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Central nervous system (CNS) infections are often suspected in adult patients with fever-associated seizures. However, it is unclear whether lumbar puncture (LP) is routinely required in patients with fever-associated seizures. This study aimed to examine the prevalence of meningitis and encephalitis in adult patients with fever-associated seizures and to evaluate whether LP is routinely required.We retrospectively studied patients aged ≥16 years who presented to the emergency department with complaints of seizures and fever above 37.5 °C who were admitted to the hospital between January 2017 and December 2019. LP was performed when the emergency physician suspected meningitis or encephalitis. Neurologists assessed patients with normal cerebrospinal fluid (CSF) findings and those admitted without LP after hospitalization. A neurologist confirmed the diagnoses of meningitis and encephalitis.The study included 148 patients. Ninety-seven patients (65.5%) were male, and the median age was 60 years. LP was performed in 105 patients (70.9%), and 14 (13.4%) had CSF pleocytosis. Meningitis and encephalitis were diagnosed in nine patients (6.1%), of whom four (2.8%) had CNS infections. Patients diagnosed with meningitis and encephalitis were more likely to have Glasgow Coma Scale13 (P = 0.03) and less likely to have a history of seizures or epilepsy (P = 0.04) and had higher C-reactive protein levels than the other patients (P = 0.02).The prevalence of meningitis or encephalitis is relatively low in adult patients with fever-associated seizures. Lumbar puncture is considered unnecessary to be performed routinely, but its indication should be carefully considered with reference to the clinical course, comorbidities, and blood tests. Further validation studies with larger sample sizes are needed to confirm the findings of this study.

[BACKGROUND] We aimed to develop and externally validate a novel machine learning model that can classify CT image findings as positive or negative for SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR). [METHODS] We used 2, 928 images from a wide variety of case-control type data sources for the development and internal validation of the machine learning model. A total of 633 COVID-19 cases and 2, 295 non-COVID-19 cases were included in the study. We randomly divided cases into training and tuning sets at a ratio of 8:2. For external validation, we used 893 images from 740 consecutive patients at 11 acute care hospitals suspected of having COVID-19 at the time of diagnosis. The dataset included 343 COVID-19 patients. The reference standard was RT-PCR. [RESULTS] In external validation, the sensitivity and specificity of the model were 0.869 and 0.432, at the low-level cutoff, 0.724 and 0.721, at the high-level cutoff. Area under the receiver operating characteristic was 0.76. [CONCLUSIONS] Our machine learning model exhibited a high sensitivity in external validation datasets and may assist physicians to rule out COVID-19 diagnosis in a timely manner at emergency departments. Further studies are warranted to improve model specificity.

Objective Head injuries are an important problem in pediatric emergency care. The majority of head injuries are mild. Even when abnormalities are noted on computed tomography (CT), most patients have good outcomes. We aimed to evaluate the clinical course of pediatric patients who had head injuries and Glasgow Coma Scale (GCS) scores of 15, in whom abnormal findings were noted on head CT, to determine the impact of radiographic features on the need for hospitalization and clinical progression. Methods We retrospectively examined patients under 15 years of age with isolated mild head injuries, GCS scores of 15, and abnormal CT findings, and visited the emergency department between September 2011 and March 2019. Results Ninety-nine patients were included in the study. The median age was 2 years (0–15 years), and 61 (62%) patients were male. Eighty-six (87%) patients were hospitalized, and the median hospital stay was 1 day (1–10 days). Sixty-eight (69%) patients underwent repeat CT, and 12 (18%) patients showed signs of radiographic progression. These 12 patients had subdural or epidural hematomas, and surgical intervention was required for two patients (2%). In patients with isolated skull fracture or subarachnoid hemorrhage alone, no deterioration was noted radiographically or clinically. Conclusion Pediatric head injuries with GCS scores of 15 may rarely require surgical intervention, even when CT shows abnormalities. In particular, patients diagnosed with isolated skull fracture or subarachnoid hemorrhage on CT may not require routine hospitalization. A validation study is needed to confirm the findings of this study.

