Derivation of Coagulation Phenotypes and the Association with Prognosis in Traumatic Brain Injury: A Cluster Analysis of Nationwide Multicenter Study.

BACKGROUND: The pathogenesis and pathophysiology of traumatic coagulopathy during traumatic brain injury is not well understood, and the appropriate treatment strategy for this condition has not been established. This study aimed to evaluate the coagulation phenotypes and their effect on prognosis in patients with isolated traumatic brain injury. METHODS: In this multicenter cohort study, we retrospectively analyzed data from the Japan Neurotrauma Data Bank. Adults with isolated traumatic brain injury (head abbreviated injury scale > 2; abbreviated injury scale of any other trauma < 3) who were registered in the Japan Neurotrauma Data Bank were included in this study. The primary outcome was the association of coagulation phenotypes with in-hospital mortality. Coagulation phenotypes were derived using k-means clustering with coagulation markers, including prothrombin time international normalized ratio (PT-INR), activated partial thromboplastin time (APTT), fibrinogen (FBG), and D-dimer (DD) on arrival at the hospital. Multivariable logistic regression analyses were conducted to calculate the adjusted odds ratios of coagulation phenotypes with their 95% confidence intervals (CIs) for in-hospital mortality. RESULTS: In total, 556 patients were enrolled and five coagulation phenotypes were identified. The median (interquartile range) score for the Glasgow Coma Scale was 6 (4-9). Cluster A (n = 129) had the closest to normal coagulation values; cluster B (n = 323) had a mild high DD phenotype; cluster C (n = 30) had a prolonged PT-INR phenotype with a higher frequency of antithrombotic medication in elderly patients than in younger patients; cluster D (n = 45) had a low amount of FBG, high DD, and prolonged APTT phenotype with a high incidence of skull fracture; and cluster E (n = 29) had a low amount of FBG and extremely high DD phenotype with high energy trauma and a high incidence of skull fracture. In the multivariable logistic regression analysis, the association of clusters B, C, D, and E with in-hospital mortality yielded the corresponding adjusted odds ratios of 2.17 (95% CI 1.22-3.86), 2.61 (95% CI 1.01-6.72), 10.0 (95% CI 4.00-25.2), and 24.1 (95% CI 7.12-81.3), respectively, relative to cluster A. CONCLUSIONS: This multicenter, observational study identified five different coagulation phenotypes of traumatic brain injury and showed associations of these phenotypes with in-hospital mortality.

Discriminative Ability of Dynamic Chest Radiography to Identify Left Ventricular Dysfunction.

BACKGROUND: Dynamic chest radiography (DCR) produces sequential radiographs within a short examination time. It is also inexpensive and only uses a low dose of radiation. Because of the lack of reports of evaluating cardiac function using DCR in humans, we investigated its discriminative ability for left ventricular (LV) dysfunction in a study cohort.Methods and Results: We analyzed the DCR pixel values of 4 circular regions of interest (ROIs) in the hearts of 61 patients with cardiovascular disease and 10 healthy volunteers. We evaluated the relationship between changes in pixel value in the heart and the LV ejection fraction (LVEF) by echocardiography. We constructed receiver operating characteristic (ROC) curves to evaluate whether the percent change in pixel value (%∆pixel value) could be used to identify patients with reduced LVEF. A total of 21 patients had reduced LVEF (LVEF <50%), and 40 had preserved LVEF (LVEF ≥50%). The correlation between LVEF and %∆pixel value in each ROI was significant, and the area under the ROC curve of the %∆pixel values for identifying patients with reduced LVEF was satisfactory (0.808-0.827) in 3 ROIs where the entire circular area was within the cardiac shadow. CONCLUSIONS: LV dysfunction can be detected by changes in the pixel value on DCR.

Verification of Usefulness of Pediatric Head Trauma Imaging Protocol Combining Computerized Tomography, Observation Unit, and Magnetic Resonance Imaging.

