Experience of Triage During an A/H1N1 Influenza Pandemic in After-Hours Emergency Centers.

During the 2009 A/H1N1 influenza pandemic in Sendai, two primary emergency clinics, which are after-hours emergency centers managed by the Sendai Emergency Medical Service Foundation, were inundated with many influenza patients. In the course of the pandemic, from August 1, 2009 to March 31, 2010, a total of 47,831 internal medicine and pediatric patients visited the two clinics and rapid influenza tests were performed in 17,167 of patients, in which 6,697 patients tested A-positive. Consequently, 10,743 patients were diagnosed with influenza, which included 1,447 patients that tested negative, and 2,599 patients that were not tested. Prior to the physicians check up, nurses performed triage and divided the patients into two groups, isolated and non-isolated. We examined the effect of triage, using the results of the rapid influenza test and antiviral drug administration, in each of the early, middle and maximum pandemic phases. Triage was considered effective in the early and middle phases, where the average number of influenza patients that visited the clinic per day were 21.4 and 50.6, respectively. But in the maximum phase where the average number of influenza patients soared to 275.3 per day, one out of three patients in the non-isolated group was clinically diagnosed as influenza. We were unable to separate influenza patients effectively in the maximum phase of pandemic.

[Hemorrhagic infarction complicated by obliteration of the superior sagittal sinus by depressed skull fracture after a hammer injury: a case report].

The authors have encountered a case of compound depressed skull fracture in a 59 year-old-man complicated by occlusion of the anterior 1/3 part of the superior sagittal sinus (SSS). He was hit by a hammer at the midline of the frontal region, and transferred to our emergency care unit. On admission, there was laceration of skin at the midline of the forehead, but the patient had no neurological deficit. Skull radiograph showed a depressed skull fracture over the SSS. Computed tomography (CT) scan showed a small brain contusion adjacent to the depressed fracture. Digital subtraction angiography (DSA) showed occlusion of the anterior 1/3 part of SSS, and extravasations of contrast medium from cortical arterioles and capillaries. CT taken at 4 hours after injury showed enlargement of the lesion with extravasations of contrast medium and the patient manifested consciousness disturbance at this point. Distribution of extravasations suggested the occurrence of hemorrhagic infarction. Elevation of the depressed skull was thus performed under general anesthesia. There was laceration of the dura 5 mm away from the SSS and lacerations of cortical vessels, but there was no apparent damage to SSS itself. The depressed bone was replaced with artificial bone. The patient was discharged without any neurological deficit. Preoperative angiography was helpful to understand the hemodynamics and risk of massive bleeding during the operation.

JSNT-Guidelines for the Management of Severe Head Injury (Abridged edition).

The aim of this article is to introduce the principal part of the JSNT-guidelines for the management of severe head injury in adults. The JSNT-guidelines were developed in 2000 by the Guidelines Committee of the Japan Society of Neurotraumatology (JSNT) based on the results of literature review and the Committee consensus. The guidelines updated in 2006 consist of 7 topics pertaining not only to prehospital care, initial, ICU and surgical management, but also the management of pediatric and geriatric patients. The JSNT-guidelines are of practical nature accounting for the difference in the medical system and conditions in Japan, but in their essence they are similar to those of Western countries. Reports on the application of these guidelines indicate their positive affect on the results of management of severe head injury.

Acute epidural hematoma of the posterior fossa--cases of acute clinical deterioration.

PURPOSE: Posterior fossa epidural hematoma (PFEDH) is an uncommon complication of head injury, which is sometimes associated with acute clinical deterioration (ACD) without significant warning symptoms and may results in death. We investigated clinical characteristics of PFEDH with ACD to identify the process of ACD. METHODS: A retrospective case-control review of all patients admitted with a diagnosis of PFEDH between September 1989 and February 1999 was performed. RESULTS: Twenty-one patients (14 men and 7 women) were admitted for PFEDH to Sendai City Hospital. Four patients suffered ACD. All patients had struck their occipital region and had occipital fracture. Patients were treated conservatively on admission because computed tomography (CT) showed no significant findings in 2 patients and PFEDH with minimal symptoms in the others. All patients suffered acute deterioration of consciousness after vomiting. Follow-up CT showed large PFEDH with severe mass effect. Emergency surgery was performed and identified the bleeding point as the venous sinus. The presence of nausea/vomiting was significant risk factor of ACD (Fisher exact test: P = .021). Of the 4 patients, 2 achieved excellent recovery without deficit, 1 was moderately disabled, and 1 died. The outcome of patients with ACD was worse compared to those without ACD (Fisher exact test: P = .046). CONCLUSIONS: We should note that vomiting itself could be a significant risk factor of ACD for occipital head trauma. The patients with occipital fracture and vomiting must be observed closely and followed up by CT, even if the initial CT is negative. CT performed shortly after the trauma may reveal no evidence of PFEDH but cannot exclude the development of delayed hematoma.

