Language：Japanese   Publisher：(一社)日本外傷学会  

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Language：Japanese   Publisher：(一社)日本災害医学会  

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Language：Japanese   Publisher：(一社)日本脳神経外傷学会  

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Language：Japanese   Publisher：(一社)日本脳神経外傷学会  

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Language：Japanese   Publisher：(一社)日本外傷学会  

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Language：Japanese   Publisher：(一社)日本外傷学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本外傷学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本外傷学会  

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Language：Japanese   Publisher：(株)へるす出版  

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Language：Japanese   Publisher：(一社)日本臨床神経生理学会  

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Language：Japanese   Publisher：日本医科大学医学会  

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BACKGROUND: Due to aging of the Japanese population, traumatic brain injuries (TBI) in elderly individuals have increased. However, the effectiveness and prognosis of intensive treatment in geriatric TBI have not yet been determined. Thus, we analyzed the prognostic factors of intensive and aggressive treatments using nationwide data from Japan Neurotrauma Data Bank (JNTDB) projects. METHODS: We analyzed 1,879 geriatric TBI cases (≥65 years old) registered in four JNTDB projects, Project 1998 (P1998) to Project 2015 (P2015). Clinical features, aggressive treatment usage, and 6-month outcomes on the Glasgow Outcome Scale (GOS) were compared among study projects. Logistic regression was performed to clarify prognostic factors in aggressively-treated patients. RESULTS: The percentage of geriatric TBI cases significantly increased across time (P1998: 30.1%, Project 2004 (P2004) : 34.6%, Project 2009 (P2009) : 43.9%, P2015: 53.6%, p<0.0001). Aggressive treatment usage also significantly increased, from 67.0% in P1998 to 69.3% in P2015 (p<0.0001). Less invasive methods, such as trepanation and normothermic targeted temperature management, were more often chosen for geriatric patients. These efforts resulted in a significant decrease in the 6-month mortality rate, from 76.2% in P1998 to 63.1% in P2015 (p=0.0003), although the percentage of severely disabled patients increased, from 8.9% in P1998 to 11.1% in P2015 (p = 0.0003). Intraventricular hemorrhage was the most unfavorable prognostic factor for the 6-month outcome (OR 3.79, 95% CI 1.78-8.06, p<0.0001). CONCLUSIONS: Less invasive treatments reduce mortality in geriatric TBI but do not improve functional outcomes. The patients' age does not seem to be the strongest prognostic factor; thus, physicians should not adhere to only age.

DOI： 10.1272/jnms.JNMS.2021_88-404

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Language：Japanese   Publisher：(一社)日本脳神経外傷学会  

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Language：Japanese   Publisher：(一社)日本脳神経外傷学会  

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Language：Japanese   Publisher：(NPO)日本脳神経外科救急学会  

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Language：Japanese   Publisher：(NPO)日本脳神経外科救急学会  

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Language：Japanese   Publisher：日本救急医学会-関東地方会  

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Language：Japanese   Publisher：日本救急医学会-関東地方会  

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Language：Japanese   Publisher：(一社)日本脳神経外傷学会  

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DOI： 10.1007/s00701-019-04078-x

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Language：Japanese   Publisher：日本医科大学医学会  

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Language：Japanese   Publisher：日本医科大学医学会  

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Language：Japanese   Publisher：日本医科大学医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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BACKGROUND: The association between traumatic brain injury (TBI) and coagulopathy is well established. While coagulopathy prophylaxis in TBI involves replenishing coagulation factors with fresh frozen plasma (FFP), its effectiveness is controversial. We investigated the relationship between plasma fibrinogen concentration 3 h after initiating FFP transfusion and outcomes and evaluated the correlation with D-dimer levels at admission. METHODS: We retrospectively examined data from 380 patients with severe isolated TBI with blood samples collected a maximum of 1 h following injury. Plasma fibrinogen and D-dimer concentrations were obtained at admission, and plasma fibrinogen concentration was again assessed 3-4 h following injury. The patients were divided into two groups based on whether or not they received FFP transfusion. Patients were also divided into subgroups according their fibrinogen level: ≥ 150 mg/dL (high-fibrinogen subgroup) or < 150 mg/dL (low-fibrinogen subgroup) 3 h after injury. Demographic, clinical, radiological and laboratory data were compared between these subgroups. RESULTS: Glasgow Outcome Scale (GOS) scores at discharge and 3 months after injury were significantly lower in the FFP transfusion group than in the FFP non-transfusion group. Among patients who received FFP, GOS scores at discharge and 3 months after injury were significantly higher in the high-fibrinogen subgroup than in the low-fibrinogen subgroup. Elevated admission D-dimer predicted subsequent fibrinogen decrease. CONCLUSIONS: In FFP transfusion, fibrinogen level ≥ 150 mg/dL 3 h after injury was associated with better outcomes in TBI patients. Assessing the admission D-dimer and tracking the fibrinogen are crucial for optimal coagulopathy prophylaxis in TBI patients.

DOI： 10.1007/s00701-019-04010-3

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Language：Japanese   Publisher：(一社)日本てんかん学会  

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Language：Japanese   Publisher：(一社)日本てんかん学会  

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Language：English   Publisher：MARY ANN LIEBERT, INC  

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Language：Japanese   Publisher：日本脳死・脳蘇生学会  

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Language：English   Publisher：TAYLOR & FRANCIS LTD  

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Language：Japanese   Publisher：日本救急医学会-関東地方会  

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Human neural stem cells (hNSCs) transplantation in several brain injury models has established their therapeutic potential. However, the feasibility of hNSCs transplantation is still not clear for acute subdural hematoma (ASDH) brain injury that needs external decompression. Thus, the aim of this pilot study was to test feasibility using a rat ASDH decompression model with two clinically relevant transplantation methods. Two different methods, in situ stereotactic injection and hNSC-embedded matrix seating on the brain surface, were attempted. Athymic rats were randomized to uninjured or ASDH groups (F344/NJcl-rnu/rnu, n = 7-10/group). Animals in injury group were subjected to ASDH, and received decompressive craniectomy and 1-week after decompression surgery were transplanted with green fluorescent protein (GFP)-transduced hNSCs using one of two approaches. Histopathological examinations at 4 and 8 weeks showed that the GFP-positive hNSCs survived in injured brain tissue, extended neurite-like projections resembling neural dendrites. The in situ transplantation group had greater engraftment of hNSCs than matrix embedding approach. Immunohistochemistry with doublecortin, NeuN, and GFAP at 8 weeks after transplantation showed that transplanted hNSCs remained as immature neurons and did not differentiate toward to glial cell lines. Motor function was assessed with rotarod, compared to control group (n = 10). The latency to fall from the rotarod in hNSC in situ transplanted rats was significantly higher than in control rats (median, 113 s in hNSC vs. 69 s in control, P = 0.02). This study first demonstrates the robust engraftment of in situ transplanted hNSCs in a clinically-relevant ASDH decompression rat model. Further preclinical studies with longer study duration are warranted to verify the effectiveness of hNSC transplantation in amelioration of TBI induced deficits.

