The aim of neuromonitoring in the management for traumatic brain injury is to detect and correct intracranial abnormalities immediately before they cause additional physical damage to the brain. Bed-side brain monitoring of parameters such as intracranial pressure, jugular venous saturation, partial pressure of brain tissue oxygen, and cerebral microdialysis allows estimation of cerebral blood flow, oxygenation, and metabolism and can be used to modify treatment or evaluate the response to therapeutic interventions, which may help guide therapy and predict outcome. There is now further evidence that treatment targets may need to be individualized. Assessment of optimum cerebral perfusion pressure and cerebral autoregulation is the focus of ongoing research. Further studies are required to identify the most useful monitoring parameters for individual cases, and the demonstration of improved outcomes with the use of goal-directed therapy based on the monitoring techniques must be reported in large-scale clinical trials, in order to provide a new "window" into the black box of the injured brain.

View full abstract

High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). Decompressive surgery is one of the second-line therapies to control ICP, and it is now playing a more important role especially for the treatment of medically refractory intracranial hypertension. Patients with parenchymal mass lesions, e. g. cerebral contusion and signs of progressive neurological deterioration should be treated operatively (internal decompression; contusion necrotomy). Decompressive craniectomy (external decompression) within 48 hours of injury is a treatment option for patients with diffuse and medically refractory posttraumatic cerebral edema and swelling. In this review, the authors focus on the role of decompressive surgery (external and internal decompression) and discuss their indications, surgical techniques, results, and complications. They also address the current evidence for the ongoing randomized studies of decompressive craniectomy in TBI.

View full abstract

There have been no standard therapeutic guidelines for severely head injured children in Japan. Last year, the Japan Society of Neurotraumatology revised their therapeutic guidelines for severe head injury, including a special chapter for children and the aged. Herein, the guideline for children is briefly introduced. Therapeutic problems are also discussed by comparing this new guideline with the guideline published in the USA by Adelson, et al. in 2003. In Japan, the use of hypertonic saline and external ventricular drainage are not common. Clinical data such as ICP and CPP were scarce. An Optimal head injury treatment regimen for children should be clarified and further studies are required to identify age specific ICP, CPP and other physiological variables.

View full abstract

To dispute the aspect of standard Cognitive Rehabilitation and the indication of Psychological Treatment: First, we summarized clinical protocols of Process Oriented Cognitive Rehabilitation (POCR) and our group rehabilitation program 'Orange Club'. In these protocols, our main therapeutic target was simply the higher brain functions which are prefrontal functions. And we utilized the schematic paradigm of the neuropsychological pyramid developed by Dr. Ben-Yishay; Rusk Institute, New York University. Psychologists were there as skill-trainers for patients' families and had a coordinating role of group dynamics attributed to laughter and play in the sessions. Second, we extracted optional sub-symptoms, which were assigned special attention. As options with present symptoms of higher brain function disturbance, some cases showed PTSD symptoms, MDI-like symptoms, Schizophrenia-like symptoms, or any socio-financial problems, and so on. Psychologists are often expected to point out these symptomatic options, and therefore their clinical interventions should be practical. Stated another way, in the care of Traumatic Brain Injury sequela, we initially should consider the use of play, laughter, etc. The conventional medical treatment requires both psychotherapy and a new age approach. These will maintain Positive Behavioral Support, which are then experienced in a fun atmosphere created by patients and their families. Next, other problems are usually never investigated during the main session. Nevertheless, psychologists still need to recognize the importance of focusing on the special requirements of medical treatment for sychotherapeutic options, such as the above-mentioned psychiatric abnormalities. Interventions for these are also an essential role of psychologists. Third, we furthermore tried cost calculation of the concrete POCR individual interview, group rehabilitation, and also the price of these arrangements from the viewpoint of medical economics. Consequently, it reconfirmed the importance of a close collaboration among medical specialists. We think that the activity of NPO JUTRA will help to integrate and generate a new movement for such needs.

View full abstract

In the late 1990s, people with impairments in higher-level cognitive functions due to disorders, such as traumatic brain injury and cerebrovascular disease, and their families started to make complaints that they were not be covered by any of the supporting frameworks in Japan. To appropriately respond to these complaints, the Minisitry of Health, Labor and Welfare launched a "five-year model project for supporting persons with higher brain dysfunctions" in fiscal 2001 as a 5-year plan, clearly defined impairments as organic mental disorders, and formulated operational diagnostic criteria to distinguish them from endogenous psychosis and degenerative disorders. In addition, the Ministry developed a medical training program and support program for social rehabilitation that serve as standard programs. Furthermore, the Ministry recommended measures to build support networks that take into account the geographical conditions and social resources by prefecture to meet varied local circumstances. The core recommendation was to establish a local support base organization in each prefecture and have support coordinators deployed at these bases. This model project ended in fiscal 2005. The project was then succeeded by a higher brain dysfunction support promotion project, as part of a local life support project in accordance with enactment of the Support for the Independence of Persons with Disabilities Act to become a general project conducted throughout Japan.

View full abstract

Supraorbital keyhole craniotomy via an eyebrow skin incision (Perneczky method) is an alternative to conventional craniotomy for the treatment of various pathologies including aneurysms. We treated unruptured internal carotid artery aneurysms and anterior communicating artery aneurysms using the Perneczky method. We also developed the pterional keyhole approach to middle cerebral artery aneurysms through an outer canthal skin incision. Forty-four keyhole clipping surgeries (46 aneurysms) were performed in 42 patients. Scalp hair shaving, drainage placement, and anti-convulsant medication were not required. Most patients were discharged on the 2nd or 3rd postoperative day (mean 2.8±0.99 days), except for one patient who suffered hemiparesis due to lacunar infarction. Keyhole clipping surgery is another treatment option for relatively small unruptured anterior circulation aneurysms.

View full abstract

A 0.010 inch diameter ED coil (Kaneka medics, Kanagawa, Japan) was newly developed and came to market recently. Early experiences using this detachable coil are reported. Fifteen intracranial saccular aneurysms were treated at our institution since Oct. 2006. There are soft and extrasoft type-10 ED coils and the both types were used. Fifty-one coils were deployed for 15 aneurysms. As the coil part and junction with the delivery wire is very soft, type-10 ED coils are easy to advance even in a very tortuous vessels and less likely to unintentionally move a microcatheter due to friction than other available detachable coils. There were no premature detachments, no coils unraveled, and no failures to detach. As for case complications, there was no intraprocedural aneurysmal ruptures and no thromboembolisms. There was one instance of coil migration with the smallest and shortest coil. It resulted in a small asymptomatic infarction. As the coil is itself very soft, smaller ones should be more carefully deployed within the coil basket to avoid coil migration. The device was considered to be effective and safe for endosaccular embolization of cerebral aneurysms.

View full abstract