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.

[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.

[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.

Cytologic diagnosis of central neurocytoma in intraoperative squash preparations: a report of 2 cases.

BACKGROUND: Central neurocytoma is a rare central nervous system tumor typically found in the lateral ventricles and at the spectrum pellucidum. Two patients with central neurocytoma underwent intraoperative frozen section diagnoses, and the cytologic evaluations are described. CASES: Case 1 was a 21-year-old female who complained about reduced visual acuity. Magnetic resonance imaging (MRI) showed enhancement of a ventricular tumor. Over 80% of the tumor was removed, but after 14 months' follow-up, the disease progressed and regrowth occurred. The patient had a second tumor resection with gamma knife surgery. Case 2 was a 30-year-old female who presented with headaches. An MRI showed an enhancement of a ventricular tumor, and complete tumor removal was achieved. Cellular samples of both cases typically revealed ill-defined cytoplarm, oval nuclei with finely granular chromatin and micronucleoli. A fibrillose matrix in the background was noted. A typical appearance of perinuclear halo was also recognized. In both cases histopathologic examination was consistent with a central neurocytoma. Immunohistochemistry of both tumors was synaptophysin(+), NSE (+), NeuN(+), GFAP(-), but MIB-1 labeling index was 3.4% in case 1 and 1.1% in case 2. CONCLUSION: These are 2 illustrative cases in which the authors report cytologic evaluation of central neurocytomna in intraoperative preparations. These tumors possess distinct cellular features that help with the intraoperative distinction from other intraventricular tumors. Moreover, it should be emphasized that immunostains for neural markers are essential for distinguishing them from other clear cell tumors of the brain, especially oligodendroglioma and clear cell ependymomal neoplasm. A combination of imaging, cytomorphology and immunohistochemical features of central neurocytoma can help to differentiate this condition from other intraventricular tumors. It is thought that careful scrutiny of intraoperative preparations allows one to make a distinction.

[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.

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.

Place-and-Clip Method for Fixing the Suture Thread in Deep-Brain Vascular Lesions: A Technical Case Report.

BACKGROUND: Intracranial vascular injury incurred during surgery must be repaired as quickly as possible. The standard repair procedure is surgical suturing. However, the narrow and deep working space may obstruct creating a knot with the suture thread. CASE DESCRIPTION: Resection of an olfactory groove meningioma was performed in a 73-year-old woman via the right lateral supraorbital approach. Tumor retraction caused an injury to the pericallosal artery. After temporary clipping of the vessel, a 10-0 nylon thread was placed on the vascular lesion and the end of the thread was fixed with an aneurysm clip. CONCLUSIONS: Fixing the suture thread with an aneurysm clip can be a rescue technique in suturing procedures on deeply located vascular lesions.

Langerhans cell histiocytosis of the skull on cytologic squash preparations.

We present a case in which a primary cytodiagnosis of Langerhans cell histiocytosis (LCH) of the skull was made using squash preparations. The patient, a 25-year-old male, presented with raised intracranial pressure and decreased visual acuity. Magnetic resonance imaging revealed a large skull lesion with osteolytic features in the left frontal bone. The patient underwent surgical resection by the extended basal frontal epidural approach. The squash preparation smears were cellular and demonstrated a mixed population of small, mature lymphocytes, eosinophils, and a high histiocytes content. The histiocytes occurred as isolated or loosely cohesive and clustered. They possessed abundant cytoplasm with rounded cell shape and had characteristic nuclear features, composed of fine chromatin and delicate nuclear membranes. The cytologic features of these histiocytes were consistent with Langerhans cells (LCs). A final impression of LCH of the skull was rendered. Subsequent histopathology confirmed the diagnosis. LCs reacted with both S-100 protein and CD1a immunohistochemically. The demonstration of Birbeck granules on electron microscopic study was also noted. Whenever squash preparation yields a mixed population of mature lymphocytes, eosinophils, and histiocytes, the cytologists should be aware of and consider LCH as a diagnostic possibility.

[Clipping of upward projecting anterior communicating aneurysms via pterional craniotomy: approach from the side of A2 of anterior displacement].