DOI： 10.3389/fneur.2019.00082

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This study aimed to identify neurological and pathophysiological factors that predicted return of spontaneous circulation (ROSC) among patients with out-of-hospital cardiac arrest (OHCA). This prospective 1-year observational study evaluated patients with cardiogenic OHCA who were admitted to a tertiary medical center, Nippon Medical School Hospital. Physiological and neurological examinations were performed at admission for quantitative infrared pupillometry (measured with NPi-200, NeurOptics, CA, USA), arterial blood gas, and blood chemistry. Simultaneous blood samples were also collected to determine levels of neuron-specific enolase (NSE), S-100b, phosphorylated neurofilament heavy subunit, and interleukin-6. In-hospital standard advanced cardiac life support was performed for 30 minutes.The ROSC (n = 26) and non-ROSC (n = 26) groups were compared, which a revealed significantly higher pupillary light reflex ratio, which was defined as the percent change between maximum pupil diameter before light stimuli and minimum pupil diameter after light stimuli, in the ROSC group (median: 1.3% [interquartile range (IQR): 0.0-2.0%] vs. non-ROSC: (median: 0%), (Cut-off: 0.63%). Furthermore, NSE provided the great sensitivity and specificity for predicting ROSC, with an area under the receiver operating characteristic curve of 0.86, which was created by plotting sensitivity and 1-specificity. Multivariable logistic regression analyses revealed that the independent predictors of ROSC were maximum pupillary diameter (odds ratio: 0.25, 95% confidence interval: 0.07-0.94, P = 0.04) and NSE at admission (odds ratio: 0.96, 95% confidence interval: 0.93-0.99, P = 0.04). Pupillary diameter was also significantly correlated with NSE concentrations (r = 0.31, P = 0.027). Conclusively, the strongest predictors of ROSC among patients with OHCA were accurate pupillary diameter and a neuronal biomarker, NSE. Quantitative pupillometry may help guide the decision to terminate resuscitation in emergency departments using a neuropathological rationale. Further large-scale studies are needed.

DOI： 10.1038/s41598-018-34367-x

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Language：Japanese   Publisher：日本医科大学医学会  

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DOI： 10.1002/jja2.12086

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER SCIENCE INC  

OBJECTIVE: With the increase in the aged population, geriatric traumatic brain injury (gTBI) is also rapidly increasing in Japan. There is thus a need to review the effect of intensive treatments for gTBIs. The aim of this study was 1) to assess how intensive treatments influenced patient outcome and 2) to identify the refractory factor against these intensive treatments in gTBI, from the Japan Neurotrauma Data Bank (JNTDB).
METHODS: Of all 3194 patients in the JNTDB, 1165 (&gt;= 65 years old) with severe gTBIs were enrolled in this study. The clinical features and their outcomes based on the Glasgow Outcome Scale on discharge and 6 months after injury were compared.
RESULTS: Intensive treatments were administered to 71.4% of all patients with severe gTBI showing a significant increase over 15 years. Accordingly, mortality decreased significantly (from 62.7% to 51.1%, P = 0.001). On the other hand, severely disabled dependent survivors, who need daily help from others for living, increased accordingly (from 63.2% to 68.4%). The existence of intraventricular hemorrhage (IVH) rather than the patient's age was identified as the strongest refractory factor (odds ratio, 5.762; 95% confidence interval, 1.317-25.216) against intensive treatment.
CONCLUSIONS: This study clarified that 1) intensive treatments are associated with higher survival rates (however, they also increase the incidence of severely disabled survivors) and 2) the strongest refractory factor for intensive treatment in cases of severe gTBI was not age but the existence of IVH. These results warrant further establishment of a seamless strategy for both the acute and the chronic phase of gTBI.

DOI： 10.1016/j.wneu.2015.09.105

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Language：English   Publisher：JAPAN NEUROSURGICAL SOC  

Brain death (BD) is a physiological state defined as complete and irreversible loss of brain function. Organ transplantation from a patient with BD is controversial in Japan because there are two classifications of BD: legal BD in which the organs can be donated and general BD in which the organs cannot be donated. The significance of BD in the terminal phase remains in the realm of scientific debate. As indicated by the increasing number of organ transplants from brain-dead donors, certain clinical diagnosis for determining BD in adults is becoming established. However, regardless of whether or not organ transplantation is involved, there are many unresolved issues regarding BD in children. Here, we will discuss the historical background of BD determination in children, pediatric emergencies and BD, and unresolved issues related to pediatric BD.

DOI： 10.2176/nmc.ra.2015-0231

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Language：Japanese   Publisher：Japanese Society for Emergency Medicine  

DOI： 10.11240/jsem.19.703

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DOI： 10.3892/br.2015.454

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：PUBLIC LIBRARY SCIENCE  

We demonstrated that 3-nitrotyrosine and 4-hydroxy-2-nonenal levels in mouse brain were elevated from 1 h until 8 h after global brain ischemia for 14 min induced with the 3-vessel occlusion model; this result indicates that ischemia reperfusion injury generated oxidative stress. Reactive oxygen species production was observed not only in the hippocampal region, but also in the cortical region. We further evaluated the neuroprotective effect of xanthine oxidoreductase inhibitors in the mouse 3-vessel occlusion model by analyzing changes in the expression of genes regulated by the transcription factor nuclear factor-kappa B (including pro-inflammatory cytokines interleukin-1 beta (IL-1 beta) and tumor necrosis factor-alpha (TNF-alpha), matrix metalloproteinase-9 and intercellular adhesion molecules-1). Administration of allopurinol resulted in a statistically significant decrease in IL-1 beta and TNF-alpha mRNA expression, whereas febuxostat had no significant effect on expression of these genes; nevertheless, both inhibitors effectively reduced serum uric acid concentration. It is suggested that the neuroprotective effect of allopurinol is derived not from inhibition of reactive oxygen species production by xanthine oxidoreductase, but rather from a direct free-radical-scavenging effect.

DOI： 10.1371/journal.pone.0133980

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：JAPAN NEUROSURGICAL SOC  

Global cerebral ischemia and reperfusion (I/R) often result in high mortality. Free radicals play an important role in global cerebral I/R. Xanthine oxidoreductase (XOR) inhibitors, such as allopurinol, have been reported to protect tissues from damage caused by reactive oxygen species (ROS) by inhibiting its production through XOR inhibition. The recently introduced XOR inhibitor febuxostat, which is a more potent inhibitor than allopurinol, is expected to decrease free radical production more effectively. Here, we analyzed the effects of allopurinol and febuxostat in decreasing global severe cerebral I/R damage in mice. Mice were divided into three groups: a placebo group, an allopurinol group, and a febuxostat group. Pathological examinations, which were performed in each group in the CA1 and CA2 regions of the hippocampus 4 days after I/R surgery, revealed that there was a decrease in the number of neuronal cells in the 14-min occlusion model in both regions and that drugs that were administered to prevent this damage were not effective. The enzymatic activity was extremely low in the mouse brain, and XOR could not be detected in the nonischemic and ischemic mice brains with western blot analyses. Thus, one of the reasons for the decreased effectiveness of XOR inhibitors in controlling severe whole-brain ischemia in a mouse model was the low levels of expression of XOR in the mouse brain.

