3 age groups (65-74, 75-84, and >= 85 years), and intergroup differences in the demographics and outcomes at discharge were evaluated. The influence of the use of anti-platelet/anti-coagulant (AP/AC) agent on outcomes was also investigated. Comparison of demographic variables demonstrated significant differences in the frequency of preinjury alcohol consumption and use of AP/AC agents between the 3 groups, indicating that the causes or triggers of fall might be substantially different between the 65-74 years group and the other two groups combined. The frequency of unfavorable outcomes increased with age, and the increase was statistically significant. The 82 patients were divided into two subgroups depending on the use of AP/AC agents. The outcomes of the a >= 85 years group taking AP/AC agents were particularly poor compared with those of the a >= 85 years group not using AP/AC agents. Advancing age may be associated with unfavorable outcomes in elderly patients with fall-related TICH, and patients aged >= 85 years taking AP/AC have the greatest risk of unfavorable outcomes. Physicians must consider the risk/benefit analysis before prescribing AP/AC agents to patients aged >= 85 years.

Aim: Food Food asphyxiation is uncommon but unignorable cause of sudden death in the elderly. Several autopsy studies, which identified those at particular risk, have been conducted on the subject. Resuscitation profiles and outcomes of food asphyxiation victims presenting with out-of-hospital cardiac arrest (OHCA) to the emergency department, however, have rarely been reported. Methods: Data on adults (>= 20 years) presenting with OHCA after witnessed food asphyxiation were retrieved from an institutional database. Clinical variables were evaluated to identify their demographic characteristics. Their outcomes, represented by return of spontaneous circulation (ROSC) and survival rate, were also investigated. Results: Sixty-nine food asphyxiation victims presenting with OHCA were identified during the 4-year period. Food asphyxiation occurred most frequently in the age group of 71-80 years, followed by that of 81-90 years. The majority of victims had medical conditions that adversely affected mastication/swallowing, such as dementia. Bystander cardiopulmonary resuscitation (CPR) was performed only in 26%, although bystanders often attempted to clear the airway without performing CPR. Despite the high ROSC rate of 78%, only 7% survived to discharge. Asphyxiation-ROSC interval might play a crucial role in determining the outcomes: the interval was <= 10 min in all survivors, while it was longer than 10 min in all non-survivors. Conclusion: Because of their advanced age and debilitating general condition, it may be difficult to substantially improve the outcomes of food asphyxiation victims. Effort should be directed to prevent food asphyxiation, and public education to perform standard CPR for food asphyxiation victims including the Heimlich manoeuvre is warranted. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

BACKGROUND: Neurosurgeons have been familiar with the idea that hypothermia is protective against various types of brain injuries, including traumatic brain injury (TBI). Recent randomized controlled trials, however, have failed to demonstrate the efficacy of therapeutic hypothermia (TH) in patients with TBI. On the other hand, TH becomes popular in the treatment of out-of-hospital cardiac arrest (OHCA) survivors, after randomized controlled trials have shown that survival rate and functional outcome is improved with the use of TH in selected patients. We believe that knowledge on the recent progress in TH for OHCA is useful for neurosurgeons, because feedback of information obtained in the treatment of OHCA may revitalize the interest in TH for neurosurgical disorders, particularly TBI. METHODS: A review of the literature was conducted with the use of PubMed. RESULTS: Various cooling techniques and devices have been developed and trialed in the treatment of OHCA survivors, including prehospital cooling with bolus ice-cold saline, endovascular cooling catheters, and new generation surface cooling devices, some of which have already been known to neurosurgeons. The efficacy of these new methods and devices has been demonstrated in many preliminary studies, and phase III trials are also expected. CONCLUSIONS: Neurosurgeons and critical care medicine physicians pursue the same goal of rescuing the brain from the secondary injury despite the difference in etiology (focal trauma vs. global ischemia), with the presumption that earlier and faster implementation of TH will result in better outcome. Thoughtful application of knowledge and techniques obtained in OHCA to TBI under a rigorously controlled situation will make a small, but significant difference in the outcome of TBI victims.

