Authorship：Corresponding author   Language：English   Publishing type：Research paper (scientific journal)  

Rheumatoid meningitis is a rare central neurological complication associated with rheumatoid arthritis. We report an unusual case of rheumatoid meningitis presenting with clinical and radiological findings resembling subarachnoid hemorrhage, with no history of rheumatoid arthritis diagnosis and negative serum rheumatoid factor. A woman in her fifties presented with a severe headache and loss of consciousness. Magnetic resonance imaging suggested subarachnoid hemorrhage involving the interhemispheric fissure and adjacent bilateral cerebral sulci. Cerebral angiography did not reveal any vascular abnormalities, and an initial diagnosis of subarachnoid hemorrhage of unknown etiology was made. Follow-up magnetic resonance imaging failed to identify a source of bleeding, evidence of hematoma resolution, or new vascular lesions. Although she had a family history of rheumatoid arthritis, she had no formal rheumatoid arthritis diagnosis, and serum rheumatoid factor tests were negative. Contrast-enhanced magnetic resonance imaging showed leptomeningeal thickening along the falx cerebri, raising suspicion of an inflammatory condition such as meningitis. Her symptoms progressively worsened, and on day 16, a meningeal biopsy was performed. Histopathological examination confirmed meningitis and subsequent blood tests revealed positive anticyclic citrullinated peptide antibodies. A comprehensive evaluation ultimately led to the diagnosis of rheumatoid meningitis. This case highlights that rheumatoid meningitis can mimic the clinical and imaging findings of subarachnoid hemorrhage, even in patients without a prior rheumatoid arthritis diagnosis or with negative serum rheumatoid factor. Furthermore, rheumatoid meningitis may show progressive deterioration, emphasizing the importance of early meningeal biopsy during the acute phase for accurate diagnosis and improved prognosis. Clinicians should closely monitor changes in clinical and radiological findings and consider early biopsy in such cases.

DOI： 10.2176/jns-nmc.2024-0342

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Authorship：Lead author,　Corresponding author   Language：English   Publishing type：Research paper (scientific journal)  

The monitoring of intraoperative optic nerve protection using visual evoked potential has been increasingly used in neurosurgical procedures. Although visual evoked potential is a valuable tool, its application is often hindered by anesthetic limitations and challenges related to measurement and recording environments. This case study indicates the successful use of visual evoked potential monitoring during long-term anesthesia maintenance and in artifact-prone environments for the treatment of a ruptured cerebral arteriovenous malformation. We report the case of a woman in her 30s who underwent surgical treatment for a ruptured cerebral arteriovenous malformation in the right occipital lobe, adjacent to the optic radiation. Visual evoked potential monitoring was essential during both transarterial embolization and subsequent microsurgical resection. During transarterial embolization, the implementation of improved measurement environments, localized light stimulation, and optimized recording conditions facilitated stable visual evoked potential monitoring despite the high levels of environmental noise in the angiography suite. Post-embolization, deep sedation was required to mitigate the risk of postoperative bleeding, causing an 18-hr duration of anesthesia before microsurgical resection. Despite the prolonged anesthesia, visual evoked potential monitoring was successfully maintained by carefully managing anesthesia depth. This case shows that visual evoked potential monitoring can be reliable and reproducible during extended periods of anesthesia and in challenging, artifact-rich environments. These findings underscore the feasibility of using visual evoked potential in complex neurosurgical cases, even under less-than-ideal conditions.

DOI： 10.2176/jns-nmc.2024-0341

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Language：English   Publishing type：Research paper (scientific journal)  

The conventional transcranial approach for treating lower basilar artery aneurysms is challenging because the deep and narrow surgical field limits surgical maneuvering for clipping. We report a case of a 77-year-old female who presented with right hemiparesis caused by a partially thrombosed giant aneurysm in her lower basilar artery. We performed neck clipping and thrombus debulking using a combined transcranial and endonasal approach. This approach enabled us to secure the parent artery from the endonasal side, which is difficult to achieve with the transcranial approach alone. It also allowed for early thrombus removal, thereby widening the surgical field on the transcranial side. Additionally it compensated for the transcranial blind spot by observing the clip tip from the endonasal side. After surgery, the patient required 3 months of rehabilitation for residual right hemiparesis before being discharged. Follow-up imaging revealed a reduction in the size of the partially thrombosed aneurysm. To our knowledge, this is the first report of a combined transcranial and endonasal approach for the treatment of a basilar artery aneurysm. For lower basilar artery aneurysms, this combined approach may offer advantages in achieving safe parent artery control, thrombus debulking, and neck clipping.