DOI： 10.2176/nmc.oa.2013-0307

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：MEDICAL ASSOC NIPPON MEDICAL SCH  

Background and Purpose: Few studies have described the risk factors associated with the development of neurological pulmonary edema (NPE) after subarachnoid hemorrhage (SAH). We have hypothesized that acute-phase increases in serum lactate levels are associated with the early development of NPE following SAH. The aim of this study was to clarify the association between lactic acidosis and NPE in patients with nontraumatic SAH.
Methods: We retrospectively evaluated 140 patients with nontraumatic SAH who were directly transported to the Nippon Medical School Hospital emergency room by the emergency medical services. We compared patients in whom NPE developed (NPE group) and those in whom it did not (non-NPE group).
Results: The median (quartiles 1-3) arrival time at the hospital was 32 minutes (28-38 minutes) after the emergency call was received. Although the characteristics of the NPE and non-NPE groups, including mean arterial pressure (121.3 [109.0-144.5] and 124.6 [108.7-142.6] mm Hg, respectively; P=0.96), were similar, the median pH and the bicarbonate ion (HCO3-) concentrations were significantly lower in the NPE group than in the non-NPE group (pH, 7.33 [7.28-7.37] vs. 7.39 [7.35-7.43]); P=0.002; HCO3-, 20.8 [18.6-22.6] vs. 22.8 [20.9-24.7] mmol/L; P=0.01). The lactate concentration was significantly higher in the NPE group (54.0 [40.3-61.0] mg/dL) than in the non-NPE group (28.0 [17.0-37.5] mg/dL; P&lt;0.001). Multivariable regression analysis indicated that younger age and higher glucose and lactate levels were significantly associated with the early onset of NPE in patients with SAH.
Conclusion: The present findings indicate that an increased serum lactate level, occurring within 1 hour of the ictus, is an independent factor associated with the early onset of NPE. Multicenter prospective studies are required to confirm our results.

DOI： 10.1272/jnms.81.305

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DOI： 10.3893/jjaam.25.757

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：JAPAN NEUROSURGICAL SOC  

Traumatic cerebrovascular injury (TCVI) is a serious complication of severe head injury, with a high mortality rate. To establish a proper treatment strategy for TCVI, we investigated patients with a high risk of TCVI according to the Guidelines for the Management of Severe Head Injury (hereafter "the Guidelines") to elucidate the validity of the criteria for TCVI in the Guidelines and the appropriate screening timing and methods. Of those transported to our facility between December 2008 and June 2012, 67 individuals with a high risk of TCVI were evaluated to reveal the proper timing and methods of vascular evaluation. Of the 67 patients, 21 had a diagnosis of TCVI based on cerebral angiography, three-dimensional computed tomography angiography (3DCTA), or magnetic resonance imaging (Mm), accounting for 6.4% of all patients with severe head injury and as high as 31.3% of patients with a high risk of TCVI according to the Guidelines. In addition, according to the Glasgow Outcome Scale (GOS), outcomes were three deaths due to primary brain injury, six cases of persistent vegetative state, five cases of severe disability, three cases of moderate disability, and four cases of good recovery. Although 3DCTA is a simple and convenient diagnostic method, cerebral angiography is necessary to evaluate dissecting lesions. If patients have any signs or symptoms of TCVI, as described in the Guidelines, cerebral angiography or 3DCTA should be performed as an initial screening method within 72 hours of admission, followed by cerebral angiography on postadmission Day 14 +/- 2 to prevent failed diagnosis.

DOI： 10.2176/nmc.st2013-0079

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：WILEY-BLACKWELL  

Nestin, a class VI intermediate filament protein, is expressed by neuronal progenitor cells in the subventricular zone (SVZ). In the present study, we analyzed the nestin expression and phosphorylation levels in nerve cells in a mouse model of cerebral ischemia and reperfusion. C57BL/6 mice were subjected to three-vessel occlusion for 14min, and were killed either 1 or 4 days after the procedure. The percentages of cells in the SVZ that were positive for nestin, Thr(1495)-phosphorylated nestin or Ki67 did not significantly differ between the ischemic reperfusion and sham groups. Conversely, in the striatum and cornu ammonis 2 (CA2) regions, the mice at 4 days after ischemic reperfusion showed significantly higher numbers and percentages of nerve cells that were positive for nestin, Thr(1495)-phosphorylated nestin and Ki67 compared to results from the other groups. To our knowledge, this is the first description of phosphorylated nestin expression in neural progenitor cells in the SVZ of adult mice. In this cerebral ischemia and reperfusion mouse model, cells positive for Thr(1495)-phosphorylated nestin were increased in the striatum and CA2 field of the hippocampus; suggesting that nestin phosphorylation may play an important role in mitotically active neuronal progenitor cells.

DOI： 10.1111/pin.12092

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In a mass decontamination during a nuclear, biological, or chemical (NBC) response, the capability to command, control, and communicate is crucial for the proper flow of casualties at the scene and their subsequent evacuation to definitive medical facilities. Information Technology (IT) tools can be used to strengthen medical control, command, and communication during such a response. Novel IT tools comprise a vehicle-based, remote video camera and communication network systems. During an on-site verification event, an image from a remote video camera system attached to the personal protective garment of a medical responder working in the warm zone was transmitted to the on-site Medical Commander for aid in decision making. Similarly, a communication network system was used for personnel at the following points: (1) the on-site Medical Headquarters; (2) the decontamination hot zone; (3) an on-site coordination office; and (4) a remote medical headquarters of a local government office. A specially equipped, dedicated vehicle was used for the on-site medical headquarters, and facilitated the coordination with other agencies. The use of these IT tools proved effective in assisting with the medical command and control of medical resources and patient transport decisions during a mass-decontamination exercise, but improvements are required to overcome transmission delays and camera direction settings, as well as network limitations in certain areas.

DOI： 10.1017/S1049023X13000095

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER IRELAND LTD  

Japan has experienced numerous incidents of chemical disasters and terrorist attacks. Here we review the history of changes in countermeasures against such incidents. Since 2004, the Civil Protection Law, more formally known as the "Law Concerning the Measures for Protection of the People in Armed Attack Situations etc" was enacted to fully prepare the nation for chemical terrorism. According to this law, the Japanese government must carry out Civil Protection Exercises on an annual basis to gauge response. Problem areas that remain are chosen and addressed one by one until they are judged to be resolved in subsequent exercises. (C) 2013 Published by Elsevier Ireland Ltd.

