Objective: Time optimization is a critical factor in reperfusion therapy for acute ischemic stroke (AIS). This study aimed to evaluate the outcomes of the stroke protocol implemented at our institution and to identify future challenges.

Methods: A retrospective analysis was performed on 214 AIS patients who underwent intravenous thrombolysis (rt-PA) or endovascular thrombectomy (EVT) among 773 AIS cases treated at our hospital between 2018 and 2023.

Results: Following protocol implementation, the annual AIS caseload increased from approximately 100 to 150, while the proportion of patients receiving reperfusion therapy rose from 15-20% to about 30%. The mean door-to-needle time (D2N) decreased from 90 to 64 minutes, and door-to-puncture time (D2P) was reduced from 136 to 104 minutes. D2N and D2P times varied based on initial imaging modalities: CT alone (35.4/49.9 minutes), CT+CTA (58.5/91.8 minutes), MRI alone (61.7/89.3 minutes), and CT+MRI (84.7/132 minutes). CT alone yielded the most significant time reductions, whereas CT+MRI was associated with significant delays. No significant difference in D2P was observed between rt-PA+EVT and EVT alone, suggesting that skipping rt-PA is unlikely to expedite D2P.

Conclusion: Protocol implementation yielded measurable improvements; however, further refinements, particularly in minimizing D2P, are imperative, underscoring the importance of multidisciplinary collaboration.

Objective: This study aimed to evaluate the feasibility and clinical outcomes of non-intubated general anesthesia (NGA) combined with continuous EEG (C-EEG) monitoring in patients with refractory non-convulsive status epilepticus (NCSE).

Methods: We retrospectively reviewed consecutive NCSE cases admitted to our institution between August 2023 and July 2024. Among these, patients with refractory NCSE who received NGA using midazolam were included. Clinical characteristics, EEG findings, diagnosis, treatment, and outcomes were analyzed. Patients were further classified into two groups based on EEG modality: those monitored with C-EEG and those monitored with routine EEG (R-EEG), and comparisons were made between the groups.

Results: A total of 38 NCSE cases were identified, of which 17 were refractory and 14 underwent NGA. The median age was 75 years, with 9 male patients. Twelve patients completed the treatment, and there were no deaths. Vital sign instability occurred in 7 patients, including one treatment discontinuation and one requiring intubation. Among the 7 C-EEG cases, seizure detection was significantly higher (71% vs. 0%), with no marked difference in clinical outcomes compared to the R-EEG group.

Conclusion: NGA for refractory NCSE appears to be feasible and safe. C-EEG monitoring during NGA may enhance seizure detection without increasing adverse events.

The definition of transient ischemic attack (TIA) has shifted from Time-based to Tissue-based TIA. In the case of Tissue-based TIA, defined as the absence of acute infarct lesion, the relevant lesion and classification of subtype are estimated based on the clinical course and symptoms, which is not easy to diagnose TIA. We aimed to clarify the frequency and characteristics of perfusion abnormalities in Tissue-based TIA. We analyzed 18 patients with Tissue-based TIA who were urgently admitted to our hospital and underwent computed tomography perfusion (CTP). Of the 18 patients, 4 patients (22%) showed prolonged time to peak (TTP) and mean transit time (MTT), and decreased cerebral blood flow (CBF). Two cases (11%) also had decreased cerebral blood volume (CBV). Patients with perfusion abnormalities had severe symptoms on admission, and the time from the onset (or last known well) to CTP was within 1 hour of onset. In conclusion, perfusion abnormalities occurred in one~fifth of patients with Tissue-based TIA, and tended to be more frequently detected in patients with high NIHSS or early from onset.

Cerebral amyloid angiopathy (CAA) and reversible cerebral vasoconstriction syndrome (RCVS) are well known as the cause of convexity subarachnoid hemorrhage (cSAH), and CAA is the most common cause, especially in the elderly. On the other hand, there are a few reports of cSAH caused by vascular stenosis. In this case, we had difficulty differentiating CAA from cervical internal carotid artery stenosis as a cause of cSAH.

A 78-year-old man presented with repeated attacks of weakness in the right upper limb. CT showed a cSAH in the left cerebral hemisphere and MR imaging showed an acute ischemic lesion on the left side as well as the hemorrhage. CT angiography showed severe stenosis of the left cervical internal carotid artery. After admission, we started treatment with antiplatelet drug therapy, but the patient still had repeated attacks of weakness. The symptoms were disappeared after starting antiepileptic drug, therefore possibility of partial epilepsy due to cSAH was considered as a cause of symptoms.

