In the last decade, we have experienced substantial changes of medicosocial systems, e.g. introductions of the treatment guidelines, the diagnosis-related groups/prospective payment system by diagnosis procedure combination (DPC), and the compulsory system for postgraduate clinical training, which may influence medical affairs and hospital management. The present study evaluated the impact of these alterations on severe head injury management. The results indicated that the executing rates of brain hypothermia, steroid therapy, barbiturate therapy, and hyperventilation therapy decreased, while the rate of hypertonic diuretic therapy increased. The executing rate of intracranial pressure (ICP) monitoring showed the largest reduction. Analysis of medical expenses revealed that the expense for "medical procedure", which includes the cost for ICP monitoring, etc, showed a large decrease, suggesting that DPC attenuated the execution of medical procedures at bed side. These findings suggest that management of severe head injury has become uniformed and simplified in the last decade.

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A guideline for severe brain injury was published by The Japan Society of Neurotraumatology (JSNT) in 2000. The Guideline Committee verified the usage of the guideline by distributing a questionnaire to member institutes from 2003 to 2004. 1) Subject: Institutions to which the representative members of The Japan Society of Neurotraumatology (JSNT) belong. Answering rate: 94% (46 out of 49 institutions), Description of the institutions: (1)96% of the institutions have a neurosurgical intensive care unit (ICU). (2)Annual numbers of patients with head injury: 34% of the institutions have over 40 head injury patients, 39% have from 39 to 10, and 7% have less than 10, (3)Number of neurosurgeons who belong exclusively to ICU: 9% of the institutions have over 4 neurosurgeons, 13% have 3, 13% have 2, 20% have 1, and 44% have none. 2) Result of questionnaire: (1)39% of the institutions have management protocol and follow the guideline 20% refer to the guideline. 2% have an original protocol. 39% do not have a management protocol. (2)Rate of ICP monitoring of severe head injury patients: 43% of the institutions perform ICP monitoring for over 50% of head injury patients, 39% perform monitoring for less than 49% of the patients, and 17% do not perform monitoring. (3)Number of doctors and nurses who utilize the guideline in daily management: 83% of neurosurgeons and 22% of nurses. Recommendations: (1)To revise the guideline from a literature-based or consensus-based guideline to an evidence-based guideline. (2)To make it applicable for children and the elderly. (3)To make it applicable for managing multiple injuries including pre-hospital care. A revised edition is scheduled to be published in 2006.

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In 2001, the Japanese Society of Insurance built a grading of 'higher brain dysfunction due to TBI,' and then the Japanese Ministry of Welfare and Labor promoted a three year TBI support program. Today, its diagnostic name has been recognized as a government-use diagnosis, and the enterprise continued for a second term in 2004, 2005. Otherwise, we have originally postulated the psychosocial issues of this disease from the viewpoints of psychological traumatology, revealed the subsided paradigm, and enlightened them for an improvement of clinical outcome. Simultaneously, we conducted a grandiose questionnaire survey covering all of Japan in 2004, and this was the first time that the plight of TBI survivors and families with profound suffering many years after injury rose to the surface. (Objective: To conduct one of the most global questionnaire surveys in Japan. Subjects: 635 respondents (recovery rate was 45.6%). Method: The Questionnaire inqwired about a patient's background, clinical course aspects like social participation, daily and social activity (FIM/FAM+our original activity parallel to daily living (APDL) scale) and mental status of patient & family (our original suffering scale), and their welfare support situation. Results: Results of patient scores at 1 year after injury were analyzed with factor analysis, to determine obvious three factors; which were explained as the dementia factor, the PTSD factor, and the family functioning factor. Then, we extracted the higher score group and lower score group of each factor score, and compared them as to their clinical course of APDL. When focusing on the PTSD factor, the lower group indicated uniform recovery to the 56 points level in about 1 year. While, the higher group remained at a low level of APDL, and showed recovery once but then regressed again. Additionally, if patient should have a high level of PTSD symptoms, the suffering of the family will not be relieved, or generally worsened. Conclusion: These patients' and families' suffering must indeed be lightened. Moreover, we conceptualized process-oriented cognitive rehabilitation-POCR-after psychology, and realized more efficient social rehabilitation. In reality, an intervention study showed about an 80% return rate at three years after injury, against 22.1% of the questionnaire survey. Now we are expanding this POCR to a daycare group approach. First of all, the actual prognosis was not obvious in the field of TBI. A research integrated among many medical specialists of body and mind-such as reexamination of the initial medical treatment effect for psychopathology-, will be expected in the future. By focusing the survivors and their families, construction of a medical system when each department cooperats closely can be achieved.

