In Japan, social concern for child abuse has risen since the enactment in 2000 of a law designed to prevent child abuse, the Abuse Prevention Law. Intracranial hemorrhage is the most serious problem in child abuse because it can result in fatality or a poor prognosis. Shaken baby syndrome (SBS) has become a familiar term and is used as a synonym for abusive head injury. But non-accidental traumatic brain injury (non-accidental TBI) or inflicted traumatic brain injury (ITBI) is more appropriate. This is because ITBI is not only caused by shaking but also by direct impact from hitting, dropping or throwing the child. For the diagnosis, it is important to check the whole body, such as for bruises, burns and fractures. MRI is an important modality to detect not only fresh hematomas but also old hematoma and hypoxic ischemic injury. Retinal hemorrhage is observed in 65〜89% of ITBI and it is a specific finding in ITBI. Therefore ophthalmoscopy is necessary in making the diagnosis. The most common findings in cases of ITBI are acute subdural hematoma along the inter-hemispheric fissure, over the convexities and around the cerebeller tentorium. Outcomes for children with ITBI is very poor. Their mortality rate ranges from 15 to 38%. Thirty percent to 50% of survivors have disabilities. Full recovery is estimated to be 30%. In 31〜43% of the cases, abuse is repeated after the patient returns home. Whether acute subdural hematomas accompanying retinal bleeding caused by domestic minor injury, which have hitherto been reported as Nakamura's type 1 of infantile acute subdural hematoma (IASDH), should be classified as abuse or as an other clinical entity still remains controversial.

View full abstract

Medical doctors have to play an important role for preventing child abuse and neglect. Their early detection and referral to the proper authorities can well change the prognosis of a child's life. In Japan, the measures to prevent child abuse and neglect spread widely after the law was enacted in 2000. The law also strengthened doctors' awareness of their duty to refer such cases. But doctors have occasionally misunderstood that their role is limited to detection and referral. Early detection and referral is just an initial approach, and not a goal. In a community network, every network member must play their own role first. The main role of a doctor is a medical issue. The daily practice of neurosurgeons closely relates to detecting child abuse and neglect, for example, head injury and shaken baby syndrome. The child rearing ability of parents sometimes effects the natural prognosis of a child's disease. Childhood handicaps caused by injury or congenital malformation may be a risk factor for children suffering abuse and neglect. So, a proper medical follow-up by a doctor can prevent such abuse. Now, all children wish that their doctors including neurosurgeons assume their responsibility.

View full abstract

The number of patients with epilepsy (PWE) who legally obtained their driving licenses has been increasing since the amendment of driving license regulations in 2002. In most cases the attending physicians assessed for fitness for driving and in 4% of cases, designated epileptologists were asked to assess the patients fitness. Problems concerning assessment included difficulty in deciding the time for reassessment, distress of PWE over cancellation (instead of stopping) of driving license because they were unfit to drive and responsibility of the assessing physicians in case of seizure recurrence. Physicians' understanding of the regulations plays a pivotal role for assessment in favor of people with epilepsy, although there should occur some amendments of the regulations such as shortening the seizure-free period for fitness to drive and special guidelines for different conditions such as recently diagnosed epilepsy and oligo-epilepsy.

View full abstract

The driving regulations in Japan were amended in 2002, which granted license to persons with epilepsy (PWE) under certain conditions. To clarify the effect and identify any problems after the new driving regulations, a questionnaire survey were carried out both to the driving authorities of Hiroshima and to the doctors in charge of practices. The results were as follows: 1. Many doctors recognized the new regulations, but negatively informed their PWE. 2. As news of the change spread, the increase in the number of PWE, who newly applied and obtained driving license rose markedly compared to the general population (38.1% vs 12.5%; p<.0001), but some doctors also mentioned the difficulties in assessing seizure recurrence and the withhold periods. 3. The ratio of traffic accidents (TA) in PWE is presumed to be about 5.5%, or almost the same as in the general population in Hiroshima, but a relation to seizures and TA, and low compliance of antiepileptic drug regime in PWE, were suggested. Overall, more flexibility in driver license assessment and further enlightenment both for PWE and for their doctors are needed.

View full abstract

Cerebral concussion has come to the front of sports medicine research for the past decade, and the significance of concussion prevention is now emphasized. Why should concussion, which represents relatively mild head injury, be prevented? Sport-related concussion is characterized by its recurrent nature, leading to posttraumatic encephalopathy and/or concussion syndrome. Premature return to competition may induce second impact syndrome and/or acute subdural hematoma. It has been reported that a sports environment with high incidence of cerebral concussion has high a mortality rate with acute subdural hematoma, thus a campaign against cerebral concussion leads to a reduction in mortality in contact sports such as American football, rugby football, and Judo. The authors review the current concept for the managements of cerebral concussion in sports.

View full abstract

Cerebral concussion, the most common form of brain injury, has been closed up in terms by the development of sports medicine. There are several problems following concussion such as acute subdural hematoma, second impact syndrome, and chronic traumatic encephalopathy. Concerning these problems, treatment and care for concussed athletes should be emphasized as an important issue. In concussion evaluation, the clinical post-concussive symptoms may be more important than the presence or duration of amnesia and/or loss of consciousness. To this end, several neuro-psychological evaluation tools have been introduced. During the period of recovery in the first few days following the injury, it is important to emphasize to the athlete that physical and cognitive rest is required. The return to play following a concussion should be conducted as a stepwise process.

View full abstract

We retrospectively analyzed the ten year results of our experience in the treatment of 39 unruptured basilar artery tip aneurysms by either conservative treatment or surgical treatment (direct surgery or coil embolization). Direct surgery was performed in seven cases. Successful clipping was performed in five cases, and wrapping in two cases. Endovascular treatment was performed in ten cases. There were eight cases of complete occlusion, one case of neck remnant, one case of dome filling. Therapeutic result of surgical treatment were 5.9% permanent morbidity and no mortality. Long-term follow-up revealed only one aneurysmal rupture in the surgical group. Conservative treatment in 22cases, aneurysmal rupture was found in six cases (annual rupture rate was 9.2%). Our management of the unruptured basilar artery tip aneurysms provide satisfactory therapeutic result in the surgical group. It is important in selecting the best method of treatment for the unruptured basilar artery tip aneurysms: direct surgery, endovascular treatment, conservative treatment.

View full abstract

Objective: We experienced and reported two rare cases with multiple dural arteriovenous fistulas (DAVFs). Case reports: Case 1: A 73-year-old woman presented with diplopia. Angiography revealed multiple DAVFs involving both the left cavernous and the left transverse-sigmoid sinuses. The cavernous sinus lesion was associated with retrograde leptomeningeal venous drainage (RLVD) into the pons, which was successfully obliterated with transvenous embolization. Case 2: A 75-year-old woman presented with diplopia. Multiple DAVFs were found both in a region that was like a parallel sinus adjacent to the sinus confluence and the left cavernous sinus, which were successfully treated with transarterial embolization. Conclusion: Multiple DAVFs are rare, accounting for 7 to 8% of all intracranial and spinal DAVFs. Many of those lesions were reported to have RLVD with a high risk of bleeding. Selecting the proper treatment is important based on a precise diagnosis on the hemodynamic condition of the brain and the fistulas.

View full abstract