Background: Although patients with severely impaired consciousness require a rapid response, it is commonly difficult to obtain detailed histories and perform accurate physical examinations of these patients. Therefore, this study examined the causes of patients with severely impaired consciousness and the clinical characteristics in prehospital settings that are useful for differential diagnosis. Methods: We conducted a single-center retrospective study using data from the Kobe City Fire Department database. We retrospectively examined patients aged ≥16 years with Japan Coma Scale III-digit codes during paramedic contact and transported them to our hospital between January 2018 and December 2018. Furthermore, we evaluated the age, systolic blood pressure (sBP), presence of airway obstruction, and mortality for each final diagnosis. Results: Overall, 227 patients were included in this study. One hundred and twelve patients (49.3%) were male, and the median age was 71 years (interquartile range 50–83 years). Stroke was the most common cause (30%). In addition, intoxication and psychiatric disorders were significantly more common in younger patients (P < 0.01). sBP was the highest inpatients with stroke. Airway obstruction was found most frequently in patients with stroke (73.5%), with a significant difference compared with other differential diseases,except for environmental disorders and cardiovascular diseases (P < 0.01). Mortality was the highest in stroke (55.9%), which was significantly higher than that for other differential diagnoses, except for environmental disorders and cardiovascular diseases.Among the patients with stroke, 45.6% had ocular abnormalities. Conclusion: Stroke was the most common cause of severely impaired consciousness. However, age, sBP, the presence of airway obstruction, and ocular abnormalities can be useful indicators for differential diagnosis in prehospital settings in patients with severe disturbance of consciousness.

Background: Helicobacter cinaedi, a Gram-negative spiral bacterium, is a rare cause of bacteraemia in humans. It is increasingly reported in both immunocompetent and immunocompromised patients. Nevertheless, little is known about H. cinaedi infections in the emergency departments (ED). Our study aimed to describe the clinical features of H. cinaedi infections in the ED.Methods: We conducted the descriptive study at the ED of Kobe City General Hospital between November 2011 and December 2020. We included all ED patients with H. cinaedi infections, and all H. cinaedi were isolated in blood cultures. Following bacterial culture, clinical specimens with gram-negative spiral bacilli underwent polymerase chain reactions to confirm H. cineadi infection. We retrospectively obtained the patient data from the electronic medical records and described patient characteristics, clinical course, and management of H. cinaedi bacteraemia. Results: During the study period, 22 patients in the ED were diagnosed with H. cinaedi bacteraemia. The youngest patient was 32 years old, and the oldest was 91 (median: 65.5 [interquartile range, 49.3 to 63.3] years). Diabetes mellitus was the most common comorbidity (7/22, 31.8%), followed by haematological malignancy and solid tumour (5/22, 22.7%), recent chemotherapy (4/22, 18.2%), while 3/22 (13.6%) patients had no comorbidities. In our cohort, complicated cases were identified: vertebral osteomyelitis (three cases), infected aortic aneurysm (two cases), and infected cyst (renal cyst, and pancreatic cyst with concomitant empyema) (two cases). Tetracycline (minocycline) was most commonly prescribed; administered intravenously in 5/15 (33.3%) and orally in 9/20 (45.0%) patients. Only one (4.5%) patient required surgical interventions. None died in the hospital.Conclusions: We reported 22 cases of H. cinaedi bacteraemia in the ED, most of which were successfully treated with antibiotics, primarily tetracycline. This report gives an important insight into the presentation and management of such infections. We suggest that future studies are warranted to evaluate the optimal choice and route of antibiotic treatment in H. cinaedi infections.

Purpose Coronavirus disease 2019 (COVID-19) has placed a great burden on critical care services worldwide. Data regarding critically ill COVID-19 patients and their demand of critical care services outside of initial COVID-19 epicenters are lacking. This study described clinical characteristics and outcomes of critically ill COVID-19 patients and the capacity of a COVID-19-dedicated intensive care unit (ICU) in Kobe, Japan. Methods This retrospective observational study included critically ill COVID-19 patients admitted to a 14-bed COVID-19-dedicated ICU in Kobe between March 3, 2020 and June 21, 2020. Clinical and daily ICU occupancy data were obtained from electrical medical records. The last follow-up day was June 28, 2020. Results Of 32 patients included, the median hospital follow-up period was 27 (interquartile range 19–50) days. The median age was 68 (57–76) years; 23 (72%) were men and 25 (78%) had at least one comorbidity. Nineteen (59%) patients received invasive mechanical ventilation for a median duration of 14 (8–27) days. Until all patients were discharged from the ICU on June 5, 2020, the median daily ICU occupancy was 50% (36–71%). As of June 28, 2020, six (19%) died during hospitalization. Of 26 (81%) survivors, 23 (72%) were discharged from the hospital and three (9%) remained in the hospital. Conclusion During the first months of the outbreak in Kobe, most critically ill patients were men aged ≥ 60 years with at least one comorbidity and on mechanical ventilation; the ICU capacity was not strained, and the case-fatality rate was 19%. Supplementary Information The online version contains supplementary material available at 10.1007/s00540-021-02897-w.