DOI： 10.1016/j.forsciint.2012.11.008

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

Predictive variables of delayed cerebral ischemia (DCI) and pulmonary edema following subarachnoid hemorrhage (SAH) remain unknown. We aimed to determine associations between transpulmonary thermodilution-derived variables and DCI and pulmonary edema occurrence after SAH. We reviewed 34 consecutive SAH patients monitored by the PiCCO system. Six patients developed DCI at 7 days after SAH on average; 28 did not (non-DCI). We compared the variable measures for 1 day before DCI occurred (DCI day -1) in the DCI group and 6 days after SAH (non-DCI day -1) in the non-DCI group for control. The mean value of the global end-diastolic volume index (GEDI) for DCI day -1 was lower than that for non-DCI day -1 (676 +/- 65 vs. 872 +/- 85 mL/m(2), P = 0.04). Central venous pressure (CVP) was not significantly different (7.8 +/- 3.1 vs. 9.4 +/- 1.9 cm H2O, P = 0.45). At day -1 for both DCI and non-DCI, 11 patients (32%) had pulmonary edema. Global end-diastolic volume index was significantly higher in patients with pulmonary edema than in those without this condition (947 +/- 126 vs. 766 +/- 81 mL/m(2), P = 0.02); CVP was not significantly different (8.7 +/- 2.8 vs. 9.2 +/- 2.1 cm H2O, P = 0.78). Although significant correlation was found between extravascular lung water (EVLW) measures and GEDI (r = 0.58, P = 0.001), EVLW and CVP were not correlated (r = 0.03, P = 0.88). Thus, GEDI might be associated with DCI occurrence and EVLW accumulation after SAH.

DOI： 10.1097/SHK.0b013e31826a3813

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：JAPAN NEUROSURGICAL SOC  

Inflammation and the coagulation system may influence the genesis of chronic subdural hematoma (CSDH). The appearance of CSDH on computed tomography (CT) varies with the stage of the hematoma. This study investigated the pathogenesis and the recurrence of CSDH by comparing cytokine levels with the CT features of CSDH in 26 patients with 34 CSDHs who underwent single burr-hole surgery at our hospital between October 2004 and November 2006. The hematoma components removed during the procedure were examined, and the hematoma serum levels of cytokines measured such as thrombomodulin (TM), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF alpha), and interleukin-10 (IL-10). Using CT, mixed density hematomas were distinguished from other homogeneous hematomas, and found that the TM level was significantly higher in mixed density hematomas than in homogeneous hematomas (p = 0.043). Mixed density hematomas were classified into three subtypes (laminar, separated, and trabecular hematomas). The TM level was significantly higher in laminar and separated hematomas than in other hematomas (p = 0.01). The levels of IL-6, TNFa, and IL-10 were extremely high, but showed no significant differences in relation to the CT features. Mixed density hematomas had high recurrence rate, as reported previously, and TM level was high in mixed density hematomas such as laminar and separated mixed density hematomas. The present findings suggest that the types of CSDH associated with high TM levels tend to have higher recurrence rate.

DOI： 10.2176/nmc.52.810

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：MEDICAL ASSOC NIPPON MEDICAL SCH  

On March 11, 2011, an earthquake occurred off the coast of Honshu, Japan. The quake was followed by a powerful tsunami that caused extensive damage to the east coast of the Tohoku and Kanto regions. This disaster destroyed the medical system in place and thus drastically reduced the ability of the healthcare system to handle the large number of casualties. During the initial response to this disaster, we participated in several types of outreach medical relief teams dispatched to the affected area from the day of the earthquake onwards. The ratio of persons injured to persons missing or dead for the 2011 Japan disaster (0.31: 5,994 to 19,371) was much lower than for the Indian Ocean Tsunami of 2004 in Thailand (1.01: 8,457 to 8,393) and for the Great Hanshin-Awaji Earthquake of 1995 in Japan (6.80; 43,792 to 6,437). The different ratios for the different types of disasters indicate that medical relief efforts in response to natural disasters should be tailored to the type of disaster to optimize the effectiveness of the response and prevent further deaths. From a medical viewpoint, unnecessary deaths must be prevented following natural disasters. Doing so requires appropriate information transmission and an understanding of the mission's overall and specific objectives: 1) rapid search and rescue: 2) early care in the field, evacuation centers, and primary clinics: 3) definitive evaluation at disaster base hospitals; and 4) proper evacuation to unaffected areas. We propose a descriptive device that can guide headquarters in dealing with the commonalities of a disaster. (J Nippon Med Sch 2012; 79: 312-315)

DOI： 10.1272/jnms.79.312

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DOI： 10.1097/TA.0b013e31823b5b90

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This report describes our onsite medical rounds and fact-finding activities conducted in the acute phase and medical relief work conducted in the subacute phase in Miyagi prefecture following the Great East Japan Earthquake and subsequent tsunami that occurred off northeastern Honshu on March 11, 2011. As part of the All-Japan Hospital Association medical team deployed to the disaster area, a Nippon Medical School team conducted fact-finding and onsite medical rounds and evaluated basic life and medical needs in the affected areas of Shiogama and Tagajo. We performed triage for more than 2,000 casualties, but in our medical rounds of hospitals, clinics, and nursing homes, we found no severely injured person but did find 1 case of hyperglycemia. We conducted medical rounds at evacuation shelters in Kesennuma City during the subacute phase of the disaster, from March 17 through June 1, as part of the Tokyo Medical Association medical teams deployed. Sixty-seven staff members (17 teams). including 46 physicians, 11 nurses, 3 pharmacists, and 1 clinical psychotherapist, joined this mission. Most patients complained of a worsening of symptoms of preexisting conditions. such as hypertension, respiratory problems, and diabetes, rather than of medical problems specifically related to the tsunami. In the acute phase of the disaster, the information infrastructure was decimated and we could not obtain enough information about conditions in the affected areas, such as how many persons were severely injured, how severely lifeline services had been damaged, and what was lacking. To start obtaining this information, we conducted medical rounds. This proved to be a good decision, as we found many injured persons in evacuation shelters without medication, communication devices, or transportation. Also, basic necessities for life, such as water and food, were lacking. We were able to evaluate these basic needs and inform local disaster headquarters of them. In Kesennuma City, we found that some evacuation shelters could not contact others even after 1 week after the earthquake. We realized from our experiences that, unlike our activities following more localized earthquake disasters, the first task following such large-scale disasters is to acquire information on basic life needs, including medication needs, and the number of persons requiring assistance. We must provide medical relief according to the unique characteristics of the disaster-affected areas as well as the specific nature of the disaster, in this case, a tsunami. (J Nippon Med Sch 2011; 78: 401-404)

DOI： 10.1272/jnms.78.401

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：MEDICAL ASSOC NIPPON MEDICAL SCH  

On March 11. 2011, after the Great East Japan Earthquake and tsunami, the government declared a nuclear emergency following damage to the Fukushima Daiichi Nuclear Power Plant. A second hydrogen explosion occurred on March 14 at the plant's No. 3 reactor and injured 11 people. At that time the prime minister urged people living 20 to 30 km from the Daiichi plant to stay indoors. Under these circumstances, many residents of Iwaki City, which was largely outside the 30-km zone, left the city, making it difficult to get supplies to the remaining residents. The only transportation route open for supplies and medical resources was roads, and many drivers feared the rumor that the city was contaminated by radioactive materials and, so, refused to go there. Nippon Medical School (NMS) heard that medical resources were running short at Iwaki Kyoritsu Hospital, which requested water, medications, food, fuel (gasoline), medical support, and the evacuation of 300 inpatients. As a first step, NMS decided to evaluate the situation at the hospital and, on March 16, the director of the NMS Advanced Emergency Center visited the hospital and helped provide triage for about 200 patients. Critically ill patients receiving ventilatory support were given priority for evacuation because they would be most at risk of not being able to evacuate should the Japanese government order an immediate evacuation of the city. We tried to evacuate the inpatients via an official framework, such as the Disaster Medical Assistance Team (DMAT), but DMAT could not support this mission because this hospital was not within the 30-km evacuation zone. Moreover. the Iwaki City government could not support the evacuation efforts because they were fearful of the rumor that Iwaki was contaminated by radioactive material. Ultimately, we realized that we had to conduct the mission ourselves and, so, contacted our colleagues in the Tokyo metropolitan area to prepare enough hospital beds. We evacuated 15 patients to 8 hospitals over a 5-day period. As a result, we could reduce the number of patients at Iwaki Kyoritsu Hospital, and, thereby, the collapse of medical services in the city was avoided. In retrospect, someone might say the government either central or local should ideally have carried out this mission and created a system by which to do it. At the same time, however, to overcome any future bureaucratic issues, we should also prepare private networks, such as those used by NMS. because they can respond flexibly to unexpected large-scale disasters. (J Nippon Med Sch 2011: 78: 393-396)