METHODS: This prospective observational study conducted in our hospital between October 2016 and September 2019 included 1946 patients aged 0 to 15 years with head trauma, of whom 1137 were analyzed. Computed tomography scan rate and imaging examination (CT or MRI) rate of our protocol were investigated. Sensitivity and negative predictive value (NPV) were calculated. We also compared our protocol and other clinical decision rules with respect to CT scan rate, sensitivity, and NPV in the same cohort and outcomes. RESULTS: The CT scan rate of our protocol was 7.9%, and the imaging examination rate, including MRI, was 12.2%. When the outcome was set to intracranial injury, the sensitivity and NPV of our protocol were each 100%. The CT scan rates in each cohort were 14.5% for PECARN (8.1% for our protocol), 34.7% for CATCH (23.2% for ours), and 13.6% for CHALICE (7.9% for ours). The sensitivity and NPV in each cohort were 100% and 100% for PECARN (92.3% and 100% for ours), 64.7% and 92.6% for CATCH (100% and 100% for ours), and 83.9% and 99.5% for CHALICE (100% and 100% for ours), respectively. CONCLUSIONS: The protocol we created by combining CT, observation unit, and MRI was considered to be useful for practice in pediatric head injury cases.

Does Transport by a Doctor Helicopter Affect Blood Pressure in Stroke Patients?

OBJECTIVE: Herein we investigate whether transportation by doctor helicopter (DH) affects blood pressure (BP) in stroke patients. METHODS: A total of 119 stroke patients treated by the DH between April 2015 and March 2019 were analyzed. The average BP before and after admission to the DH was compared for all stroke patients. The average BP before and after in the infarct group (cerebral infarction/transient ischemic attack) and the bleeding group (cerebral hemorrhage/subarachnoid hemorrhage) was compared. The average BP before and after in Glasgow Coma Scale (GCS) mild, moderate, and severe groups was also compared. Statistical analysis was performed using a paired t-test. RESULTS: The average BP of stroke patients increased after admission to the DH (before = 156.8 mm Hg and after = 165.0 mm Hg, P < .01). Both the infarct group and the bleeding group had elevated BP after admission (infarct group: before = 151.2 mm Hg and after = 157.8 mm Hg, P = .02; bleeding group: before = 167.5 mm Hg and after = 178.5 mm Hg, P = .04). The BP after admission was elevated only in the mild GCS group. CONCLUSION: When transporting conscious stroke patients by the DH, it is necessary to keep in mind that BP may elevate.

Criminal mercury vapor poisoning using heated tobacco product.

We report an unusual case of mercury vapor poisoning from using a heated tobacco product. The suspect had added grains of mercury into 20 cigarettes in a pack. When a 36-year-old Japanese man inserted one of these cigarettes into the battery powered holder, it was heated to a temperature of 350 °C, and he inhaled vaporized mercury. After using 14 of the cigarettes over 16 h, he noticed he had flu-like symptoms so he visited the hospital. Although no physical abnormalities were revealed, 99 µg/L of mercury was detected in his serum sample. His general condition improved gradually and his whole blood mercury level had decreased to 38 µg/L 5 days later. When the remaining six cigarettes in the pack were examined, many metallic grains weighing a total of 1.57 g were observed. Energy dispersive X-ray fluorescence spectrometry confirmed the grains as elemental mercury. Accordingly, the victim was diagnosed with mercury poisoning. Because the mercury was incorporated into cigarettes, an unusual and novel intoxication occurred through the heating of the tobacco product. Both medical and forensic scientific examination confirmed this event as attempted murder.

[Subarachnoid Hemorrhage of Unknown Origin at Initial Imaging Investigation].

In some patients with spontaneous subarachnoid hemorrhage(SAH), initial imaging investigations may not be able to detect a bleeding source;repeat imaging may be necessary to reveal these lesions. We reviewed a consecutive series of 45 patients with SAH and negative initial digital subtraction angiograms(DSA)during a 15-year period. The aims were to document the frequency and reason for the negative initial investigations, to determine the appropriate modality and timing of repeat examinations, and to investigate the identified bleeding sources. Twenty-eight(62%)patients underwent repeat DSA, 35(78%)underwent magnetic resonance imaging(MRI), and 33(73%)underwent computed tomography angiography(CTA). Nine lesions(5 small aneurysms, 2 craniocervical junction arteriovenous fistulas, 1 arteriovenous malformation, and 1 internal carotid artery dissection)were identified on subsequent DSA after 2-3 weeks. Most aneurysms were identified on an atypical vascular tree. CTA or MRI alone were unable to disclose the culprit lesions. In retrospect, human errors including oversight were the major reasons for the negative initial investigation results. It is, however, difficult to search for a tiny vascular lesion that might be anywhere in the cranium. Repeat DSA is still the gold standard for the inspection of hidden bleeding sources in patients with SAH of unknown origin.