Background We developed and validated a machine learning diagnostic model for novel coronavirus (COVID-19) disease, integrating artificial-intelligence-based computed tomography (CT) imaging and clinical features. Methods We conducted a retrospective cohort study in 11 Japanese tertiary care facilities that treated COVID-19 patients. Participants were tested using both real-time reverse transcription polymerase chain reaction (RT-PCR) and chest CT between January 1 and May 30, 2020. We chronologically split the dataset in each hospital into training and test sets, containing patients in a 7:3 ratio. Light Gradient Boosting Machine model was used for analysis. Results A total of 703 patients were included with two models — the full model and the A-blood model — developed for their diagnosis. The A-blood model included eight variables (the Ali-M3 confidence, along with seven clinical features of blood counts and biochemistry markers). The areas under the receiver-operator curve of both models (0.91, 95% confidence interval (CI), 0.86 to 0.95 for the full model and 0.90, 95% CI, 0.86 to 0.94 for the A-blood model) were better than that of the Ali-M3 confidence (0.78, 95% CI, 0.71 to 0.83) in the test set. Conclusions The A-blood model, a COVID-19 diagnostic model developed in this study, combines machine-learning and CT evaluation with blood test data and is better than the Ali-M3 framework existing for this purpose. This would significantly aid physicians in making a quicker diagnosis of COVID-19.

BACKGROUND: We developed and validated a machine learning diagnostic model for the novel coronavirus (COVID-19) disease, integrating artificial-intelligence-based computed tomography (CT) imaging and clinical features. METHODS: We conducted a retrospective cohort study in 11 Japanese tertiary care facilities that treated COVID-19 patients. Participants were tested using both real-time reverse transcription polymerase chain reaction (RT-PCR) and chest CTs between January 1 and May 30, 2020. We chronologically split the dataset in each hospital into training and test sets, containing patients in a 7:3 ratio. A Light Gradient Boosting Machine model was used for the analysis. RESULTS: A total of 703 patients were included, and two models—the full model and the A-blood model—were developed for their diagnosis. The A-blood model included eight variables (the Ali-M3 confidence, along with seven clinical features of blood counts and biochemistry markers). The areas under the receiver-operator curve of both models [0.91, 95% confidence interval (CI): 0.86 to 0.95 for the full model and 0.90, 95% CI: 0.86 to 0.94 for the A-blood model] were better than that of the Ali-M3 confidence (0.78, 95% CI: 0.71 to 0.83) in the test set. CONCLUSIONS: The A-blood model, a COVID-19 diagnostic model developed in this study, combines machine-learning and CT evaluation with blood test data and performs better than the Ali-M3 framework existing for this purpose. This would significantly aid physicians in making a quicker diagnosis of COVID-19.

Background Visceral disseminated varicella zoster virus (VZV) infections frequently affect immunocompromised patients. Diabetes mellitus has been associated with VZV infection, and most cases of disseminated infection involve patients with poorly controlled blood glucose levels. It initially presents as severe abdominal pain, which is evaluated as an acute abdomen, however, the cause is typically unidentified due to unremarkable computed tomography (CT) findings. We report a case of visceral disseminated VZV infection in a patient with well-controlled diabetes mellitus with fat stranding around the celiac and superior mesenteric artery on CT. Case presentation A 61-year-old Japanese woman with well-controlled diabetes mellitus presented to the emergency department with severe abdominal pain that gradually worsened. She had stable vital signs and skin rashes, suggestive of varicella. Abdominal CT showed fat stranding around the celiac and superior mesenteric arteries. The patient tested positive for the VZV antigen and was diagnosed with a visceral disseminated VZV infection. Acyclovir was administered, and the patient was discharged on the 14th day. Conclusions Visceral disseminated VZV infection may affect patients with well-controlled diabetes mellitus and causes acute abdomen. Periarterial fat stranding on CT is associated with abdominal pain due to visceral disseminated VZV infection.