DOI： 10.1272/jnms.78.393

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：MEDICAL ASSOC NIPPON MEDICAL SCH  

At 14:46 on March 11, 2011, the Great East Japan Earthquake and tsunami occurred off the coast of Honshu. Japan. In the acute phase of this catastrophe, one of our teams was deployed as a Tokyo Disaster Medical Assistance Team (DMAT) to Kudan Kaikan in Tokyo, where the ceiling of a large hall had partially collapsed as the result of the earthquake, to conduct triage at the scene: 6 casualties were assigned to the red category (immediate), which included 1 case of cardiopulmonary arrest and 1 of flail chest; 8 casualties in the yellow category (delayed); and 22 casualties in the green category (minor). One severely injured person was transported to our hospital. Separately, our medical team was deployed to Miyagi 2 hours after the earthquake in our multipurpose medical vehicle as part of Japan DMAT (J-DMAT). We were the first DMAT from the metropolitan area to arrive, but we were unable to start medical relief activities because the information infrastructure had been destroyed and no specific information had yet reached the local headquarters. Early next morning, J-DMAT decided to support Sendai Medical Center and search and rescue efforts in the affected area and to establish a staging care unit at Camp Kasuminome of the Japan Self-Defense Force. Our team joined others to establish the staging care unit. Because information was still confused until day 3 of the disaster and we could not adequately grasp onsite medical needs, our J-DMAT decided to provide onsite support at Ishinomaki Red Cross Hospital, a disaster base hospital, and relay information about its needs to the local J-DMAT headquarters. Although our medical relief teams were deployed as quickly as possible, we could not begin medical relief activities immediately owing to the severely damaged information infrastructure. Only satellite mobile phones could be operated, and information on the number of casualties and the severity of shortages of lifeline services could be obtained only through a "go and see" approach. Because there was no way to transmit or receive this vital information, disaster workers in the affected areas faced many challenges. For the future, network data links need to be made more resistant to infrastructure damage, and redundant or reach-back systems involving multitiered satellite, wireless, and radio frequency data links would provide definitive solutions. Such integrated systems should be designed around seamless connectivity based on an "always best connected" principle for maintaining communication quality. (J Nippon Med Sch 2011; 78: 397-400)

DOI： 10.1272/jnms.78.397

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

Background: The aim of this study was to evaluate the time course of recovery from cerebral vulnerability, using microdialysis (MD) technique and cerebral vascular autoregulation measurement, to clarify the appropriate timing of subsequent major surgical procedures, and to minimize the possibility of secondary brain injury in patients with severe traumatic brain injury (STBI).
Methods: In 3,470 MD samples of 25 patients with STBI, cerebral extracellular biomarkers (glucose, lactate, pyruvate, glycerol, and glutamate) were measured. In addition, to estimate cerebral vascular autoregulaton, the pressure reactivity index (PRx) was calculated with intracranial pressure (ICP) and mean arterial pressure. The data with ICP, cerebral perfusion pressure (CPP), and PRx were collected hourly for 7 days after injury and they were compared with MD biomarkers daily.
Results: During the study period, the average ICP and CPP remained stable and were within the threshold of STBI treatment guidelines. After injury, the extracellular glucose concentration decreased, and the levels of glycerol, glutamate, and lactate/pyruvate ratio (LPR), which indicate cerebral ischemia and neural cell damage, increased. On the fourth day after injury, the extracellular glucose concentration improved, and the value of LPR decreased. The average PRx decreased daily and became negative on the fifth day after injury.
Conclusion: Our results indicated that cerebral vascular autoregulation would recover on the fourth day after STBI, and cerebral perfusion might be increased by recovery of autoregulation. Thus, subsequent nonemergent surgery should be performed at least 4 days after STBI to prevent secondary brain injury. In addition, we should keep in mind that the cerebral vulnerability might persist for 4 days after suffering STBI.

DOI： 10.1097/TA.0b013e3182140dd7

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In recent years, blast injuries worldwide have primarily been caused by explosions of improvised explosive devices detonated in terrorist attacks. The most common mechanism of injury among U.S. soldiers in Iraq and Afghanistan war is explosions. Blast injuries are complicated, being compounded by injuries caused by blast waves in addition to penetrating and blunt trauma. Moreover, maintaining safety and security is a major concern in providing medical care and requires an understanding of blast physics and blast injury pathophysiology, especially in cases of blast lung injury (BLI) and blast-induced traumatic brain injury (bTBI). In this paper, we present our review of the current status of preparedness for blast injuries, which was conducted with the cooperation of the Cabinet Office of the Government of Japan and the Japan Self Defense Force. Based on this review, we created two action card systems and a medical record system in Japanese for blast injuries: "Survival Cards for Explosive Events for the First-on-scene Responder," "Survival Cards for Explosive Events for Medical Staff Providing Prehospital and Hospital Medical Care," and the "Medical Records System for Blast Injuries." These were developed with reference to preparedness guidelines issued by the United States and European countries and are available on the Cabinet Office website. As the next step, guidelines for the treatment of blast injuries should be established and full-scale drills should be conducted as preparedness activities.

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：JAPAN NEUROSURGICAL SOC  

Age may be an independent predictor of outcomes in traumatic brain injury (TBI), but the causes of the poor outcomes in elderly patients remain unclear. To clarify the differences between elderly and young patients with TBI, brain metabolism parameters were monitored with the microdialysis method in 30 patients with severe TBI (Glasgow Coma Scale scores 3-8). The microdialysis probe was inserted in the penumbra area of the brain and extracellular levels of glucose, glutamate, glycerol, lactate, and pyruvate were measured hourly for the initial 168 hours (7 days) after operation. The lactate/pyruvate ratio, which is considered to be a good indicator of neuronal ischemia, was also calculated. The patients were divided into the elderly group aged 65 years or older and the young group aged less than 65 years, and the biochemical markers were compared daily between these two groups. The value of extracellular glucose concentration was significantly lower in the elderly group than in the young group, and continued until the 7th day after injury. Moreover, the lactate/pyruvate ratio peaked on the 5th day after injury in the elderly group, later than in the young group. We concluded that neural vulnerability persisted longer in elderly patients than in young patients with TBI, and this should be considered to prevent the occurrence of additional secondary brain injury.