[Emergency Decompressive Craniotomy in the Emergency Room was Effective in Severe Acute Subdural Hematoma Treatment:Two Case Reports].

The outcome of severe acute subdural hematoma is unfavorable. In particular, patients with levels of consciousness of Glasgow Coma Scale(GCS)3 or 4 tend to be refractory to treatment. Decompressive craniotomy should be promptly performed to remove hematoma. However, if an operating room is not immediately available, emergency burr hole surgery is sometimes performed in the emergency room(primary care room)prior to craniotomy. A previous study has reported that the interval from injury to surgery influences the outcome of severe acute subdural hematoma. Therefore, emergency decompression is important to effectively treat patients with severe acute subdural hematoma. We present the cases of two patients with acute subdural hematomas. In both cases, emergency decompressive craniotomy(hematoma removal after craniotomy and external decompression)was performed in the emergency room of the Emergency and Critical Care Center. In both cases, the surgery was followed by favorable outcomes. Case 1 was a 36-year-old female. The patient's level of consciousness upon arrival was GCS 3. The interval from injury to diagnosis on the basis of CT findings was 75 minutes. Surgery began 20 minutes after diagnosis. Case 2 was a 25-year-old male. The second patient's level of consciousness upon arrival was GCS 4. The interval from injury to diagnosis on the basis of CT findings was 60 minutes. Surgery was begun 40 minutes after diagnosis. In both patients, we observed anisocoria and the loss of the light reflex. However, the postoperative course was favorable, and both patients were discharged. In summary, to treat severe acute subdural hematomas, early emergency decompressive craniotomy is optimal. Emergency decompressive surgery in the emergency room is independent of operating room or staff. Therefore, emergency decompressive craniotomy may improve the outcome of patients with severe acute subdural hematomas.

The current status of reversal therapy in Japan for elderly patients with head injury treated with antithrombotic agents: A prospective multicenter observational study.

Background: Acute exacerbation of head injury in elderly patients due to use of antithrombotic agents has become a concern in countries with aging populations. Reversal agents are recommended for treatment, but its usage is unclear. Therefore, we conducted a prospective observational study in this patient population to monitor usage of reversal therapy. Methods: The subjects were 721 elderly patients aged ≥65 years old who were hospitalized in 15 centers from December 2019 to May 2021. Patients were divided into groups who did not receive antithrombotic agents (Group A), who received antithrombotic agents, but did not receive reversal therapy (Group B), and were treated with antithrombotic agents and reversal therapy (Group C). Age, gender, mechanism of injury, neurologic and imaging findings on admission, clinical course after admission and surgery, outcomes and complications were compared among these groups. Time from injury to reversal therapy was examined based on outcomes to investigate trends in the timing of administration of the reversal agent. Results: Acute exacerbation during the clinical course occurred in 9.8 %, 15.8 % and 31.0 % of cases in Groups A, B and C, respectively, and differed significantly among the groups. On head CT, the incidences of hematoma were 35.7 %, 36.5 % and 60.4 %, respectively, with this incidence being significantly higher in Group C; and the respective rates of craniotomy were 18.8 %, 14.0 % and 50.9 %, again with this rate being significantly higher in Group C. The good outcome and mortality rates were 57.1 %, 52.5 % and 35.8 %, and 14.5 %, 18.0 % and 24.5 %, respectively, and both were poorest in Group C. Times from injury to treatment with a reversal agent were significantly shorter in patients without compared to those with acute exacerbation (405.9 vs. 880.8 min) and in patients with favorable outcomes compared to those with unfavorable outcomes (261.9 vs. 543.4 min). Conclusion: Similarly to previous studies, the incidence of acute exacerbation was increased by use of antithrombotic agents. These results suggest that patients in Japan who require hematoma evacuation due to symptom exacerbation tend to be treated with reversal agents. Although it is difficult to assess the efficacy of reversal therapy from this study, earlier treatment with reversal agents before the occurrence of acute exacerbation may be useful to improve outcomes.

