Objective: Oral anticoagulants are widely administered to patients withatrial fibrillation in order to prevent the onset of cardiogenic embolisms. However,intracranial bleeding during anticoagulant therapy often leads to fatal outcomes.Accordingly, the use of novel oral anticoagulants (NOACs), which less frequently haveintracranial bleeding as a complication, is expanding. A nationwide survey of intracranialbleeding and its prognosis in Japan reported that intracranial bleeding of advancedseverity was not common after NOAC administration. In this report, two cases from ourinstitute are presented.

Patients: Case 1 was an 85-year-old man with a right frontal lobe hemorrhagewhile under dabigatran therapy. Case 2 was an 81-year-old man who had cerebellarhemorrhage while under rivaroxaban therapy.

Result: In both patients, the clinical course progressed without aggravationof bleeding or neurological abnormalities once anticoagulant therapy was discontinued.

Conclusion: These observations suggest that intracranial hemorrhage duringNOAC therapy is easily controlled by discontinuation of the drug. NOAC administration maytherefore be appropriate despite the risk of such severe complications. Further casestudies that include a subgroup analysis with respect to each NOAC or patient backgroundwill be required to establish appropriate guidelines for the prevention of cardiogenicembolisms in patients with atrial fibrillation.

Background: Chronic subdural hematoma (CSDH) is often found in the elderly owing to slight head trauma and is associated with several neurological disorders. Neurological deficits are cured by a simple surgical removal of the hematoma; however, these deficits persist if there is insufficient hematoma removal. It is rare for patients to continue having neurological disorders once the hematoma is removed.

Case report: A 61-year-old woman presented with gait disturbance. She was diagnosed with a subdural hematoma through head computed tomography. After hematoma irrigation, her gait disturbance exacerbated, and she developed urinary tract dysfunction. Ubiquitous neurodegeneration in the midbrain and spinal cord was suspected owing to a hyperintense signal on fluid-attenuated inversion recovery of magnetic resonance imaging. The anti-aquaporin 4 antibody was detected in the patient’s serum, and she was diagnosed with neuromyelitis optica (NMO).

Conclusions: Progressive NMO caused gait dysfunction and triggered head trauma, followed by CSDH. Although NMO rarely causes CSDH, it should be considered in uncommon cases of CSDH.

　　Gallstones are frequently observed in cases with gallbladder cancer. However, no obvious evidence has proved that cholelithiasis is a risk factor for gallbladder cancer.Procedure: We presumed the ratio of asymptomatic gallbladder cancer accompanied by cho- lelithiasis in the aging-society population. The patients who were diagnosed as having choleli- thiasis but did not suffer from any gallbladder cancer were taken up in our study. The gallbladder was surgically resected and then analyzed pathologically.Results: In our hospital, 3.31% of patients suffered from gallbladder cancer or hyperplasia. The ratio of cancer carriers stood at 1.98% with that of hyperplasia carriers at 1.32%.Conclusions: According to our estimate, the ratio of gallbladder cancer among cholelithiasis patients is much higher than the one which has been recently reported. The surgical resection of the gallbladder for the sake of prevention has not been recommended. Our result suggests, however, that the surgical treatment of the gallbladder for the sake of prevention is important to avoid suffering from gallbladder cancer in the aging society. A further study is required to reconsider gallbladder resection.

　　A 71-year-old woman was admitted to our hospital as heatstroke was suspected. Although of no obvious central nerve system disorder was found, magnetic reasonance angiography of brain blood vessels showed left middle cerebral artery occlusion. SPECT revealed a reduction in left cerebral blood flow. To supply the blood flow, superficial temporal artery - middle cerebral artery anastomosis was done. The result was satisfactory. Any other neurological symptoms were not observed. Asymptomatic occlusion of the middle cerebral artery might contribute to heatstroke. This case demonstrated the importance of the assessment for brain artery dynamics on heatstroke.

Cerebral amyloid angiopathy (CAA) is observed in most cases of nonhypertensive subcortical hemorrhage involving elderly patients. We herein describe the case of a female in whom a convexal subarachnoid hemorrhage was observed at 55 years of age. The cerebral hemorrhage occurred repeatedly; however, no obvious vascular lesions were observed on a cerebral angiography, and no signs of microbleeding or lesions in the deep white matter were identified on magnetic resonance imaging (MRI). Partial excision of the right frontal cortex and hematoma evacuation were performed, and histopathological examination showed deposition of an acidophilic substance with positive staining for Direct Fast Scarlet (DFS) in the cerebral vascular wall. Finally, brain hemorrhage due to CAA was diagnosed. This case suggests that CAA is an important differential diagnosis in patients with localized non-aneurysmal subarachnoid hemorrhage in the convexity sulcus.

Objective: Medication-resistant essential tremor requires surgical treatment. Deep brain stimulation to the thalamic ventral intermediate nucleus is an established procedure to diminish tremors. Tremor on both sides needs dual deep brain stimulation implantation. Nowadays, magnetic resonance-guided focus ultrasound is broaden to treat essential tremor. However, the safety of magnetic resonance-guided focus ultrasound against dual ventral intermediate is still under discussion, since bilateral thalamotomy causes speech disturbance or ataxia.Patient and Methods: A 66-year-old right-handed man had medication-resistant essential tremor at bilateral upper extremities superior to the left arm. A treatment of magnetic resonance-guided focus ultrasound was performed by using the ExAblate transcranial system against the left ventral intermediate. One year after magnetic resonance-guided focus ultrasound treatment, the stereotactic implantation of a deep brain stimulation electrode into the right ventral intermediate was done.Results: Clinical rating scale for tremor in the right arm was reduced from 12 to 0 points by magnetic resonance-guided focus ultrasound against the left ventral intermediate. The clinical rating scale for tremor in the left arm was reduced from 23 to 1 point by deep brain stimulation to the right ventral intermediate.Conclusion: Hybrid surgery of magnetic resonance-guided focus ultrasound and deep brain stimulation refined bilateral essential tremor, without any neurological deficiencies. This combined surgery would be useful to manage medication-resistant bilateral essential tremor patients who are carrying some difficulties to introduce deep brain stimulation on the bilateral side.