Only a few studies have reported cSAH secondary to vascular stenosis, and there is no consensus on its mechanism. A possible one is the disruption of collateral anastomosis, similar to the pathogenesis of moyamoya disease, and the effects of stress due to acute hemodynamic changes. On the other hand, patients with CAA may present with transient focal neurologic symptoms caused by cSAH. Both should be noted because of the similarity of their symptoms.

A 49-year-old man was being treated for Crohn's disease with intravenous infliximab and oral azathioprine. The patient visited our hospital with chief complaints of headache, a fever, and an inability to remember the date. He had impaired consciousness and symptoms of meningeal irritation and was diagnosed with Listeria monocytogenes meningitis based on cerebrospinal fluid findings. Antibiotic treatment was started, but on day 6 of hospitalization, a decrease in the level of consciousness due to the onset of hydrocephalus was observed. External ventricular drainage was performed, and the patient's symptoms improved. The effectiveness of ventricular drainage during the acute phase of bacterial meningitis has not been established. We herein report a relatively rare case of adult-onset Listeria monocytogenes meningitis in which ventricular drainage was performed and the prognosis was favorable.

Marchiafava-Bignami disease (MBD) primarily occurs in individuals who chronically consume alcohol. It is characterized by demyelination of the corpus callosum due to thiamine (vitamin B1) deficiency, similar to the changes observed in Wernicke's encephalopathy. A 56-year-old man with a history of diabetic foot ulcers experienced disturbed consciousness and was referred from a local hospital. Upon arrival, the patient was in a comatose state (Glasgow coma scale score: 3), with a blood pressure of 140/66 mmHg (with continuous noradrenaline administration at 0.08 μg/kg/min), heart rate of 118 beats/min, and body temperature of 37.9°C. His right lower limb was necrotic, consistent with necrotizing fasciitis, and computed tomography revealed gas formation. Owing to the patient's history of alcohol abuse, we administered vitamin B1 intravenously. The patient underwent emergency right thigh amputation. However, his disturbed consciousness persisted after surgery, and T2-weighted magnetic resonance image of the brain showed a high intensity on the left side of the corpus callosum and swelling, which confirmed a diagnosis of MBD. The patient gradually regained consciousness and was transferred to the previous hospital on day 37.

A 64-year-old man working as a drafting technician presented to the emergency department with a fever and abnormal speech and behavior for four days. On examination, he was suspected of having jargon aphasia and mildly impaired consciousness. Brain magnetic resonance imaging showed high signal intensity on diffusion weighted images in the left temporal lobe and insula. Although the cerebrospinal fluid (CSF) cell count was only slightly elevated (8/mm3), we suspected herpes simplex virus encephalitis (HSVE) based on the history and imaging findings. Acyclovir was immediately started on the day of admission. Six days after admission, an alternating level of consciousness was observed. Electroencephalogram revealed non-convulsive status epilepticus, and antiepileptic drugs were started. Eight days after admission, the CSF HSV real-time polymerase chain reaction (RT-PCR) on the day of admission proved positive, and he was diagnosed with HSVE. Even after the RT-PCR became negative, sensory aphasia persisted. However, his aphasia improved to anomic aphasia after speech therapy and he restarted working 18 months after the onset. Despite the recent advent of multiplex PCR testing, such advanced testing is not always available everywhere. This case highlights the importance of early suspicion and therapeutic initiation for a better neurological outcome in HSVE.

Acute dysphagia is associated with poor long-term prognosis and increased mortality in patients with lateral medullary infarction. A 58-year-old man who presented with sudden-onset right facial pain, dysarthria, dysphagia, and lateropulsion was diagnosed as right lateral medullary syndrome. Neurological examination revealed loss of pain and thermal sensation in the right face and left limbs. Initial brain magnetic resonance imaging (MRI) showed no abnormalities; however, repeated diffusion weighted MRI identified a high intensity signal in the right lateral medulla. Swallowing assessments revealed impaired right pharyngeal and laryngeal movement with inadequate relaxation of right upper esophageal sphincter (UES). Esophageal manometry showed decreased pharyngeal pressure and increased UES pressure. Based on these findings, the patient was diagnosed with type 1 dysphasia associated with lateral medullary syndrome, and treatment was initiated, including cervical rotation to the affected side, food modification and balloon dilation therapy. Despite being unable to swallow saliva at admission, the patient regained this ability by day 25. By day 48, UES function improved, allowing discontinuation of balloon dilation therapy. The patient resumed normal oral intake by day 54 and was discharged home. This case highlights the importance of early balloon dilation therapy, guided by precise swallowing evaluations, in rapidly improving severe dysphagia.