Thrombosed vertebral artery aneurysm presenting with hemorrhage and bulbar compression: report of two cases.

Bulbar compression by vertebral artery (VA) aneurysm is extremely rare and only reported in a few cases. We report two cases with thrombosed VA aneurysm compressing medulla oblongata; one presented with bulbar apoplexy hemorrhage and the other with subarachnoid hemorrhage (SAH). A 61-year-old male (case 1) presented with consciousness disturbances, left hemiplegia, and subsequent respiratory arrest. He was subjected to controlled ventilation, and computed tomography (CT) scan showed bulbar hemorrhage. Magnetic resonance imaging (MRI) and digital subtraction angiogram (DSA) revealed fusiform right VA aneurysm with partial thrombosis and bulbar compression. Intra-aneurysmal embolization with Guglielmi detachable coils (GDCs) relieved his clinical symptom including respiratory disturbance. Three months after the onset, he remained moderately disabled. A 76-year-old male (case 2) presented with severe headache and subsequent respiratory disturbance. CT scan on admission showed subarachnoid hemorrhage with acute hydrocephalus. Ventricular drainage rapidly improved consciousness while respiratory disturbance persisted over several days. MRI and DSA suggested spontaneous thrombosis of the right VA dissection with bulbar compression. He showed gradual recovery of his respiration over a week. After ventriculo-peritoneal shunting, he was transferred with moderate disability. These results suggest that the elimination of the pulsatile effect of VA aneurysm adjacent to medulla oblongata can improve symptoms caused by aneurysm-related compression. Early diagnosis and appropriate treatment such as intra-aneurysmal embolization for ameliorating the blood flow inside the aneurysm can relieve mass effect and clinical symptoms.

Cerebral infarction in the caudate nucleus associated with acute epidural hematoma and diffuse brain injury in a child after severe head injury.

CASE REPORT: A 6-year-old boy was admitted to our hospital 20 min after receiving a direct impact to his head in an automobile accident. He was semi-comatose on admission and computed tomography showed acute epidural hematoma in the right supratentorial region. Three hours later, his consciousness deteriorated due to the enlargement of the hematoma. Surgical removal of hematoma relieved his consciousness disturbance. Post-operative magnetic resonance imaging revealed spotty high-intensity lesions in the corpus callosum on T2-weighted images, and a solitary high-intensity lesion in the left caudate nucleus extending to the medial globus pallidum on T2-weighted and diffusion-weighted images. Magnetic resonance angiography showed no abnormality in the main arteries. These results suggested cerebral infarction in the vascular territory supplied by the recurrent artery of Heubner in association with diffuse brain injury. Post-operative course was uneventful and he was discharged without neurological deficit. CONCLUSIONS: Post-traumatic cerebral infarction in the caudate nucleus is extremely rare, and its association with diffuse brain injury and epidural hematoma is apparently unique.

Hydrocephalus due to cerebrospinal fluid overproduction by bilateral choroid plexus papillomas.

CASE REPORT: A 10-month-old boy, with congenital deafness and blindness associated with chromosomal deletion [46XY, del(13)(q32)], presented with intractable ascites 9 months after ventriculo-peritoneal shunting for congenital hydrocephalus. Revision of the ventriculo-atrial shunt resulted in shunt failure 1 month later. External ventricular drainage revealed cerebrospinal fluid (CSF) overproduction (2,000 ml/day). Magnetic resonance imaging showed marked lobular enlargement of the bilateral choroid plexuses extending from the trigone to the body and inferior horn of the lateral ventricle. Multi-staged resection was performed via bilateral temporo-occipital transcortical approaches, and CSF production significantly decreased to 100 ml/day postoperatively. Histological assessment of the villous surface suggested villous hyperplasia of the choroid plexus and thorough evaluation including the proximal portion of the lobular lesion near the attachment revealed choroid plexus papilloma. He was discharged after ventriculo-peritoneal shunting without additional neurological deficits except for hyperreflexia of the left extremities. CONCLUSION: CSF overproduction caused by bilateral choroid plexus papillomas can result in hydrocephalus. Radical resection of the bilateral ventricular lesions should be considered for this entity. Thorough evaluation of the surgical specimen is recommended because histological examination of only the lobular surface of the choroid plexus lesion may fail to identify choroid plexus neoplasm.