Aim Extracorporeal cardiopulmonary resuscitation (ECPR) is the emerging resuscitative strategy to save refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) patients. We investigated whether the receiving hospitals’ ECPR capabilities are associated with outcomes in out-of-hospital cardiac arrest (OHCA) patients who have refractory VF or pulseless VT. Methods In a population-based cohort study performed in Kobe City, Japan, between 2010 and 2017, we identified all OHCA patients who had refractory VF or pulseless VT. Based on their ECPR capabilities, hospitals were categorised into ECPR facilities and conventional cardiopulmonary resuscitation (CCPR) facilities. We compared patient survivals between ECPR facilities and CCPR facilities by applying inverse probability weighting using a propensity score. Results Of all 10,971 OHCA patients, 518 had refractory VF or pulseless VT. The proportion of favourable neurologic outcomes was 43/188 (22.9%) in ECPR facilities and 28/330 (8.5%) in CCPR facilities. In the propensity analysis, hospitals’ ECPR capabilities were associated with favourable neurologic outcomes (adjusted risk difference [ARD], 9.7% [95% confidence interval [CI], 3.7%–15.7%]; adjusted risk ratio [ARR], 2.01 [95% CI, 1.31–3.09]), and overall survival (87/188 [46.3%] vs. 67/330 [20.3%]; ARD, 19.0% [95% CI, 11.1%–26.9%]; ARR, 1.88 [95% CI, 1.45–2.44]). Conclusions Hospitals’ ECPR capabilities were associated with favourable neurologic outcomes in OHCA patients who had refractory VF or pulseless VT. We should take each hospital’s ECPR capability into consideration when developing a regional system of care for OHCA.

Aim To evaluate whether vital signs can predict whether hypoglycemia can be eliminated as the cause of impaired consciousness in prehospital settings. Methods We extracted the data of patients who underwent blood glucose measurements by paramedics in Kobe City, Japan from April 2015 to March 2019. We used receiver operating characteristic curves and calculated the area under the curve (AUC) to evaluate the validity of the vital signs in distinguishing hypoglycemia. We also calculated stratum‐specific likelihood ratios to examine the threshold at which hypoglycemia becomes less likely for each vital sign. Results Of the 1,791 patients, 1,242 were eligible for analysis. Hypoglycemia was observed in 324 patients (26.1%). Significant differences in each vital sign were noted between the hypoglycemic and non‐hypoglycemic groups. Body temperature was moderately accurate in differentiating between the two groups (AUC, 0.71; 95% confidence interval, 0.68–0.74). Furthermore, in patients with systolic blood pressure, Body temperature was moderately accurate in differentiating hypoglycemia and non‐hypoglycemia in the prehospital setting. If there is a high temperature or hypotension, it is less likely that hypoglycemia is the cause of impaired consciousness.

Noninvasive positive pressure ventilation (NPPV) may be attempted for treatment of acute respiratory failure during asthma attacks. However, it is necessary to shift to respiratory management under tracheal intubation without hesitation if the asthma attack worsens rapidly. There is currently insufficient evidence that NPPV is effective for severe asthma attacks according to previous RCT studies.

ObjectivesAli-M3, an artificial intelligence, analyses chest computed tomography (CT) and detects the likelihood of coronavirus disease (COVID-19) in the range of 0 to 1. It demonstrates excellent performance for the detection of COVID-19 patients with a sensitivity and specificity of 98.5 and 99.2%, respectively. However, Ali-M3 has not been externally validated. Our purpose is to evaluate the external validity of Ali-M3 using Japanese sequential sampling data.MethodsIn this retrospective cohort study, COVID-19 infection probabilities were calculated using Ali-M3 in 617 symptomatic patients who underwent reverse transcription-polymerase chain reaction (RT-PCR) tests and chest CT for COVID-19 diagnosis at 11 Japanese tertiary care facilities, between January 1 and April 15, 2020.ResultsOf 617 patients, 289 patients (46.8%) were RT-PCR-positive. The area under the curve (AUC) of Ali-M3 for predicting a COVID-19 diagnosis was 0.797 (95% confidence intervals [CI]: 0.762-0.833) and goodness-of-fit was P = 0.156. With a cut-off of probability of COVID-19 by Ali-M3 diagnosis set at 0.5, the sensitivity and specificity were 80.6% and 68.3%, respectively, while a cut-off of 0.2 yielded a sensitivity and specificity of 89.2% and 43.2%, respectively. Among 223 patients who required oxygen support, the AUC was 0.825 and sensitivity at a cut-off of 0.5 and 0.2 were 88.7% and 97.9%, respectively. Although the sensitivity was lower when the days from symptom onset were few, sensitivity increased for both cut-off values after 5 days.ConclusionsAli-M3 was evaluated by external validation and shown to be useful to exclude a diagnosis of COVID-19.Key PointsThe area under the curve (AUC) of Ali-M3, which is an AI system for diagnosis of COVID-19 based on chest CT images, was 0.797 and goodness-of-fit was P = 0.156.With a cut-off of probability of COVID-19 by Ali-M3 diagnosis set at 0.5, the sensitivity and specificity were 80.6% and 68.3%, respectively, while a cut-off of 0.2 yielded 89.2% and 43.2%.Although low sensitivity was observed in less number of days from symptoms onset, after 5 days high increasing sensitivity was observed. In patients requiring oxygen support, the AUC was higher that is 0.825.