We report a 70-year-old woman with advanced Parkinson’s disease (PD). She exhibited motor fluctuations and psychiatric symptoms associated with anti-PD medication and was admitted to our hospital for medication modification. One day, she developed restlessness and delusional behavior. The next day, she experienced the sudden onset of right hemiparesis, with sparing of the face. She was initially diagnosed with acute ischemic stroke and received intravenous recombinant tissue-type plasminogen activator (rt-PA). However, magnetic resonance imaging (MRI) revealed no evidence of cerebral infarction. We carefully re-evaluated the X-ray CT images by changing the window level and width. High-density lesions were discovered on the dorsal side of the spinal cord. Subsequent spinal MRI confirmed the presence of spinal epidural hematoma. Emergency surgical intervention was performed, resulting in the successful evacuation of the hematoma. Her hemiparesis gradually improved following the surgery. Cervical epidural hematoma is well recognized as a stroke mimic, but cases comorbid with advanced PD are extremely rare. These patients may present with hemiparesis independent of their underlying disease-specific clinical issues, which increases the potential risk of misinterpreting focal deficits as signs of cerebrovascular events. Therefore, careful medical history, thorough clinical evaluation, and detailed neurological examination are essential.

We report a case of respiratory-onset amyotrophic lateral sclerosis (ALS) in a 77-year-old man who initially presented with exertional dyspnea. Despite the absence of significant findings in cardiological evaluation, he was prescribed benzodiazepines for anxiety and insomnia, subsequently developed decreased consciousness and abnormal behavior, necessitating emergency department presentation. While examined in the supine position, he suffered cardiac arrest. After successful resuscitation, intubation, and admission to the intensive care unit, physical examination by a neurologist revealed muscle atrophy in all extremities and trunk, and needle electromyography showed active denervation potentials in several muscles, leading to the diagnosis of respiratory-onset ALS. This case provides several crucial clinical lessons: (1) respiratory-onset ALS may mimic cardiac or pulmonary disease, potentially linking to diagnostic delay; (2) benzodiazepine in patients with unexplained respiratory symptoms requires caution, considering the possibility of neuromuscular disease such as ALS. (3) needle electromyography can detect active denervation potentials even under sedation in some cases, which may aid in the diagnosis; and (4) when evaluating dyspnea patients in the absence of cardiopulmonary disease, physicians should refer to neurologists to differentiate neuromuscular diseases.

A 72-year-old man who had been receiving oral tofacitinib for 13 months for rheumatoid arthritis presented in August 2022 with a sense of discomfort in his right upper limb and myoclonus-like involuntary movements. On the following day, he was admitted to another hospital after being noted to have right hemiparesis, ataxia of the right upper limb, and involuntary movements.

Brain MRI at that time revealed findings suggestive of cerebral infarction.

From the day after admission, he developed fever and seizures, which progressed to status epilepticus. On the third hospital day, he was transferred to our facility. Upon arrival, he was intubated, mechanically ventilated, and maintained under deep sedation, with no spontaneous limb movement observed.

Although cerebrospinal fluid (CSF) analysis showed no pleocytosis and brain MRI did not reveal the typical temporal lobe lesions, multiplex PCR (FilmArray^®) of the CSF was positive for HSV-1, leading to a diagnosis of herpes simplex encephalitis (HSE). Acyclovir treatment, which had been initiated on day 5 of illness, was continued for 21 days.

In elderly or immunosuppressed patients, HSE may present without typical imaging findings or CSF pleocytosis. Therefore, in suspected cases, early implementation of PCR testing and prompt initiation of acyclovir therapy are essential.

[Introduction] Traumatic intracerebral hematoma can usually be confirmed by head CT scan soon after injury. We report a case of delayed traumatic intracerebral hematoma.

[Case] A 43-year-old man. He was driving a car when he collided with a truck. On arrival at our hospital, he was conscious and his vital signs were stable. A systemic examination revealed a right hemopneumothorax, right multiple rib fractures, left 4th rib fracture, right clavicle fracture, right acute subdural hematoma (ASDH), and traumatic subarachnoid hemorrhage (tSAH). The ASDH was approximately 5mm thick with no midline sift, so conservative treatment was recommended. A right thoracic drainage tube was inserted and the patient was admitted to the hospital. A head CT scan taken 7 hours after the injury showed no changes. 18 hours after the injury, the patient developed generalized convulsions, and a repeat head CT scan revealed an intracerebral hematoma in the right frontal lobe. The patient was discharged home on the 27th day after.

[Discussion and conclusion] Delayed development of contusive intracerebral hematomas that cannot be detected by head CT scans at the time of admission may occur. Repeated blood tests of the coagulation system and head CT scans are necessary.