DOI： 10.2176/jns-nmc.2024-0240

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Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND AND PURPOSE: Elevated intracranial pressure (ICP) resulting from severe head injury or stroke poses a risk of secondary brain injury that requires neurosurgical intervention. However, currently available noninvasive monitoring techniques for predicting ICP are not sufficiently advanced. We aimed to develop a minimally invasive ICP prediction model using simple CT images to prevent secondary brain injury caused by elevated ICP. METHODS: We used the following three methods to determine the presence or absence of elevated ICP using midbrain-level CT images: (1) a deep learning model created using the Python (PY) programming language; (2) a model based on cistern narrowing and scaling of brainstem deformities and presence of hydrocephalus, analyzed using the statistical tool Prediction One (PO); and (3) identification of ICP by senior residents (SRs). We compared the accuracy of the validation and test data using fivefold cross-validation and visualized or quantified the areas of interest in the models. RESULTS: The accuracy of the validation data for the PY, PO, and SR methods was 83.68% (83.42%-85.13%), 85.71% (73.81%-88.10%), and 66.67% (55.96%-72.62%), respectively. Significant differences in accuracy were observed between the PY and SR methods. Test data accuracy was 77.27% (70.45%-77.2%), 84.09% (75.00%-85.23%), and 61.36% (56.82%-68.18%), respectively. CONCLUSIONS: Overall, the outcomes suggest that these newly developed models may be valuable tools for the rapid and accurate detection of elevated ICP in clinical practice. These models can easily be applied to other sites, as a single CT image at the midbrain level can provide a highly accurate diagnosis.

DOI： 10.1111/jon.13241

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Authorship：Lead author,　Corresponding author   Language：Japanese   Publisher：(一社)日本脳神経外傷学会  

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

Ichushi

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INTRODUCTION: Malignant catatonia (MC) is a movement disorder syndrome characterized by immobility, rigidity, and consciousness disorders that develops in association with mental and physical diseases. It is often fatal due to hyperthermia, rhabdomyolysis, and acute kidney injury. Its clinical symptoms are similar to those of another disorder, neuroleptic malignant syndrome (NMS), and it is often difficult to distinguish between the 2 disorders. PATIENT CONCERNS: An Asian woman in her 60s with history of schizophrenia. She was admitted to our hospital because of symptoms such as fever, unconsciousness, and muscle rigidity. Blood tests showed kidney injury and high creatinine kinase levels. DIAGNOSES: At the time of admission, she had been diagnosed with NMS complicated by pulmonary aspergillosis and was undergoing treatment although there was no improvement. INTERVENTIONS: Subsequently, the administration of propofol, a gamma-aminobutyric acid A agonist, markedly improved the symptoms, and the diagnosis was corrected to MC. At the beginning of her hospitalization, she received dantrolene, bromocriptine, amantadine, and L-3,4-dihydroxyphenylalanine as treatment for NMS, but her symptoms did not improve. With propofol, which is used for sedation, her catatonic symptoms improved markedly. Quetiapine administration further improved the symptoms, and it eventually resolved completely. OUTCOMES: The patient's MC was in remission. Prolonged intensive care management resulted in a decline in activities of daily living, and she required rehabilitation at another hospital. CONCLUSION: This is the first report of MC with suspected involvement of pulmonary aspergillosis. MC differs from NMS, in that it is treated more effectively with gamma-aminobutyric acid A agonists. Although benzodiazepines are the first choice for the diagnosis and treatment of MC, they are ineffective for majority of patients with schizophrenia. However, even in such cases, propofol and quetiapine are effective, and they facilitate diagnosis and treatment.

DOI： 10.1097/MD.0000000000025967

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Language：Japanese   Publisher：日本航空医療学会  

Ichushi

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Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Previous studies have reported poor prognosis in cases of tetanus that develops after bacteria enters via breast cancer-related skin ulcers that are not treated with surgical debridement. Herein, we review the literature concerning this presentation and report the first case of complete remission from tetanus without surgical debridement of the skin ulcer. CASE PRESENTATION: An Asian woman aged over 60 years had a history of skin ulcer caused by breast cancer. She was diagnosed with tetanus due to trismus and opisthotonus. Based on the suspicion that the skin ulcer was the portal of entry for tetanus bacteria, we considered several debridement and thoracic surgical options for tetanus treatment. However, debridement was not performed as the surgery was considered high risk and the patient did not consent to it. The patient received treatment with anti-tetanus globulin and metronidazole; sound insulation and shielding were also performed in a dark room. Subsequently, the patient's symptoms improved, and sound insulation and deep sedation management were completed on 19th day of hospitalization. With no symptom recurrence, the patient was discharged on Day 54. To date, over 3 years after treatment, no evidence of tetanus recurrence has been observed. The case was characterized by a lack of autonomic hyperactivity. The tetanus severity was likely representative of the low amount of toxin that the patient was exposed to. CONCLUSION: This case involved moderate severity tetanus originating from a chronic skin ulcer related to breast cancer. The patient survived without undergoing extensive debridement. No evidence of tetanus relapse was observed during the follow-up period, likely due to vaccination that might have restored the patient's active immunity. Debridement is not always necessary for tetanus complicated by breast cancer skin ulcers. Furthermore, appropriate toxoid vaccination is critical for preventing the onset and recurrence of tetanus in these patients.