DOI： 10.2176/nmc.51.265

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DOI： 10.11477/mf.1541101708

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：JAPAN NEUROSURGICAL SOC  

Patients with degenerative diseases of the cervical spine, such as ossification of the posterior longitudinal ligament, spondylosis, and canal stenosis, sometimes present with acute spinal cord injury caused by minor trauma. However, the relative risk of cervical cord injury with these diseases is unknown. The clinical and radiological features of 94 elderly patients with head injury, 57 men and 37 women aged from 65 to 98 years (mean 76.6 years), were retrospectively analyzed to assess the association of spinal cord injury with degenerative cervical diseases. Degenerative cervical diseases were present in 25 patients, and spinal cord injury was more common in the patients with degenerative diseases (11/25 patients) than in the patients without such diseases (3/69 patients; relative risk = 10.2). The incidence of degenerative cervical diseases seems to be increasing in Japan because life expectancy has increased and the elderly are a rapidly growing part of the population. A fall while walking or cycling is a common mechanism of head injury and/or cervical cord injury in the elderly. To decrease the occurrence of cervical myelopathy, prevention by increasing social awareness and avoiding traffic accidents and falls is important.

DOI： 10.2176/nmc.50.461

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：JAPAN NEUROSURGICAL SOC  

A 33-year-old female presented with a rare case of severe vasospasm following the rupture of an arteriovenous malformation (AVM) without subarachnoid hemorrhage. Initial computed tomography (CT) revealed a subcutaneous hematoma and cast formation of intraventricular clots without the deposition of subarachnoid blood in any basal cistern. Cerebral angiography revealed a small AVM located in the right parietal lobe without aneurysmal formations. Repeat CT demonstrated no evidence of subarachnoid clots expected with the presence of intraventricular clots and she was transferred to a general ward. She suffered sudden onset of motor aphasia and disturbance of consciousness on Day 17 after the hemorrhage. Magnetic resonance imaging indicated diffuse cortical infarction and subsequent magnetic resonance angiography revealed severe narrowing of the bilateral internal carotid arteries. Three-dimensional CT angiography on the same day indicated similar findings. She was transferred back to the intensive care unit for critical treatment. However, she suffered persistent mild right hemiparesis and motor aphasia. The characteristic features of vasospasm after intraventricular hemorrhage from AVMs are delayed onset, acute deterioration of consciousness, female predominance, and localization to the bilateral internal carotid arteries. Treatment of patients with AVM rupture should consider the risk of severe vasospasm, even if there is no subarachnoid clot.

DOI： 10.2176/nmc.50.320

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Medical Association of Nippon Medical School  

Lessons learned from the Great Hanshin-Awaji earthquake of 1995 underscored the necessity of establishing Disaster Medical Assistance Teams (DMATs) in Japan, and in 2005, the Japanese government's Central Disaster Prevention Council revised its Basic Disaster Management Plan to include full deployment of DMATs in disaster areas. Defining a DMAT as a trained, mobile, self-contained medical team that can act in the acute phase of a disaster (48 to 72 hours after its occurrence) to provide medical treatment in the devastated area, the revised plan called for the training of DMAT personnel for rapid deployment to any area of the country hit by a disaster. This paper presents descriptive data on the number and types of missions carried out by Japan DMAT (J-DMAT) in its first 5 years, and clarifies how J-DMAT differs from its counterpart in the United States (US-DMAT). The DMAT that the present authors belong to has been deployed for 2 natural disasters and 1 man-made disaster, and the operations carried out during these deployments are analyzed. Reports on J-DMAT activities published from 2004 through 2009 by the Japanese Association for Disaster Medicine are also included in the analysis. After training courses for J-DMAT personnel started in fiscal 2004, J-DMATs were deployed for 8 disasters in a period of 4 years. Five of these were natural disasters, and 3 man-made. Of the 5 natural disasters, 3 were earthquakes, and of the 3 manmade disasters, 2 were derailment accidents. Unlike in the United States, where hurricanes and floods account for the greatest number of DMAT deployments, earthquakes cause the largest number of disasters in Japan. Because Japan is small in comparison with the US (Japan has about 1/25 the land area of the US), most J-DMATs head for devastated areas by car from their respective hospitals. This is one reason why J-DMATs are smaller and more agile than US-DMATs. Another difference is that J-DMATs' activities following earthquakes involve providing treatment in confined spaces, triage, and stabilization of injuries: these services are required in the acute phase of a disaster, but the critical period is over in a much shorter time than in the case of water-related disasters. In response the kind of man-made disasters that occur in Japan - mainly transportation accidents, and occasional cases of random street violence - J-DMATs need to be deployed as soon as possible to provide medical services at the scene at the critical stage of the disaster. This means that J-DMATs have to be compact. The fact that J-DMATs are smaller and more agile than US-DMATs is a result of the types of disaster that hit Japan and the relatively small size of the country.

DOI： 10.1272/jnms.77.318

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Language：Japanese   Publisher：(一社)日本災害医学会  

被災地では急性期疾病のみならず、経時的に衛生状態の悪化に伴う疾患の増加も見られる。したがって急性期医療支援を行う一方で被災地での公衆衛生の啓蒙が重要となってくる。災害医療における健康教育について国際緊急援助隊(Japan Disaster Relief)医療チームの事例を紹介し、問題点につき検討した。【事例1】2003年のアルジェリア地震災害では衛生施設が需要を満たしていなかった。また乾燥した気候、砂埃の多い環境から呼吸器疾患の蔓延が危惧された。衛生啓蒙のため現地語のフランス語、アラビア語にて、うがいや手洗いを勧めるポスターやパンフレットを作成し掲示し、配布した。【事例2】2004年インド洋津波災害におけるタイの被災地では、下痢等の蔓延が予測された。タイ語にてポスターを作成し、手を洗うことに重点を置いた衛生啓蒙活動を行った。また小児対象に寸劇を行い公衆衛生の啓蒙を行った。【考察および結語】以上の公衆衛生啓蒙活動は、災害が急性期から亜急性期に移行していく中で偶発的に行われたものであったが、その地域における気候、言語、文化を考慮したうえで計画、実行することの有効性を経験した事例であった。今後はいかに客観的に有効性の評価を行うか検討が必要である。また事前の準備として体系的な衛生啓蒙、健康教育の方法についてもさらなる検討が必要である。(著者抄録)

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Language：Japanese   Publisher：The Medical Association of Nippon Medical School  

DOI： 10.1272/manms.5.141

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Other Link： http://search.jamas.or.jp/link/ui/2009199055

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

Background:. To demonstrate the clinical characteristics of patients with cervical cord injury (CCI) without bony injury in Japan.
Methods: Retrospective review of 127 patients with CCI without bony injury treated between January 2003 and October 2005 at 11 institutions.
Results: Prevalence of CCI without bony injury was 32.2% among all CCIs and 0.81 % among all blunt traumas. Mean age was 60.4 years (range, 19-90 years), with 104 patients (82%) &gt;= 46 years old (older group). The major mechanism of injury among younger patients (&lt; 46 years) was traffic injuries (39%), whereas minor falls (44%) predominated in older patients. High-energy mechanisms of injury were significantly more common for younger patients (35 % versus 15 %, p = 0.041). Mean injury severity score, abbreviated injury score for the head and Glasgow coma scale on admission were 17.2 +/- 4.7,0.6 +/- 0.9, and 14.2 +/- 2.1, respectively. Incomplete CCI occurred in 88.7%. On plain cervical spine radiography, spinal canal stenosis and spondylosis or ossification of the posterior longitudinal ligament were more frequent in older patients than in younger patients (43% vs. 13%, p = 0.008; 54% vs. 17%,p = 0.002, respectively). No abnormal findings were seen in 52% of younger patients.
Conclusion: CCI without bony injury occurred more frequently in this study population than previously reported. Degenerative changes and spinal canal stenosis represent important risk factors for developing CCI without bony injury and the present results suggest that this injury may occur in younger adults during high-energy injuries in the absence of pre-existing cervical spine disease.

