[Initial Experience of Stereotactic EEG Insertion with Anchor Bolt:Problem Extraction and Improvement of Insertion Accuracy].

In recent years, stereotactic electroencephalography(SEEG)has been focused on as a new invasive method for epileptic focus detection. Although the covering area of the brain surface is smaller than the invasive estimation with subdural electrodes, SEEG can evaluate foci that are deeply seated, noncontiguous leaves, and/or bilateral hemispheres. In addition, SEEG can capture consecutive changes in seizure activity in three dimensions. Due to the development of neuroimaging, computer-assisted, and robotic surgery technology, SEEG insertion began to be commonly used worldwide. Although the approximate complication rates of SEEG are estimated as 1% to 3%, which is lower than that of subdural electrode implantation, the risks of major complications, such as permanent neurological deficit and death, are equivalent. Therefore, meticulous procedure must be needed. To introduce SEEG for intractable partial epilepsy, we acquired approval from the institutional review board and concurrently imported surgical devices and electrodes from the manufacturer in the United States for two surgical candidates. We safely performed SEEG insertion, focal identification, and brain functional mapping by cortical electrical stimulation in two cases. Insertion was difficult for some electrodes, which could be due to the lack of adequate surgical device and large skull angle. Hopefully, the official installation of SEEG will be planned in the near future. We hereby reported tips and pitfalls of SEEG implantation through our own experience in a single institute.

Indocyanine Green Videoangiography for Surgery of a Ruptured Dissecting Aneurysm in the Precommunicating Anterior Cerebral Artery: A Technical Case Report.

BACKGROUND AND IMPORTANCE: Indocyanine green videoangiography (ICG-VA) is an important intraoperative adjunct for saccular aneurysm surgery, but its efficacy in surgery for dissecting aneurysms has rarely been reported. The authors describe the usefulness of preclipping ICG-VA in a rare case of a ruptured dissecting aneurysm located at the precommunicating (A1) segment of the anterior cerebral artery. CLINICAL PRESENTATION: A 52-year-old woman, with no history of connective tissue diseases or vascular disorders, presented with sudden headache and convulsion. The CT scan showed that the patient had subarachnoid hemorrhage. Angiography showed a dissecting aneurysm in the left A1 segment of the anterior cerebral artery. Thus, the patient underwent trapping of the dissecting aneurysm. ICG-VA was used as an intraoperative adjunct before and after clipping. The preclipping ICG-VA showed the heterogeneously bright dissecting aneurysm and branching arteries even in the presence of hematoma. CONCLUSION: Preclipping ICG-VA may enhance the advantage of direct surgery for dissecting aneurysm by allowing visualization of the extent of the dissected vascular wall and the related branching arteries. ICG-VA can be an indispensable adjunct to minimize the compromise from the surgical treatment for intracranial dissecting aneurysms.

Cost of physician-led home visit care (Zaitaku care) compared with hospital care at the end of life in Japan.

BACKGROUND: Physician-led home visit care with medical teams (Zaitaku care) has been developed on a national scale to support those who wish to stay at home at the end of life, and promote a system of community-based integrated care in Japan. Medical care at the end of life can be expensive, and is an urgent socioeconomic issue for aging societies. However medical costs of physician-led home visits care have not been well studied. We compared the medical costs of Zaitaku care and hospital care at the end of life in a rapidly aging community in a rural area in Japan. METHODS: A cross-sectional study was performed to compare the total medical costs during patients' final days of life (30 days or less) between Zaitaku care and hospital care from September 2012 to August 2013 in Fukuoka Prefecture, Japan. RESULTS: Thirty four patients died at home under Zaitaku care, and 72 patients died in the hospital during this period. The average daily cost of care during the last 30 days did not differ significantly between the two groups. Although Zaitaku care costs were higher than hospital care costs in the short-term (≦10 days, Zaitaku care $371.2 vs. Hospital care $202.0, p = 0.492), medical costs for Zaitaku care in the long-term care (≧30 days) were less than that of hospital care ($155.8 vs. $187.4, p = 0.055). CONCLUSIONS: Medical costs of Zaitaku care were less compared with hospital care if incorporated early for long term care, but it was high if incorporated late for short term care. For long term care, medical costs for Zaitaku care was 16.7% less than for hospitalization at the end of life. This physician-led home visit care model should be an available option for patients who wish to die at home, and may be beneficial financially over time.

[Treatment of Non-Traumatic Spinal Epidural Hematoma:A Report of Five Cases and a Systematic Review of the Literature].

Objective:Non-traumatic spinal epidural hematoma(SEH)is relatively rare. We report five cases of SEH, review the relevant literature, and discuss the current treatment strategies for non-traumatic SEH in Japan. Methods:Clinical data of cases with non-traumatic SEH treated at our institute from 2008 to 2015 were retrospectively analyzed. In addition, we identified the relevant literature using the Japan Medical Abstracts Society databases for peer-reviewed articles published from Jan 1, 1995 to Aug 31, 2015. The search terms "spinal", "epidural hematoma", and "non-traumatic OR spontaneous" were used. Treatment strategies were summarized according to the treatment criteria. Results:Five patients(1 man and 4 women;age, 59-86 years;mean age, 74 years)were treated for SEH. Hematomas were located in the cervical(n=1), cervicothoracic(n=2), thoracic(n=1), and thoracolumbar(n=1)regions. All patients suffered sudden neck and/or back pain followed by subsequent neurological deterioration. Four patients were under antithrombotic treatment, and underwent laminectomy and drainage of the hematoma due to severe and progressive neurological deficits. All patients demonstrated significant neurological recovery. Seventy-seven articles from domestic institutes and hospitals were identified. Their criteria for conservative and surgical treatments differed based on the time from the onset and severity. Conclusion:Five cases of non-traumatic SEH were treated successfully. Patients with moderate to severe neurological deficit need timely surgical management, while non-surgical treatment may be indicated in mild deficits. To standardize the optimal treatment for non-traumatic SEH, an appropriate assessment system incorporating the time from onset and severity of neurological impairment should be established.

