Severe head injury is a major cause of death by traffic accident in Japan. Unfortunately, we don't have any comprehensive data that describes the status of traffic death or severe head injury in Japan from a medical point of view. We conducted an epidemiologic study on the medical treatment administered for traumatic head injury from January, 1998 to June, 2000. We made original data sheets with 392 items containing information about the characteristics of the injury, pre-hospital care, diagnosis, treatment and follow-up information concerning outcome. Patients with severe head injury were eligible for entry with a Glasgow Coma Scale (GCS) score of 8 or less. Patients who underwent craniotomy were also included. Children under 5 years old were excluded. Ten neurosurgical emergency centers took part in our project. In the end of 2000, 721 patients were enrolled as eligible out of 811. 442 patients were victims of traffic accidents. In the multi-center study, collection, integration and analysis of data required great effort. Difficulties in the collection of follow-up data concerning outcome requires further discussion. We are still in a preliminary stage for this clinical study. We hope that our project will explain in part the actual circumstances of severe head injuries in Japan and that our report will present significant data to be used in an international comparative survey.

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The Japan Society of Neurotraumatology constructed "Japan Neurotrauma Data Bank (JNTDB)" including 721 patients with severe head injury provided by the 10 clinical centers, from 1998 to 2000. The data was analyzed from several perspectives. In the present paper, the author analyzed 602 patients with a Glasgow Coma Scale less than 9 from the point of view of their treatment and outcome. Especially, the comparison of outcome between operated cases and non-operated cases was analyzed. Differences of choice of treatment between the centers are also analyzed. Finally, some comparison between JNTDB and "the Traumatic Coma Data Bank" reported from the United State of America in 1991 was also performed.

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In recent years, snowboarding has gained great popularity, carving skiing has become the main stream instead of conventional skiing, and enthusiasts of the extremely short fan ski are increasing rapidly. Snowboarding induced head injuries are approximately five or six times more likely to occur than head injuries caused by skiing accidents in ski slope. This can be attributed to the characteristic structure of the snowboard that makes it relatively easy for snowboarders to sustain injury to the occipital region by jumps or falls on gentle slopes. With regard to more serious cases, skiing injuries are usually characterized by cranio-facial fracture or cerebral contusion caused by collisions, and snowboarding injuries tend to center around acute subdural hematoma cases often caused by falls on the slope. Acute subdural hematoma in these circumstances tends not to be accompanied by cerebral contusion, and as such, it is termed "pure subdural hematoma". Here, shear strain is the assumed mechanism of bridging vein injury. Based on both our own case studies and literature sources, we report the present circumstances of snowboarding and skiing related head injuries and methods of injury prevention.

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Head and neck injuries in sports are reviewed, with the exception of skiing and snowboarding. In Japan, no nationwide data concerning head and neck injuries in sports are currently available. The most frequent sports-related severe brain injury reported in the literature is acute subdural hematoma. Common causes include judo, rugby football, American football and boxing. Among popular collegiate sports in the United States, on the other hand, a higher rate of concussion is observed in ice hockey, American football and soccer. It is estimated that there are some hundreds of sports-related cervical injury casualties in Japan every year, with the highest frequencies seen in plunge diving, skiing and footballs. Concussion is defined as a trauma-induced alteration of mental status that may or may not involve loss of consciousness. It is rarely a critical condition unless prolonged symptoms continue without recovery. However, repeated concussion is believed to result in serious brain damage. Trainers and physicians should be circumspect before returning casualties with concussion to any sports activity. Some standards, proposed by the American Academy of Neurology (AAN) or the Concussion in Sports Group (CISG), have been presented even on the Internet. Neurosurgeons should be familiar with these standards and give such concussion-related casualties the optimum advice so they can return in an appropriate manner to training or participation.

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Neuropsychological, emotional, cognitive and vocational sequelae are prominent complications after traumatic brain injury caused by traffic accident. They are comprised of cognitive impairment such as memory disturbance, impairment of multi-task execution and loss of self-awarenes, and personality changes such as easy irritability, violent behavior and childishness. These symptoms and signs have frequently been ascribed to focal brain injury, such as in the fronto-temporal lobes. However, they are probably the product of diffuse brain injury and should be attributed to diffuse loss of white matter or neural network in the brain. This dysfunction tends to be underdiagnosed or even overlooked in medical practice, because, though the cognitive part can be assessed neuropsychologically, the emotional or personality part, which has greater influence on the social outcome, often passes unnoticed by the professionals. Rather it is sensed intuitively by the family or persons who live or work close together with the victim. Close examination of the serial neuroimaging films usually disclosed either normal-appearing brain or small hemorrhage in the early days. The ventricles become dilated within a few months post-injury. This ventriculomegaly stays permanent and is highly indicative of loss of brain tissue or white matter neural network. The severity of this dysfunction is significantly correlated with the duration of initial unconsciousness and the final increase in ventricular size compared to the day-of-injury level. Varying cerebellar ataxia in gait and speech and spastic hemiplegia are frequent neurological associations. Thus, diffuse axonal injury can be regarded as the main pathology underlying the higher brain dysfunction due to traumatic brain injury. Diffuse brain injury secondary to hypoxia and secondary to mass lesion cannot be denied as another cause of this dysfunction. It is noteworthy that this dysfunction mimicks dementia pugilista and the physiologically aged brain both clinically and neuroradiologically.

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Acute local intra-arteriral fibrinolysis (LIF) should be neutrally evaluated at present. The efficacy of LIF have never been evaluated objectively, and standard pre-therapeutic evaluation and therapeutic technique has never been established. Regarding to the efficacy, PRO ACT II was performed and finished in the USA, but a final decision is still pending. MELT Japan is now underway in Japan. The subject of both these studies is middle cerebral artery embolism, so no such study exist for basilar artery embolism. Standard pre-therapeutic evaluation and therapeutic technique are established in MELT Japan. The patient in whom LIF can be started within 6 hours after onset, with an NIH stroke scale of 5 to 22, without ischemic lesion in the cerebral cortex can be enrolled in MELT Japan.

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For safe and effective neurointervention, it is essential to understand the functional neurovascular anatomy of the brain as well as that of the head and neck regions. Embryological knowledge helps to understand such functional anatomy. In this communication, the functional neurovascular anatomy required for neurointervention is described in detail.

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The standard technique of PTA/stenting using the PercuSurge (PS) guardwire system was introduced in this paper. Initially, PS was introduced beyond the stenosis of the internal carotid artery and the distal internal carotid artery was obliterated for one minute to examine the neurological status of the patient. Then, the occlusion balloon was deflated and inflated again. Predilatation, stenting, and aspiration of the debris were performed under distal ICA occlusion in the same session. If the dilation was unsatisfactory, post dilatation was added under distal balloon occlusion. A balloon catheter with the same diameter as the normal distal ICA was chosen as the predilatation PTA balloon catheter. By using a large balloon in the process of predilatation, postdilatation was unnecessary in 80-90% of cases. The morbidity/mortality rate was 1.7% (minor stroke) in our 60 cases, although in two cases with pseudoocclusion crossing the lesion by PS failed. The PS system enabled total protection during the carotid stenting and reduced the rate of embolic complications during carotid stenting. However, this system was a little bit complicated and fragile. Therefore, adequate training is necessary before using this system for carotid stenting.

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