Aim Extracorporeal cardiopulmonary resuscitation (ECPR) is an evolving resuscitative method for refractory cardiopulmonary arrests. However, considering the substantial healthcare costs and resources involved, there is an urgent need for a full economic evaluation. We therefore assessed the cost-effectiveness of ECPR for refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). Methods We developed a decision model to estimate lifetime costs and outcomes for out-of-hospital cardiac arrest patients with VF/pVT who received either ECPR or conventional cardiopulmonary resuscitation. Quality-adjusted life-years (QALY) was used as the main outcome measure. This model was a combination of a decision tree model for the acute phase based on a prospective observational study (SAVE-J study), together with a Markov model for long-term follow-up periods extrapolated from published data. To evaluate the robustness of this model, we conducted a comprehensive deterministic sensitivity analysis (DSA) and a probabilistic sensitivity analysis (PSA). Results ECPR was cost-effective, with an incremental cost of ¥3,521,189 (Є30,227), an incremental effectiveness of 1.34 QALY, and an incremental cost-effectiveness ratio of ¥2,619,692 (Є22,489) per QALY gained. DSA revealed that the present model was most sensitive to probability of Cerebral Performance Category 1 after ECPR (¥2,153,977/QALY to ¥3,186,475/QALY), patient age (¥2,170,112/QALY to ¥3,334,252/QALY), and long-term medical cost for modified Rankin Scale 0 (¥2,280,352/QALY to ¥2,855,330/QALY). PSA indicated ECPR to be cost-effective and below the willingness-to-pay threshold of ¥5,000,000 with an 86.7 % possibility. Conclusions ECPR was an economically acceptable resuscitative strategy, and the results of the present study were robust even when considering the uncertainty of all parameters.

ObjectivesTo examine the association between facility-level adherence to phosphorus management guidelines and mortality among patients with haemodialysis, and to explore the facility-related factors associated with facility-level guideline adherence.DesignProspective cohort study.SettingThe Dialysis Outcomes and Practice Pattern Study, which included 57 representative dialysis facilities in Japan between 2012 and 2015.ParticipantsA total of 2054 adult patients who received maintenance haemodialysis were included. We defined exposure according to the following four categories, depending on whether facility-level target ranges of serum phosphorus concentration adhered to the Japanese clinical practice guidelines: adherence group (lower limit ≥3.5 mg/dL and upper limit ≤6.0 mg/dL), low-target group (lower limit 6.0) and high-target group (lower limit ≥3.5 and upper limit >6.0).Primary outcome measureThe primary outcome was the patient all-cause mortality rate.ResultsThe mortality rate among the patients was 7.3 per 100 person-years; 27 facilities (47%) set targets according to the guidelines. HRs for mortality with reference to the adherence group were 1.04 (95% CI 0.76 to 1.43) in the low-target group, 1.11 (95% CI 0.68 to 1.81) in the wide-target group and 1.95 (95% CI 1.12 to 3.38) in the high-target group. Involvement of dieticians in dialysis treatment was associated with facility-level guideline adherence (OR 4.51; 95% CI 1.15 to 17.7).ConclusionsA higher facility-level target range for phosphorus was associated with increased patient mortality. Among facilities that set the target according to the guidelines, dieticians tended to be involved in dialysis care. These findings suggest the importance of reviewing facilities’ treatment policies in relation to updated guidelines and the need to work with relevant professionals.

Nasal pillows can be useful for patients with obstructive sleep apnea syndrome requiring continuous positive airway pressure ventilation at high pressures. Nasal pillows have been successfully adapted for use in patients with obstructive sleep apnea syndrome and comorbid chronic obstructive pulmonary disease, which enables effective facilitation of activities of daily living.