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Maxillofacial fractures sustained during sports are increasing because of the large number of people who engage in sports activities. In the present study, we investigated the incidence and type of maxillofacial fractures caused by various sports to better understand the nature of these fractures. The study was carried out retrospectively using medical records from 447 hospitalized patients between 1995-2004 at Nihon University School of Dentistry at Matsudo Hospital. The factors evaluated were: type of sport involved, etiology, mechanism of injury and fracture site. The maxillofacial fractures due to sports numbered 48 cases in this series, which placed them third in the all cases. The ratio of males to females was 43:5 and the highest incidence of sport-related facial fractures was in the teen and twenties groups. The fractures mostly resulted from baseball/softball (27%), followed by karate (15%) and soccer (15%). The most common cause of fracture was impact against another player even when played with a ball such as soccer and rugby. The majority of the cases suffered from mandible fractures (79%), followed by zygoma fractures. Furthermore, the body of the mandible is the highest risk region for fracture. Although these injuries are not usually severe, initial hospitalization and surgical interventions may be required. These results suggest the need for stronger preventive and protective measures in various sports.

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Two cases of arteriovenous fistula (AVF) in the lung presenting with brain abscess are reported. A 47-year-old male developed multiple brain abscesses. Diffusion weighted images (DWI) revealed strong high signal intensity. CT of the chest demonstrated an AVF in the lung. The brain abscesses were successfully treated with antibiotic therapy, and the AVF was resected. A 62-year-old female with asymptomatic AVF in the lung developed a brain abscess in the right temporal lobe, showing a strong high intensity on DWI. Since she presented with left hemiparesis 7 days after admission, the abscess was excised, and the AVF was embolized. Because even small and clinically silent AVF in the lungs may cause a brain abscess, we should perform a close examination of the lungs. Treatment of AVFs in the lungs is necessary to prevent the recurrence of a brain abscesses.

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The authors report on a case of symptomatic basilar artery (BA) stenosis treated with stent implantation from the surgically prepared vertebral artery (VA). A 67-year-old man with a medical history of hypertension and hyperlipidemia presented with repeated brain stem transient ischemic symptoms. MRI studies showed multiple small infarcts at the pons and cerebellum and severe (≥80%) stenosis of the BA. Percutaneous procedures failed, because the origin of the left VA showed severe rigid tortuousity and the right VA terminated at the branching of the right posterior inferior cerebellar artery. Subsequently, the left VA was exposed between the occipital bone and atlas, and an excellent reconstruction of the BA was achieved by placing a S670 stent from a 5F sheath inserted at the exposed VA. Recently, endovascular treatments have been established as primary therapeutic modalities for stenotic lesions of the BA. In those procedure, a stabilized and reliable guiding system should be essential for safe and steady interventions, especially in stent implantation. When a percutaneous procedure results in failure despite use of various devices or tactics, direct puncture of a surgically exposed VA can provide excellent access.

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Two patients with hemiparesis, initially investigated for intracranial lesions, were found to have cervical spinal lesions. The first case, an 83-year-old man, presented with left hemiparesis following a trivial fall. Brain CT and MRI scans were normal. The cervical MRI scan revealed a left-side dominant OPLL from the C_3 to C_5 levels. The condition of the patient improved after laminectomy. Case 2 involved a 68-year-old woman who presented with left hemiparesis and severe neck pain. Brain CT scan was normal. Cervical CT scan revealed a left-side dominant dorsal extradural hematoma from C_1 to C_6. The condition of the patient improved after evacuation of the epidural hematoma. Although it has been rarely emphasized before, cervical lesions should be considered in the differential diagnosis of hemiparesis.

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