Epidural hematoma (EDH) is a rare complication of vacuum-assisted delivery in neonates. Although the standard treatment of EDH is surgical evacuation via craniotomy, it is an invasive procedure in neonates, and less invasive methods may be favored for hematoma evacuation. We report a case of 5-day-old infant with a massive EDH, cephalohematoma, and a depressed fracture, which were secondary to a vacuum-assisted delivery and cured by ultrasound-guided needle aspiration and drainage. Neonatal EDH may be different from adult counterpart in that the former is more liquefied and is amenable to needle aspiration than the latter. Although needle aspiration is a blind procedure, addition of transcranial ultrasound not only ensures safety by visualizing the tip of the needle but also makes real-time evaluation of the residual hematoma volume possible.

Aim: Although computed tomography (CT) signs of ischaemia, including loss of boundary (LOB) between grey matter and white matter and cortical sulcal effacement, in cardiac arrest (CA) survivors are known, their temporal profile and prognostic significance remains unclear: their clarification is necessary. Methods: Brain CT scans were obtained immediately after resuscitation in 75 non-traumatic CA survivors in a prospective fashion. They were divided into two groups according to the CA-return of spontaneous circulation (ROSC) interval: <= 20 min vs. > 20 min. The incidence of the CT signs and predictability of these signs for outcome, assessed 6 months after CA, was evaluated and compared. Results: The incidence of the positive LOB sign was 24% in the <= 20-min group and 83% in the > 20-min group, and the difference was statistically significant (p < 0.001). The interval of 20 min seemed to be the time window for the LOB development. The incidence of the positive sulcal effacement sign was 0% in the <= 20 min group and 34% in the > 20-min group, and the difference was statistically significant (p = 0.004). A positive LOB sign was predictive of unfavourable outcome with an 81% sensitivity and 92% specificity. A positive sulcal effacement sign was predictive of unfavourable outcome with a 32% sensitivity and 100% specificity. Conclusion: A time window may exist for ischaemic CT signs in CA survivors. The LOB sign may develop when the CA-ROSC interval exceeds 20 min, whereas the sulcal effacement sign may develop later. However, their temporal profile and outcome predictability should be verified by multicentre studies. (c) 2010 Elsevier Ireland Ltd. All rights reserved.

Patients with hematological malignancies may develop white matter lesions, which are usually associated with chemotherapy. Magnetic resonance imaging (MRI) is the imaging modality of choice for identifying chemotherapy-induced, or "toxic", leukoencephalopathy. Brain biopsy in patients with hematological malignancies suspected of sustaining toxic leukoencephalopathy has rarely been performed, because its characteristic MRI findings are considered pathognomotic. Biopsy may be indicated in atypical cases, however, and it may yield unexpected results. We describe a case with white matter lesions that developed in an elderly man treated for non-Hodgkin's lymphoma. The lesions, initially diagnosed with toxic leukoencephalopathy based on MRI findings, turned out to be gliomatosis cerebri.

A 23-year-old male was admitted after a motor vehicle accident with acute epidural hematoma, diffuse subarachnoid hemorrhage (SAH) in the basal cistern, and fractures at the anterior cranial base. Angiography revealed an aneurysm of the right supraclinoid internal carotid artery (ICA). His consciousness suddenly worsened on the 23rd day. Expansion of the SAH in the basal cistern and two hump aneurysms were detected. He underwent endovascular embolization of these aneurysms and the right ICA with Guglielmi detachable coil. Traumatic aneurysms are difficult to diagnose in the early period after injury and are associated with a high mortality. Endovascular treatments for traumatic aneurysms have lower mortality rate, and can be performed under local anesthesia.