Effects of dual antiplatelet therapy (DAPT) compared to single antiplatelet therapy (SAPT) in patients with traumatic brain injury.

Japan is one of the world's most aging societies and the number of elderly patients taking antithrombotic drugs is increasing. In recent years, dual antiplatelet therapy (DAPT), in which two antiplatelet drugs are administered, has become common in anticipation of its high therapeutic efficacy. However, there are concerns about increased bleeding complications in use of DAPT. Therefore, the goal of this study was to investigate the effects of DAPT in patients with traumatic brain injury (TBI). A prospective, multicenter, observational study was conducted from December 2019 to May 2021 to examine the effects of antithrombotic drugs and reversal drugs in 721 elderly patients with TBI. In the current study, the effect of DAPT on TBI was examined in a secondary analysis. Among the registered patients, 132 patients taking antiplatelet drugs only were divided into those treated with single antiplatelet therapy (SAPT) (n=106) and those treated with DAPT (n=26) prior to TBI. Glasgow Coma Scale (GCS) on admission, pupillary findings, course during hospitalization, and outcome were compared in the two groups. A similar analysis was performed in patients with a mild GCS of 13-15 (n=95) and a moderate to severe GCS of 3-12 (n=37) on admission. The DAPT group had significantly more males (67.0 % vs. 96.2 %), a higher severity of illness on admission, and a higher frequency of brain herniation findings on head CT (21.7 % vs. 46.2 %), resulting in significantly higher mortality (12.3 % vs. 30.8 %). The only significant factor for mortality was severity on admission. The rate of DAPT was significantly higher in patients with a moderate to severe GCS on admission, and DAPT was the only significant factor related to severity on admission. These findings suggest that the severity of injury on admission influences the outcome six months after injury, and that patients with more severe TBI on admission are more likely to have been treated with DAPT compared to SAPT.

[Clinical features of unruptured vertebral artery dissection presenting as isolated occipital headache and/or neck pain].

Vertebral artery dissection(VAD)presenting as isolated occipital headache and/or neck pain is being increasingly diagnosed because of the development of magnetic resonance imaging(MRI). While a majority of the patients diagnosed with this condition shows a favorable prognosis, the pain may be a predictor of fatal stroke in some patients. We aimed to find out the features of headache with VAD, identify the clinical manifestations indicative of VAD, and determine the ideal diagnostic approach to this condition to avoid fatal stroke. We reviewed medical records of 41 consecutive patients who showed VAD with isolated headache and were diagnosed between 1995 and 2008. All patients experienced pain in the occipitocervical area ipsilateral to the affected VA. Pain showed a sudden onset in 21(51%)patients, was persistent over several days in 31(76%)patients, and was severe enough to disable daily life activities in 34(83%)patients. Progression of stenosis or aneurysmal dilatation of the vessel was identified on follow-up imaging(angiography, magnetic resonance angiography)in 7 patients(17%), and was found within 14 days after pain onset in 6 of these patients(86%). Patients with persistent, severe, and unilateral pain in the occipitocervical area should undergo MRI examination, including surface anatomy scanning(SAS)imaging, and the possibility of VAD should be considered in their diagnosis. Once VAD is diagnosed, the patient should undergo meticulous blood pressure control, bed rest, and repeated MRI examination for at least 2 weeks after onset.

[Helicopter transportation of a sedated, mechanically ventilated patient with cervical cord injury].