DOI： 10.1186/s12879-020-05739-4

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Language：Japanese   Publisher：(一社)日本小児神経外科学会  

Ichushi

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

Other Link： https://search.jamas.or.jp/default/link?pub_year=2019&ichushi_jid=J00692&link_issn=&doc_id=20200422330004&doc_link_id=10.32187%2Fneurotraumatology.42.2_103&url=https%3A%2F%2Fdoi.org%2F10.32187%2Fneurotraumatology.42.2_103&type=J-STAGE&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00007_3.gif

Ichushi

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Language：English   Publishing type：Research paper (scientific journal)  

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BACKGROUND: Acute necrotizing encephalopathy (ANE), known as influenza-associated encephalitis, typically affects children. CASE PRESENTATION: A 70-year-old woman was admitted to the hospital with altered consciousness, a high temperature, and severe hypotension. Computed tomography (CT) of the head showed no abnormalities; thus, a diagnosis of suspected severe heat stroke was made. On day 2, repeated head CT revealed bilateral symmetrical lesions to the thalamus, and a rapid influenza antigen test was positive. Based on the CT findings and the medical history of influenza, a differential diagnosis of ANE was made. Subsequently, brain edema spread across the whole brain, and the patient died on day 21. CONCLUSION: In elderly patients, differentiating ANE from severe heat stroke in a high-temperature environment is difficult because of the similarities in clinical symptoms due to multiple organ failure.

DOI： 10.1002/ams2.418

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CASE: There are several reports of retroperitoneal hemorrhage induced by percutaneous femoral cannulation for extracorporeal membrane oxygenation (ECMO). However, there are no reports of delayed retroperitoneal hemorrhage, which develops a few days after ECMO initiation and is unrelated to the ECMO cannulation. Herein, we report a rare case of delayed retroperitoneal hemorrhage during veno-venous extracorporeal membrane oxygenation (VV-ECMO). OUTCOME: A 54-year-old man was referred to our hospital because of severe acute respiratory distress syndrome. We initiated VV-ECMO. The patient had severe delirium and was confined to a long-term supine position to maintain circuit safety. On day 13, computed tomography unexpectedly revealed a large retroperitoneal hemorrhage spreading around the psoas muscle. CONCLUSION: Delayed retroperitoneal hemorrhage can develop during VV-ECMO management a few days after its initiation. Anticoagulant use and forceful muscular strain could be risk factors of delayed retroperitoneal hemorrhage.

DOI： 10.1002/ams2.385

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BACKGROUND: Agonal respiration following out-of-hospital cardiac arrest is associated with favorable neurological outcomes. Resuscitation using extracorporeal membrane oxygenation could contribute to achieving favorable neurological outcomes in patients with refractory cardiac arrest. CASE PRESENTATION: We report two cases of refractory cardiac arrest with non-shockable rhythms and agonal respiration; both patients were successfully resuscitated through extracorporeal cardiopulmonary resuscitation (ECPR). Both patients were breathing spontaneously upon arrival. One patient was asystolic and the other experienced pulseless electrical activity followed by ventricular fibrillation. Agonal respiration was observed in both and ECPR was implemented, leading to a favorable neurological outcome at discharge. CONCLUSION: The presence of agonal respiration has the potential to confer a favorable neurological outcome in patients with refractory cardiac arrest if maintained, even when the initial cardiac rhythm is not shockable. In these cases, resuscitation should not be abandoned, and ECPR should be considered.

DOI： 10.1002/ams2.398

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Language：English   Publishing type：Research paper (scientific journal)  

DOI： 10.1016/j.inat.2018.07.011

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Authorship：Lead author,　Corresponding author   Language：English   Publishing type：Research paper (scientific journal)  

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Authorship：Lead author,　Corresponding author   Language：English  

CASE: A 44-year-old man intentionally stabbed himself in the anterior neck and left thorax with a fruit knife. Physical examination revealed two open wounds entering the thoracic cavity in the front chest, and a stab wound entering the trachea at the neck. Two chest tubes were initially inserted for the left lung injury with open hemopneumothorax. Nevertheless, the worsening oxygenation required positive pressure ventilation (PPV) with endotracheal intubation. OUTCOME: Right hemiparesis was found during weaning from PPV. Magnetic resonance imaging revealed multiple infarctions in the area of the bifrontal and right temporal lobes. Cerebral air embolism (CAE) was strongly suspected from the imaging findings and clinical course. CONCLUSION: We concluded that mechanical ventilation was strongly involved in the occurrence of CAE. If delayed abnormal neurological findings are observed in patients with penetrating lung injuries receiving PPV management, CAE should be considered.

DOI： 10.1002/ams2.250

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