Motor vehicle collision (MVC) is one of the most common causes of thoracolumbar junction (TLJ) injury. Although it is of no doubt that the use of seatbelt reduces the incidence and severity of MVC-induced TLJ injury, how it is protective for front-seat occupants of an automobile after rollover crashes is unclear. Among 200 consecutive patients with a major TLJ (Th11-L2) injury due to high-energy trauma admitted from 2000 to 2004, 22 patients were identified as front-seat occupants of a four-wheel vehicle when a rollover crash occurred. The 22 patients were divided into two groups: 10 who were belted, and 12 who were unbelted. Patients' demographics including the mean Injury Severity Score (ISS), incidence of neurologic deficit, level of TLJ injury, and type of TLJ injury according to the AO fracture classification were compared between the two groups. Neurologic deficit was present exclusively in the unbelted group, and the difference in the incidence was statistically significant (P = 0.04). Similarly, AO type B/C injury was present exclusively in the unbelted group. The belted group had a significantly lower mean ISS than the unbelted group (P < 0.01). Comparison between the ejected and non-ejected victims within the unbelted group revealed no statistical difference in the incidence of neurologic deficit or type of injury. It is likely that the high incidence of neurologic deficit in the unbelted group was due to the high incidence of AO type B/C injury. This study indirectly proves the efficacy of seatbelt in reducing the severity of rollover-induced TLJ injury. Because of the limited number of cases, it is uncertain whether ejection from vehicle, which occurs exclusively in the unbelted victims, is a crucial factor in determining the severity or type of injury after rollover crashes.

Headache is one of the most common manifestations of non-traumatic intracranial hemorrhage, which is an uncommon, but not rare, cause of cardiac arrest in adults. History of a sudden headache preceding collapse may be a helpful clue to estimate the cause of out-of-hospital cardiac arrest (OHCA). Medical records of witnessed OHCA patients were reviewed to identify those who complained of a sudden headache preceding collapse, and the incidence of intracranial hemorrhage among them as well as their clinical characteristics was investigated retrospectively. During the 12-month period, 124 patients who sustained a witnessed OHCA were treated. Among them, 74 (60%) collapsed without any pain complaint, and only 6 (5%) complained of a sudden headache preceding collapse. All of the six patients were resuscitated: four had a severe subarachnoid hemorrhage (SAH), while the other two had a massive cerebellar hemorrhage. By contrast, 39 of the 74 patients who collapsed without any pain were resuscitated. Among them, another six patients were found to harbor an SAH. Thus, a total of 12 among the 124 witnessed OHCA (10%) sustained a fatal intracranial hemorrhage. While OHCA patients who collapse complaining of a sudden headache are uncommonly seen in the emergency room, they have a high likelihood of harboring a severe intracranial hemorrhage. It should also be reminded that approximately half of patients whose cardiac arrest is due to an intracranial hemorrhage may collapse without complaining of a headache. The prognosis of those with cerebral origin of OHCA is invariably poor, although they may relatively easily be resuscitated temporarily. Focus needs to be directed to avoid sudden death from a potentially treatable cerebral lesion, and public education to promote the awareness for the symptoms of potentially lethal hemorrhagic stroke is warranted.

Aim: Aneurysmal subarachnoid haemorrhage (SAH) is a relatively common cause of out-of-hospital cardiac arrest (OHCA). Early identification of SAH-induced OHCA with the use of brain computed tomography (CT) scan obtained immediately after resuscitation may help emergency physicians make therapeutic decision as quickly as they can. Methods: During the 4-year observation period, brain CT scan was obtained prospectively in 142 witnessed non-traumatic OHCA survivors who remained haemodynamically stable after resuscitation. Demographics and clinical characteristics of SAH-induced OHCA survivors were compared with those with "negative" CT finding. Results: Brain CT scan was feasible with an average door-to-CT time of 40.0 min. SAH was found in 16.2% of the 142 OHCA survivors. Compared with 116 survivors who were negative for SAH, SAH-induced OHCA survivors were significantly more likely to be female, to have experienced a sudden headache, and trended to have achieved return of spontaneous circulation (ROSC) prior to arrival in the emergency department less frequently. Ventricular fibrillation (VF) was significantly less likely to be seen in SAH-induced than SAH-negative OHCA (OR, 0.06; 95% CI, 0.01-0.46). Similarly, Cardiac Trop-T assay was significantly less likely to be positive in SAH-induced OHCA (OR, 0.08; 95% CI, 0.01-0.61). Conclusion: Aneurysmal SAH causes OHCA more frequently than had been believed. Immediate brain CT scan may particularly be useful in excluding SAH-induced OHCA from thrombolytic trial enrollment, for whom the use of thrombolytics is contraindicated. The low VF incidence suggests that VF by itself may not be a common cause of SAH-induced OHCA. (C) 2009 Elsevier Ireland Ltd. All rights reserved.