We report helicopter transportation of a sedated, mechanically ventilated patient with cervical cord injury. A 20-year-old male sustained traumatic injury to the cervical spinal cord during extracurricular activities in a college. On arrival at the hospital, a halo vest was placed on the patient and tracheostomy was performed. On the 38th hospital day, he was transported a distance of 520km by helicopter to a specialized hospital in Fukuoka for medical repatriation. Cabin space was narrow. Since power supply and carrying capacity were limited, battery-driven and portable medical devices were used. In consideration for patient's psychological stress, he was sedated with propofol. RSS (Ramsay sedation scale) scores were recorded to evaluate whether the patient was adequately sedated during helicopter transportation. Prior to transport, we rehearsed the sedation using bispectral index monitoring (BIS) in the hospital to further ensure the patient's safety during the transport.

[Criteria for applying imaging diagnosis and initial management for pediatric head trauma].

It may be difficult to perform CT for pediatric head trauma because of body movement and radiation exposure. Imaging application criteria were established, in which patients diagnosed as less likely to have an intracranial lesion meeting the criteria were not indicated for imaging and subjected to course observation at home, and this policy was explained to the parents. When consent was obtained, patients were followed up at home, and we checked on the condition by making a phone call 4-8 hours after injury. The patients were 103 infants aged 15 years or younger brought to the emergency medical care center of our hospital between May and August 2008. Imaging was basically indicated for cases of traffic accidents, falls from a high level, those brought in by ambulance, referred cases, and cases with disturbance of consciousness, neurologically abnormal findings, vomiting on examination, and trauma requiring X-ray examination in addition to that for the head. However, apart from these cases, imaging was not required. Imaging was not necessary for 94% of infant cases. The parents were convinced by the explanation and selected course observation at home in 94% of cases for which imaging was judged as unnecessary. None of the patients required re-examination based on the conditions reported in phone calls to homes. Imaging diagnosis for pediatric head trauma is not always necessary, and its application should be decided on after consultation. When no imaging is performed, this should be fully explained at the initial treatment before selecting course observation at home. Checking on the child's condition by making a phone call several hours after injury is useful for both patients and physicians.

Clinical data on rare case of spontaneous disappearance of intracranial Aneurysm.

The data contained within this paper are related to another paper entitled "Rare Spontaneous disappearance of intracranial aneurysm" (Yokoya et al., 2020). Spontaneous disappearance of an unruptured non-giant aneurysm of the anterior circulation is very rare. We identified a saccular cerebral aneurysm, which disappeared spontaneously and was followed up for 12 years. The present article describes the relevant clinical data of the patient, including her medical history and imaging findings.

Aneurysm of Distal Medial Lenticulostriate Artery: Report of 2 Cases.

BACKGROUND: Aneurysms originating from the distal portion of the lenticulostriate artery (LSA) are uncommon. Distal medial LSA (MLSA) aneurysms are particularly uncommon when compared with distal lateral LSA aneurysms, and their clinical features are unclear. Here, we present 2 patients with aneurysms of the distal MLSA who exhibited hemorrhages of the caudate nucleus and intraventricular region (intraventricular hemorrhage [IVH]). CASE DESCRIPTION: Patient 1 is a 50-year-old woman who was admitted to our hospital because of a hemorrhage in the left caudate nucleus and ventricles. She underwent external ventricular drainage (EVD). Cerebral angiography (CAG) performed on hospital day 24 showed an aneurysm located in the distal portion of the MLSA; however, CAG performed on admission revealed no abnormal vessels. We excised the aneurysm using a transcallosal-transventricular approach. Patient 2 is an 88-year-old woman who was admitted to our hospital with a right caudate nucleus hematoma and a dense IVH. She underwent emergent EVD. CAG demonstrated a 2.5-mm aneurysm in the distal MLSA, and a 6-mm aneurysm which originated from the right horizontal portion of the anterior cerebral artery (A1)-MLSA bifurcation aneurysm. We performed direct clipping of the A1-MLSA bifurcation aneurysm with proximal ligation of the distal MLSA aneurysm. CONCLUSIONS: We should consider the possibility of a ruptured distal MLSA aneurysm when diagnosing a patient with IVH-with or without a caudate nucleus hematoma. Repeated imaging evaluations may be necessary to find the lesion.

Fatal Subarachnoid Hemorrhage: A Rare Presentation of Ruptured A2 Dissecting Aneurysm.