A distal anterior cerebral artery aneurysm in infant: disappearance and reappearance of the aneurysm.

The incidence of intracranial aneurysms in childhood is rare, especially in infancy. Spontaneous thrombosis of a cerebral aneurysm in a child is very rare, particularly in a non-giant aneurysm. We report a case of a 1-month-old girl with a distal anterior cerebral artery aneurysm which disappeared spontaneously after subarachnoid hemorrhage and reappeared 6 months later. Surgical resection of the aneurysm was performed and she discharged uneventfully 10 days later. Histological examination revealed an aneurysm with a fibrous muscular layer, absence of the internal elastic lamina and partial hypertrophy of the intimal layer. Though the pathogenesis of this aneurysm is uncertain, two hypotheses are discussed.

[Two cases of impending herniation due to multiple traumatic acute subdural hematomas: combination of burr hole evacuation and craniotomy].

A contralateral extra-axial hematoma sometimes occurs during an operation on an acute subdural hematoma and may become fatal. Using a combined procedure of burr hole evacuation and craniotomy, we treated 2 cases of multiple traumatic acute subdural hematomas. Our policy for such cases is first to perform a burr hole evacuation for the acute subdural hematoma in the emergency room, while simultaneously preparing the operation room for a possible further operation. Next, we perform computed tomography (CT) of the brain. If the evacuation does not provide enough decompression, we either carry out a craniotomy at the same site, or, we observe the patient without resorting to craniotomy. However, if the patient's condition deteriorates, burr hole evacuation is repeated and/or craniotomy is carried out as soon as possible on the lesion at the already prepared operation room. Both of our patients received craniotomy for another subdural hematoma after the burr hole evacuation. Though his intracranial pressure was well managed during the acute stage, one of the patients died 21 days after the trauma due to an extensive brain infarction caused by vasospasm. The other regained consciousness and was able to walk 5 months after the trauma in spite of cerebral infarction from vasospasm. The possible mechanism of vasospasm in severe head injury is also discussed.

[A case of vertebral artery occlusion following heading play in soccer].

A 13-year-old boy suffered from cerebeller infarction due to right vertebral artery occlusion after heading a ball during a rainy soccer game. Dissection of the vertebral artery after trivial head trauma is well known, but heading as the cause has not been reported. We speculated in this present case that excessive impact force to the young boy's neck due to the heavy rain-soaked ball might have caused right vertebral artery dissection and occlusion. High quality balls are recommended for young amateur players on rainy days.

Unruptured carotid-duplicated middle cerebral artery aneurysm: case report.

We demonstrate the first case with unruptured carotid-duplicated middle cerebral artery (IC-Dup MCA) aneurysm combined with ruptured opposite carotid aneurysm. Eleven IC-Dup MCA aneurysm reported until now had all ruptured. It is noteworthy that 8 patients of the 11 were Japanese.

Symptom changes caused by movement of a calcified lateral ventricular meningioma: case report.

BACKGROUND: Large calcified psammomatous meningioma in the left lateral ventricle with a long silent interval of 16 years was presented. The symptoms varied by its moving not enlargement, which was described by sequential images of the brain computer tomography. Combined approaches of transcallosal and transinferior temporal sulcus routes were superior to prevent injury of the speech center in the dominant hemisphere.

Growth of small unruptured intracranial aneurysm: case report.

Magnetic resonance angiography (MRA) revealed silent but rapid growth of a small unruptured intracranial aneurysm until it was surgically treated to prevent rupture. Modern neuroimaging methods such as MRA and 3-dimensional computed tomography have increased opportunity to detect small unruptured cerebral aneurysms. Strict follow up is an option for the incidentally discovered small intact aneurysms using these methods.

Single burr hole evacuation for traumatic acute subdural hematoma of the posterior fossa in the emergency room.

A 57-year-old man and a 55-year-old man presented with acute subdural hematoma of the posterior cranial fossa due to trauma. Both were comatose preoperatively. Emergent single burr hole evacuation in the posterior cranial fossa was performed in the emergency room immediately after computed tomography. Neurological symptoms improved dramatically just after initiating the burr hole evacuation in both patients. A 57-year-old man became alert and could walk unassisted 1 month after surgery. The other could walk with assistance 4 months after surgery, although psychic disturbance resulting from cerebral contusion remained. Single burr hole evacuation in the emergency room is a useful treatment for acute subdural hematoma of the posterior cranial fossa because the procedure can be performed easily and rapidly, thus achieving reduction of intracranial pressure. Progressing neurological deterioration, reversibility of brainstem function by mannitol administration and the sign of brainstem compression and noncommunicating hydrocephalus are good indicators for this treatment.