DOI： 10.1097/TA.0b013e31817db11d

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：JAPAN NEUROSURGICAL SOC  

Elevated serum levels of thrombomodulin (TM) and von Willebrand factor (vWf) are good indicators of injury and activation of cerebral endothelium in patients with severe simple head injury. The present study evaluated cerebral endothelial injury or activation as the serum levels of TM and vWf in elderly and younger patients with similar brain trauma, to evaluate the primary parenchymal injury of the brain. Patients with head injury were classified into the young group (16-30 years), the middle-aged group (31-65 years), and the elderly group (over 66 years). There was no difference in Glasgow Coma Scale on admission between the three groups. The serum levels of TM and vWf at 2 hours after injury were significantly higher in the elderly group than in the other groups. However, the serum levels of TM and vWf were not significantly different at 3 and 7 days after injury. Cerebral endothelial activation and injury were significantly higher in elderly patients just after head injury than in younger patients, which suggests that greater sensitivity to endothelial injury and activation may be important in the worse outcome after head injury in elderly patients compared with younger patients.

DOI： 10.2176/nmc.47.383

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Vertebral artery injury associated with non-penetrating cervical trauma is rare. We report 11 cases of vertebral artery injury diagnosed with magnetic resonance imaging (MRI) after blunt trauma to the cervical spine and discuss about the importance of MRI in the diagnosis of this injury. Seven cases were caused by motor vehicle accidents, three by diving accidents, and one by static compression of the neck. All of the patients had documented cervical spine fractures and dislocations. In three patients, the diagnosis of complete occlusion of the vertebral artery was made on the basis of MRI and digital subtraction angiography (DSA). In the other patients, mural injuries of the vertebral artery were demonstrated with DSA. These 11 patients presented with acute, nonspecific changes in neurological status. Two had infarctions of the cerebellum and brainstem. None were treated with anticoagulants. All of them survived and were discharged to other hospitals for physical and occupational therapy. Although DSA remains the gold standard for diagnosing vertebral artery injuries. MRI is a newer modality for assessing cervical cord injury, and it may be useful for evaluating the presence of vertebral injury after blunt cervical spine trauma.

DOI： 10.1272/jnms.74.293

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It is very important to collect and accumulate data of same-type events from the point of view of appropriate preparedness for mass gathering medicine. On the basis of the experience of the 2002 FIFA World Cup Korea/Japan, the Japanese Association of Disaster Medicine organized the emergency medical assistance team during large football events. The objective was to analyze all clinical presentations available to the on-site physicians during this event. The total number of patients was 51 (patient presentation rate: 0.25/1000 spectators). Trauma, abdominal pain and common cold were the main pathologies encountered. Eight patients were transported to hospital. Forty-one patients (80.4% of total) were treated within the medical station and were not transported to hospital. These dispositions were considered to lighten the burden imposed on activities of local emergency medical services. Sharing databases with local medical services and surveying the outcome of patients are needed to allow patient presentation provision.

DOI： 10.1097/01.mej.0000224439.74493.b3

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Cambridge University Press  

Introduction: Past history of mass casualties related to international football games brought the importance of practical planning, preparedness, simulation training, and analysis of potential patient presentations to the forefront of emergency research. Methods: The Japanese Ministry of Health, Labor, and Welfare established the Health Research Team (HRT-MHLW) for the 2002 FIFA World Cup game (FIFAWC). The HRT-MHLW collected patient data related to the games and analyzed the related factors regarding patient presentations. Results: A total of 1,661 patients presented for evaluation and care from all 32 games in Japan. The patient presentation rate per 1,000 spectators per game was 1.21 and the transport-to-hospital rate was 0.05. The step-wise regression analysis identified that the patient presentations rate increased where access was difficult. As the number of total spectators increased, the patient presentation rate decreased. (p &lt
0.0001, r = 0.823, r2 = 0.677). Conclusion: In order to develop mass-gathering medical-care plans in accordance with the types and sizes of mass gatherings, it is necessary to collect data and examine risk factors for patient presentations for a variety of events. Copyright © World Association for Disaster and Emergency Medicine 2004.

DOI： 10.1017/S1049023X00001874

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本てんかん学会  

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Language：Japanese   Publisher：日本脳低温療法・体温管理学会  

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Language：Japanese   Publisher：日本脳低温療法・体温管理学会  

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Language：Japanese   Publisher：(一社)日本外傷学会  

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Language：Japanese   Publisher：(一社)日本臨床救急医学会  

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Language：Japanese   Publisher：(一社)日本脳神経外傷学会  

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Language：Japanese   Publisher：(NPO)日本脳神経外科救急学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：日本救急医学会-関東地方会  

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Language：Japanese   Publisher：The Japanese Association for the Surgery of Trauma  

<p> A 41-year-old women was admitted to our hospital for seizure. Brain CT revealed subarachnoid hemorrhage (SAH) and digital subtraction angiography demonstrated an aneurysm located in the left internal carotid artery, which was thought to be the cause of SAH. In addition, bilateral cervical internal carotid artery dissections (CICADs) were identified. Clipping of the aneurysm was carried out. CT at 1 day post-procedure demonstrated cerebral infarction. According to her detailed medical story, she had begun chiropractic care 27 days before admission. Chiropractic care was considered to have caused the bilateral CICADs, which in turn caused the thromboembolism and cerebral infarction. Antiplatelet therapy was administered, and she was transferred to the rehabilitation hospital 29 days after admission. MRA at 3 months post-procedure demonstrated improvement of bilateral CICADs.</p>

DOI： 10.11382/jjast.33.398

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：日本医科大学医学会  

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Language：Japanese   Publisher：日本脳死・脳蘇生学会  