Anterior cerebral artery dissection (ACAD), especially simultaneously presenting with subarachnoid hemorrhage (SAH) and cerebral infarction (CI), is rare. Only a few cases of severe SAH due to ACAD have been reported. Herein, we present an unusual case of severe SAH with simultaneous CI caused by ACAD. A 56-year-old male was brought to our hospital for severe disturbance of consciousness. Head computed tomography (CT) disclosed SAH with intracerebral hematoma. We suspected ruptured anterior communicating artery saccular aneurysm on CT angiography. Emergency craniotomy was performed to avoid cerebral herniation which confirmed the ruptured ACAD of right A2. The dissecting site was treated by wrapping with a Goretex sheet. ACAD of A2 may present with a severe hemorrhagic event.

Factors Associated with Poor Outcomes in Patients with Mild or Moderate Acute Subdural Hematomas.

The factors influencing the outcomes of mild/moderate acute subdural hematoma (ASDH) are still unclear. Retrospective analyses were performed to identify such factors. The medical records of all patients who were admitted to Saiseikai Shiga Hospital with mild (Glasgow Coma Scale [GCS] score of 14-15) or moderate (GCS score of 9-13) ASDH between April 2008 and March 2017 were reviewed. Comparisons between the patients who exhibited favorable and poor outcomes were performed. Then, independent factors that contributed to poor outcomes were identified via logistic regression analyses. A total of 266 patients with a mean age of 70.2 were included in this study. The most common concomitant injuries were subarachnoid hemorrhages (SAHs; 56.8%). The patients' Injury Severity Scores (ISS) ranged from 16 to 75 (median: 21). The 66 moderate ASDH patients exhibited significantly higher frequencies of surgery and mortality (24.2% and 13.6%, respectively) than the 200 mild ASDH patients (8.0% and 4.5%, respectively). The factors associated with poor outcomes were age (odds ratio [OR]: 1.06) and the ISS (OR: 1.24) in the mild ASDH patients, and older age (OR: 1.09) and the higher ISS (OR: 1.15) in the moderate group, too.

Organized Chronic Subdural Hematoma Treated with Middle Meningeal Artery Embolization and Small Craniotomy: Two Case Reports.

The most preferred treatment for organized chronic subdural hematoma (OSDH) remains controversial. Although a large craniotomy has been reported to be necessary and effective for the treatment of an OSDH, a craniotomy is associated with postoperative hemorrhagic complications and recurrence. Although middle meningeal artery (MMA) embolization has been reported to be effective for a refractory chronic subdural hematoma (CSDH), its efficacy for an OSDH remains unclear. We report two cases of OSDH treated with MMA embolization followed by hematoma removal via a small craniotomy under local anesthesia with good progress. Case 1: A 71-year-old man underwent a single burr hole irrigation for a CSDH, which failed due to a solid hematoma. He underwent a small craniotomy under local anesthesia after an MMA embolization. During the craniotomy, a small hemorrhage from the hematoma and its outer membrane was observed. Postoperatively, the symptoms disappeared immediately, and the hematoma did not recur. Case 2: A 77-year-old man underwent a burr hole irrigation, but the hematoma was not evacuated because of an OSDH, and he remained in motor aphasia. After an MMA embolization, a craniotomy was performed under local anesthesia. Intraoperative hemorrhage was minimal, and after the craniotomy, his neurological symptoms improved without any recurrence. MMA embolization and hematoma removal with a small craniotomy could be a treatment option for an OSDH.

Association between physician-staffed ambulances and patient prognoses after out-of-hospital cardiac arrests with respect to shockable and non-shockable rhythms: a retrospective observational study in a southern area of Shiga Prefecture Japan.