A 66-year-old man developed tension pneumocephalus after failed lumbar drainage before clipping surgery for a ruptured anterior communicating artery aneurysm. After puncture with a Tuohy needle, the spinal catheter could not be inserted into the spinal dura, so surgery proceeded without the catheter placement. The patient's neurological status deteriorated suddenly into coma within 15 hours after uneventful clipping of the aneurysm. Computed tomography revealed tension pneumocephalus with marked brain shift. Intracranial hypotension was probably caused by continuous cerebrospinal fluid leakage from the iatrogenic spinal dural tear, resulting in air entry and accumulation into the cranium from an unidentified opening of the cranial dura. The patient was immediately treated with autologous epidural blood patch administration in the lumbar spine, followed by reopening of the craniotomy incision and flap to evacuate the accumulated air. The patient made a quick and uneventful neurological recovery after the rescue procedure.

目的：近年，法医学の分野で，死後に血清のケトン体を測定することが，死因の推定において有用であるとする報告がある。我々は当院救命救急センターに搬送された院外心肺停止症例に対し，血清ケトン体である3-ヒドロキシ酪酸（3-hydroxybutyrate; 3-HB）を測定し検討した。対象と方法：2008年1月から2008年4月までの間に当施設に搬送された院外心肺停止症例125例（外傷による心肺停止例，小児例は除く）のうち，3-HBを測定し得た69例を対象とした。69例は3-HB値に基づき4群に分類した。3-HB値が1,000 μmol/l以上をA群，200～1,000 μmol/lをB群，50～200 μmol/lをC群，50 μmol/l以下をD群とした。3-HB値を測定し得た症例の診療録をもとに病歴・身体所見・血液検査所見・画像所見からケトン体の上昇を来す病態（飢餓・高血糖・感染）を有する症例を抽出した。69例のうち自殺・明らかな窒息・溺水の11例を除く内因性の院外心肺停止症例58例について，病悩期間なく突然に心肺停止に至ったものをaccidental episodes群（AE群32例），病悩期間を経て心肺停止に至ったものを非AE群26例とした。両群間の3-HB値を検討し，Mann-Whitney's U testを用いて有意差検定を行い，p<0.05を有意差ありとした。結果：69例の内訳は，男性37例，女性32例，年齢は16歳から92歳（中央値75歳）であった。69例のうち19例にケトン体の上昇を来す病態である飢餓・高血糖・感染を認めた。ケトン体の上昇を来すとされる要因が，それぞれA群で100%（5例），B群で86%（6例），C群で22%（6例），D群で7%（2例）に認められた。またAE群，非AE群間の比較では，非AE群において有意に3-HB値が高値であった。結語：心肺停止患者の3-HB値が高値である場合には，心肺停止に先立ちケトン体の上昇を来す病態が存在した可能性が高い。

A 28-year-old woman presented with classic signs of measles and subsequently developed bilateral retrobulbar optic neuritis and Guillain-Barre syndrome. Her radiographic and CSF findings were consistent with acute measles encephalitis. However, encephalopathy, such as behavioral changes and alteration in consciousness, was not presented. Improvements in the clinical, radiographic, and electrophysiological studies were observed during the steroid therapy. The overlap of CNS and PNS involvement as neurological complications of measles infection is very rare.