【背景・目的】心停止患者において蘇生の中止基準は明記されておらず、蘇生の限界を判断する客観的な指標も科学的エビデンスに乏しいのが現状である。われわれは院外心停止患者において赤外線瞳孔計による客観的瞳孔所見評価、血中IL-6迅速モニタリング値およびneuron-specific enolase(NSE、神経特異エノラーゼ)が蘇生の可能性を予測し得るかを検討した。【対象・方法】当院に搬送された内因性心肺停止患者のなかで心原性と推定された53人を対象とした。初療室入室時に自己心拍再開前の血中IL-6値を迅速測定した。また同血清を用いてELISA法によりNSEを測定した。さらに赤外線瞳孔計pupillometryを用いた客観的瞳孔対光反射測定を同時に施行し、自己心拍再開群と自己心拍非再開群において比較した。【結果】自己心拍再開群では自己心拍非再開群と比して瞳孔最大径[3.550(4.923〜2.173)mm vs.5.2(5.948〜4.760)mm、p=0.00008]、IL-6[42.0(144.0〜23.5)pg/mL vs.116.0(972.0〜35.0)pg/mL、p=0.04546]、NSE[24.2(44.4〜18.6)ng/mL vs.61.4(91.6〜39.4)ng/mL、p=0.00001]で、いずれも有意に低値であった。また自己心拍再開群では自己心拍非再開群と比して瞳孔収縮率は[1.5(1.0〜2.0)% vs.0.0(0.0〜0.0)%、p=0.01165]で高値であった。瞳孔最大径、瞳孔収縮率、IL-6、NSEのカットオフ値はそれぞれ4.699mm(感度0.66、特異度0.62、AUC=0.81197)、0.65%(感度1.00、特異度0.47、AUC=0.61111)、61.25pg/mL(感度0.61、特異度0.62、AUC=0.66506)、40.60ng/mL(感度0.72、特異度0.72、AUC=0.8576)であった。【考察】NSEは瞳孔収縮率やIL-6と同様に自己心拍再開と相関した。今後は客観的瞳孔所見評価、IL-6値、NSE値に影響を与える因子の除外や目撃者・バイスタンダーCPRの有無などのプレホスピタル因子を含めた総合的な検討が必要である。【結語】NSE値は客観的瞳孔所見評価、IL-6値と同様に自己心拍再開を予測する指標として今後の研究に役立つ可能性が示唆された。(著者抄録)

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Language：Japanese   Publisher：(一社)日本外傷学会  

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Language：Japanese   Publisher：日本脳死・脳蘇生学会  

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Language：Japanese   Publisher：(一社)日本インターベンショナルラジオロジー学会  

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Language：Japanese   Publisher：The Japanese Congress on Neurological Emergencies  

Background: The mortality of bacterial meningitis is still high even in modern era, even if antimicrobial therapy has been developed. We report a case of Streptococcus pneumoniae meningitis followed by intracranial hemorrhage which craniotomy was performed. Clinical presentation: A 69-year-old man suffered fever and loss of consciousness. With cerebrospinal fluid examinations, antibiotic and steroid therapy was started with diagnosis of Streptococcus pneumoniae meningitis. The initial head CT scan revealed a cerebral hemorrhage. CT scan taken at the day 4 showed exacerbation of hemorrhage in frontal lobe and brain herniation. Intervention: The operation of hematoma removal was performed. During the operation, the brain tissue was easily bleeding and difficult to stop bleeding. Pathologically, microscopic examinations showed vasculitis and microvascular embolisms. It was considered that vasculitis due to meningitis and abnormal blood coagulation promoted hemorrhage. Conclusion: We experienced a craniotomy for cerebral hemorrhage due to Streptococcus pneumoniae meningitis. We also learned the importance of careful haemostasis and frequent imaging in surgery for hemorrhage with coagulopathy following meningitis.

DOI： 10.11170/jjsnecc.30.2_53

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Language：Japanese   Publisher：Japanese Association for Acute Medicine of Kanto  

<p>A male in his 50's with a history of alcoholic liver dysfunction and hepatitis C, was taken to our emergency department with a chief complaint of sever liver and kidney dysfunction and thrombocytopenia. Our detailed interview revealed that he was a sanitary worker. We suspected leptospirosis based on his symptoms and background, and confirmed the diagnosis from serum PCR. Leptospirosis is uncommon and potentially fatal disease in Japan. We need to keep in mind leptospirosis in case a patient has thrombocytopenia, liver and kidney dysfunction of uncertain etiology.</p>

DOI： 10.24697/jaamkanto.39.2_326

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Language：English   Publisher：HUMANA PRESS INC  

Targeted temperature management (TTM) is often used in neurocritical care to minimize secondary neurologic injury and improve outcomes. TTM encompasses therapeutic hypothermia, controlled normothermia, and treatment of fever. TTM is best supported by evidence from neonatal hypoxic-ischemic encephalopathy and out-of-hospital cardiac arrest, although it has also been explored in ischemic stroke, traumatic brain injury, and intracranial hemorrhage patients. Critical care clinicians using TTM must select appropriate cooling techniques, provide a reasonable rate of cooling, manage shivering, and ensure adequate patient monitoring among other challenges.
The Neurocritical Care Society recruited experts in neurocritical care, nursing, and pharmacotherapy to form a writing Committee in 2015. The group generated a set of 16 clinical questions relevant to TTM using the PICO format. With the assistance of a research librarian, the Committee undertook a comprehensive literature search with no back date through November 2016 with additional references up to March 2017.
The Committee utilized GRADE methodology to adjudicate the quality of evidence as high, moderate, low, or very low based on their confidence that the estimate of effect approximated the true effect. They generated recommendations regarding the implementation of TTM based on this systematic review only after considering the quality of evidence, relative risks and benefits, patient values and preferences, and resource allocation.
This guideline is intended for neurocritical care clinicians who have chosen to use TTM in patient care; it is not meant to provide guidance regarding the clinical indications for TTM itself. While there are areas of TTM practice where clear evidence guides strong recommendations, many of the recommendations are conditional, and must be contextualized to individual patient and system needs.

DOI： 10.1007/s12028-017-0469-5

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Language：Japanese   Publisher：日本医科大学医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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DOI： 10.1272/manms.12.161

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DOI： 10.1272/manms.12.161

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Language：Japanese   Publisher：日本脳低温療法・体温管理学会  

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DOI： 10.7887/jcns.25.220

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Language：Japanese   Publisher：日本脳低温療法・体温管理学会  

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

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DOI： 10.7887/jcns.23.973

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

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DOI： 10.11382/jjast.28.143

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：MARY ANN LIEBERT, INC  

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Language：Japanese   Publisher：The Japanese Congress of Neurological Surgeons  

&emsp;&emsp;With the innovation of measuring techniques, research into several biomarker has been ongoing in neurocritical care. In addition to the usual biomarkers such as neuron specific enolase, S100&beta; and glutamate, several new biomarkers along with their pathomechanisms have been studied in traumatic brain injury (TBI) patients. These biomarkers are neurofilament families derived from neural cytoskeleton, tau protein derived from dendritic microtubules, microtubule-associated protein 2 derived from dendritic cell body, myelin basic protein from oligodendrocyte and myelin, ubiquitin C-terminal hydrolase-L1 derived from neural cells and glial fibrillary acidic protein from glial cells.<br>&emsp;&emsp;In this article, we will review the basic and clinical data of these biomarkers. Then, we will discuss the efficacy of these biomarkers for the &ldquo;visualization&rdquo; of TBI pathophysiology.

DOI： 10.7887/jcns.23.973

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：MARY ANN LIEBERT, INC  

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