Intraprocedural detection of cerebral hyperperfusion by flat detector computed tomography in the evaluation of cerebral blood volume during carotid artery stenting. A case report.

Cerebral blood volume (CBV) can be measured using a C-arm flat detector angiographic system. The present report describes a case in which cerebral hyperperfusion was detected with the Neuro parenchymal blood volume (PBV) system (syngo Neuro PBV IR, Siemens Medical Solutions, Erlangen, Germany) during carotid artery stenting (CAS). An 89-year-old man was referred to our hospital for cerebral brain infarction and severe stenosis of the left carotid artery. CAS was performed, and Neuro PBV was used to measure CBV both during and after the procedure. Postoperative Neuro PBV revealed dramatically increased CBV, and a hyperperfusion state was suspected. The next day, subarachnoid hemorrhage along the sulcus of the left hemisphere was revealed on computed tomography. Strict management of blood pressure was instituted just after the detection of hyperperfusion, and the patient was ultimately discharged from the hospital without any new neurological deficits. Neuro PBV has the advantage that it can be performed in the angiography suite and does not require patient transfer to an alternate setting. Therefore, intracranial hemodynamic changes can be detected during the procedure. We conclude that the Neuro PBV system is useful for monitoring intracranial hemodynamics during endovascular procedures.

[Promotion to home-based care from acute phase hospital - the problems and the role of community cooperation].

It has been emphasized that problems with the system and a lack of resources for home-based care were ones to blame for preventing a promotion of home-based care. However, the real big problems appear to be laid on the unconsciousness and lack of knowledge of home-based care by acute phase hospital, functionality of community cooperation and lack of communication with patients. We examined the actual condition of home-based care by questionnaires to the doctors who took a palliative care study session. The response rate was 73.3%(93/127). It appeared that the doctors of acute phase hospital realized and expressed the necessity of home based care and their desire to participate. However, they are deficient in experiences and trainings. In the terminal care period, the patient and family thought that a medical treatment of intravenous drip and infusion was important, though the doctor would not regard such treatment was suitable to the patient. In reality, the patient gets what he wants. With regard to consulting of a future discharge plan, it is desirable to have it done as quickly as possible. However, there were many instances where the decision was made at the last moments: when the treatment was reached at the limit, and when to offer a support to leave the hospital. Therefore, we should strive for a fulfillment of home based care study, training and resources. Furthermore, functional community cooperation is essential for a promotion of home based care.

[Elements necessary for end-of-life care for terminal cancer patients and standardization of discharge planning].

AIM: Unitil now, most terminal cancer patients have received end-of-life care service in a hospital. How, recently, home health care services have received much attention instead of the hospital care. In this study, we investigated important factors affecting smooth transition to home health care from hospital care. METHODS: We examined the records of 66 deceased subjects with terminal cancers who received medical care by staff of home heath care agency "Yunomori Tnapopo clininc" were included in this study. METHODS: The categories evaluated were: 1) general condition, 2) breakdown of family caregivers, 3) rate of application for care insurance, 4) the percentage of cases with a discharge planning conference, 5) the time of death and, 6) frequency of visiting care in the first 1 week and the last 1 week. RESULTS: The 66 subjects consisted of 38 men (58%) and the average age of the group was 71.1 2.0. 1) Dementia was indicated in 20 (30%) patients and 23% of the patients were reliant on intravenous nutrition. Oxygen treatment was required for 45% of the patients. Some help for excretion was required by 70% of the patients. 2) 70% of a main care giver were woman and the average number of persons per household was 2.0. 3) 50% of the patients did not apply for care insurance. 4) Discharge planning conferences between the hospital and the clininc were held in only 21% of the case. 5) over 70% of the patients died outside duty hours (between 8AM and 6PM). 6) Although the average duration of stay at home was 62.5 days, 10% of the cases died or had to leave their home due to worsening condition during the first 2 weeks. Vsits by medical doctor in the last 1 week significantly increased in frequency compared to that in the last 1 week. (5.0 0.2 vs. 3.9 0.2, p<0.01). In addition, frequency of care visits by nurses increased significantly as well (3.2 0.2 vs. 2.4 0.2, p<0.01). Overall the number of care visits in the last 1 week was more than once a day. CONCLUSION: 1. A home-health care clinic which gives 24-hour care is necessary so that the patients receive end-of-life care as well as hospital care. 2. Earliest possible transfer to the home health care setting is needed so trhat the patients could have enough time to live in their hom with their family. On this account, it is most important to convene a conference co-organaized by the home health care adjusytment. In addition, the patients or their family need to apply to the munided office for care insurance. Medical staff should provide information and help them.