In order to investigate the effect of loading rate on the hysteresis response of R/C framed shearwalls (hereafter referred to as Shearwall), we conducted the lateral loading tests on the 1/4 scale model shearwalls. The specimens were subjected to the reversed cyclic lateral load under a constant axial load. The experimental variables included in the test series were loading rates, failure modes and loading path. The flexural yielding failure mode and the shear failure mode were planned. The increase rate of lateral load carrying capacity due to the increase of the loading rate was larger in shear failure mode than in flexural yielding mode.

We investigated the reasons for intensive care unit (ICU) readmission of patients with acute respiratory failure. Of 88 patients re-admitted to our ICU over a 15-month period, 16 were suffering from acute respiratory failure. Body weight, blood gases, time without food during the initial ICU stay and excess extracellular fluid (∆ECF) were determined. The interval until ICU readmission (D) was defined as the time between the last day of the first admission and the first day of the second admission. Significant correlations were found among the values for D, ∆ECF and P/F ratio; a patient with a P/F ratio below 200 on the day of release from ICU and a ∆ECF over 3 kg was likely to return to the ICU within four days. Hence, we conclude that fluid-management failure may be associated with ICU readmission in acute respiratory failure patients.

Objective: The aim of this experimental study was to examine the potential of local recombinant human insulin-like growth factor-1 (rhIGF-1) application through a biodegradable hydrogel for the treatment of cochleae. Methods: A hydrogel immersed with rhIGF-1 was placed on the round window membrane of Sprague-Dawley rats while a hydrogel immersed with physiological saline was applied to control animals. On day 3 after drug application, the animals were exposed to white noise at 120 dB sound pressure level (SPL) for 2 hours. Cochlear function was monitored using measurements of auditory brain stem responses (ABRs) at frequencies of 8, 16, and 32 kHz. The temporal bones were collected 7 or 30 days after noise exposure and the loss of hair cells was quantitatively analyzed. Results: Local rhIGF-1 treatment significantly reduced the elevation of ABR thresholds on days 7 and 30 after noise exposure. Histologic analysis revealed that local rhIGF-1 treatment significantly prohibited the loss of outer hair cells. Conclusions: These findings demonstrate that local IGF-1 application through the biodegradable hydrogel has the potential for protection of cochleae from noise trauma.

Patients with acute exacerbation of tuberculosis can now be treated successfully with noninvasive ventilation (NIV) [1]. NIV is effective not only in cases of rapidly progressive mycobacterial tuberculosis but also in chronic cases where the disease has exacerbated. NIV use may reduce the high demand for intensive care unit (ICU) beds [2]. This is the first study to assess clinically the risk of spread of mycobacterial tuberculosis infection by droplet or aerosol during NIV.

Acute abdominal aortic thrombosis is a rare but potentially fatal condition. The patient was a 56-year-old man who developed lower back pain and arrived at our emergency room in a state of shock. He was alert, but could not move his legs. Cardiac echo revealed abnormal movement of the heart, and acute myocardial ischaemia was suspected as a differential diagnosis. Emergency coronary angiography and aortography together with percutaneous cardiopulmonary support were attempted. Both femoral arteries were punctured, but the guide wire could not be advanced from the bifurcation to the aorta. Heart stoppage occurred and lifesaving treatment was ineffective. A large thrombus from the abdominal aorta to both common iliac arteries was observed by aortography. To reduce mortality in acute abdominal aortic thrombosis, the disease must be recognised early based on clinical symptoms, followed by immediate contrast CT and surgical management by thrombectomy or re-establishment of the blood circulation.

A 37-year-old man was admitted to hospital for treatment of perineum damage and haematoma in the scrotum. His consciousness deteriorated after two intramuscular injections of pentazocine 15 mg. Faint low signals in the left putamin to frontal island and frontal lobe and obnubilation of the corticomedullary junction were apparent on head CT, which led to suspicion of cerebral infarction. MR angiography showed bilateral obstruction of the middle cerebral artery and moyamoya disease was diagnosed. Treatment with edaravone, argatroban and heparin was ineffective for opening the middle cerebral artery and serious after effects occurred. This case suggests that cerebrovascular accident should be suspected in a young patient with disturbance of consciousness but stable breathing and circulation, particularly if previous drug treatment has affected brain circulation. Moyamoya disease should be suspected based on medical or family history. In such a case, MR angiography is required for early diagnosis to facilitate treatment by re-establishment of blood circulation.