AIM: Out-of-hospital cardiac arrests (OHCA) are a significant public health problem; to improve patients' prognoses, various interventions, such as providing physician-staffed ambulances, have been implemented. We aimed to examine whether physician-staffed ambulances were associated with patients' prognoses after OHCA with respect to first-monitored rhythms. METHODS: This retrospective observational study was undertaken between 1 September 2011 and 31 December 2015, using data based on Utstein-style guidelines. We extracted data on age, sex, first-monitored rhythm (shockable or non-shockable), presence of a witness, bystander cardiopulmonary resuscitation, time from call to arrival at the scene, out-of-hospital adrenaline administration, out-of-hospital intubation, return of spontaneous circulation before arrival at the hospital, and survival and neurological outcomes 30 days after OHCA, according to cerebral performance categories. We undertook logistic regression analyses to assess the association between physician-staffed ambulances and patients' prognoses. RESULTS: A total of 882 OHCA patients were eligible for this study. Physician-staffed ambulances attended to 164 OHCA patients. Multivariable analysis found that in non-shockable rhythm patients, physician-staffed ambulances significantly improved good neurological outcome (odds ratio, 3.65; 95% confidence interval [CI], 1.28-10.50; P = 0.02), return of spontaneous circulation before arrival at the hospital (odds ratio, 2.68; 95% CI, 1.62-4.42; P < 0.001), and 30-day survival (odds ratio, 2.90; 95% CI, 1.30-6.45; P = 0.009). However, physician-staffed ambulances were not associated with patient prognoses in shockable rhythm patients. CONCLUSION: Despite our study's limitations, physician-staffed ambulances might be associated with good neurological outcomes in non-shockable rhythm patients. Our observations could provide more appropriate prehospital treatment options for OHCA patients.

Aplastic or Twig-Like Middle Cerebral Artery Presenting with Intracerebral Hemorrhage During Pregnancy: Report of Two Cases.

BACKGROUND: An aplastic or twig-like middle cerebral artery (Ap/T-MCA) is a rare congenital anomaly that can present with both ischemic and hemorrhagic stroke. The etiology of this pathology has remained unclear. Here, we report 2 cases of intracerebral hemorrhage (ICH) owing to an Ap/T-MCA in pregnant patients. CASE DESCRIPTION: In both patients, cerebral angiography revealed a steno-occlusive lesion and an abnormal arterial network on the unilateral middle cerebral artery. One patient was treated conservatively for a putaminal hemorrhage, and a cesarean section was performed uneventfully 6 months after onset of the ICH. The other patient underwent a craniotomy for evacuation of the lobar hemorrhage. Subsequently, a cesarean section was performed uneventfully. Both patients gradually recovered without significant disabilities. CONCLUSIONS: An Ap/T-MCA is a rare congenital anomaly and is a potential cause of ICH for pregnant patients. A cesarean section is a useful option for pregnant patients with this condition.

[The influence of the primary management on the outcome of severe traumatic brain injury: role of neurosurgeons].

OBJECTIVE: To evaluate the influence of the primary management on the outcome in severe head-injured-patients, we retrospectively studied the patients transported to our hospital directly and the those referred from other hospitals. METHODS: The subjects include 83 patients with severe head injury with a Glasgow coma scale (GCS) score of 8 or lower at the time of arrival at the emergency room during the periods of between January, 2003 to March, 2006. Forty nine patients were transported directly (direct group) and 34 referred from other hospitals (transfer group). The patients in direct group was transported by a helicopter or an ambulance car, and the patients in transfer group were carried by an ambulance car. The variables analyzed in these 2 groups of patients were the initial GCS score, injury severity score (ISS), and the presence or absence of light reflex or shock at the time of transportation, the time periods from the injury and primary management, the time from the injury and operation in surgical patients, the type of primary managements and outcomes. RESULT: The number of patients with shock was significantly larger in the transfer group than that in the direct group. The shock was considered to be developed during the transportation. The outcomes were then significantly poorer in the transfer group than those in the direct group. There was no significant difference between the time from the injury and primary management in these 2 groups, but the primary management seemed to be more appropriate in the direct group compared to that in the transfer group. These findings suggested that outcomes of severe high-impact head injuries, such as injuries caused by a traffic accident, would be markedly affected by the primary treatment. CONCLUSION: The doctor-helicopter system, in which emergency physicians arrive at the site shortly after the occurrence of injury, and start primary examination, will influence outcomes of multiple injuries accompanying severe head injury. Severe head-injured patients by high-impact injury should be transported as early as possible to the emergency medical center, and neurosurgeons have an important role in the primary management.