The majority of anterior communicating artery(Acom) aneurysms can be approached via pterional craniotomy. When the fundus points superiorly, craniotomy in the side of A2 of posterior displacement may be advantageous for catching the aneurysm and both ACAs on the same plane. Sometimes, however, surgeons have to deliberately select a "contralateral" craniotomy to deal with other lesions in the same operative session. The first author has operated on 111 patients with Acom aneurysms during the last 8 years; 26 aneurysms projected superiorly, and 7 were approached via contralateral craniotomy because of the aneurysm multiplicity. We reviewed surgical problems in the 7 upward projecting aneurysms approached from the "contralateral" side. All aneurysms were successfully secured without any surgery related complication. However, in each case, aneurysm and both ACAs formed a straight line in the narrow surgical field, and it was difficult to handle the aneurysm behind the ipsilateral A2, particularly when it tightly adhered to the A2. Anticipating this prior to surgery allows the surgeon to know the possible problems in aneurysm dissection that may occur. Practically, wide separation of interhemispheric fissure with removal of the gyrus rectus, and dissection of the posterior aspect of the ipsilateral A2 facilitates the mobilization of A2 and exposure of the aneurysm neck. When the aneurysm is tightly adherent to the A2, however, isolation of the entire aneurysm risks tearing the aneurysm at its A2 junction. An aperture clip should be considered to avoid serious bleeding during dissection.

Criteria for CT and Initial Management of Head Injured Infants: A Review.

Criteria for computed tomography (CT) to head injured infants have not been established. Since the identification of neurological findings is difficult in infants, examination by CT may be necessary in some cases, but it may be difficult to perform CT because of problems with radiation exposure and body movement. Moreover, even though no intracranial abnormality was found immediately after injury, abnormal findings may appear after several hours. From this viewpoint, course observation after injury may be more important than CT in the initial treatment of head trauma in infants. The complaints and neurological manifestations of infants, particularly those aged 2 or younger, are frequently unclear; therefore, there is an opinion that CT is recommended for all pediatric patients. However, the appropriateness of its use should be determined after confirming the mechanism of injury, consciousness level, neurological findings, and presence/absence of a history of abuse. Among the currently available rules specifying criteria for CT of infants with head trauma, the Pediatric Emergency Care Applied Research Network (PECARN) study may be regarded as reliable at present. In Japan, where the majority of emergency hospitals are using CT, it may be necessary to develop criteria for CT in consideration of the actual situation. CT diagnosis for pediatric head trauma is not always necessary. When no imaging is performed, this should be fully explained at the initial treatment before selecting course observation at home. Checking on a state of the patients by telephone is useful for both patients and physicians.

Direct Microsurgical Embolectomy for Acute Occlusion of the Internal Carotid Artery and Middle Cerebral Artery.

BACKGROUND: Surgical embolectomy is the most promising therapy for physically removing emboli from major cerebral arteries. However, it requires an experienced surgical team, time-consuming steps, and is not incorporated into acute stroke therapy. METHODS: We established seamless collaboration between services, refined surgical techniques, and conducted a prospective trial of emergency surgical embolectomy. Surgical indications included the presence of acute hemispheric symptoms, absence of low-density area on computed tomography, evidence of internal carotid artery terminus or proximal middle cerebral artery occlusion, and availability of resources to start surgery within 3 hours of symptom onset. The indications were confirmed by an interdisciplinary team. We assessed revascularization rates, time from admission to surgery and from surgery to recanalization, procedural complications, and clinical outcomes. RESULTS: Between 2005 and 2014, 14 consecutive patients with acute proximal middle cerebral artery or internal carotid artery terminus occlusion underwent emergency surgical embolectomy. All patients showed complete recanalization. Twelve patients survived and 7 had fair functional outcome (Rankin Scale score, ≤3). No significant procedural adverse events occurred. The mean times from admission to start of surgery, from surgery to recanalization, and from onset to recanalization were 14 minutes, 79 minutes, and 223 minutes, respectively. CONCLUSIONS: Our results suggest that microsurgical embolectomy can rapidly, safely, and effectively retrieve clots and deserves reappraisal, although the choice largely depends on local institutional expertise.

[A guide to initial management of minor head injury].

We reviewed the records of 1,335 minor head injury patients with initial Glasgow Coma Scale (GCS) scores of 15 treated by our neurosurgery service between January 1998 and December 2000. Skull X-ray was performed in 945 patients (71%), and Computed tomography (CT) was performed in 590 patients (44%). Skull fracture was shown radiographically in 24 patients (2.5%), and abnormalities on the initial CT were seen in 29 patients (4.9%). The most frequent intracranial lesion on CT was acute epidural hematoma with skull fracture. Significantly more intracranial lesions were found in those with a fracture than in those without by chi2 analysis. Post-traumatic vomiting was significantly associated with radiographical abnormalities, but headache and nausea did not increase the risk of skull fracture and intracranial lesions on the CT. Patients required neurosurgical intervention in 4 cases, and all of those were acute epidural hematoma with skull fracture. In this study, the first thing we should do for asymptomatic minor head injury patients with a GCS score of 15 is to investigate the presence of a skull fracture by skull X-ray. Head trauma patients with a skull fracture and post-traumatic vomiting should undergo CT to facilitate detection of intracranial lesions, even when there are no abnormal neurological signs.