The Japan Neurotrauma Data Bank (JNTDB) was established in 1996, and has conducted 2-year studies to register patients presenting with serious neurological status as Glasgow Coma Scale 8 or less on admission three times in 1998, 2004, 2009, and ever since. Data for over 200 items were obtained from each patients. The total number of registered cases is approximately 3,000 to date. A new project consisting of 30 institutes will take off in 2015 under a newly arranged system. Fruitful results have been harvested as follows. We have found 1) a decrease in the number of cases presenting serious neurological status, 2) a decrease in the number of patients having diffuse injury, and 3) an increase in cases where fall/tumble are the causes of injury, instead of a decrease in traffic accident and vice versa. From the aspect of treatment, we have also found a couple of interesting results as 1) intracranial pressure (ICP) monitoring was performed in 30% and 2) any kind of surgery was performed in 50% of cases, and 3) management of body temperature was carried out in 40%. Further, overall mortality decreased but the number of patients showing a vegetative state categorized by Glasgow Outcome Scale increased inversely. The One Week Study (OWS), a cross-sectional nationwide registry of head injury that was also conducted by JNTDB, tried to validate patients' selection bias regarding the JNTDB Project. Most factors of bias were denied but others such as age and incidence of multiple injuries remained to be considered. The relatively small number of cases registered with the JNTDB and OWS was a disadvantage and analyzing the real world scenario in Japan is an intricate and difficult task. To solve this problem several approaches could be fielded such as participation in the Japan Trauma Data Bank or National Clinical Database and founding an interoperable platform, or utilizing data from the Diagnosis Procedure Combination. A randomized controlled trial performed by JNTDB members themselves may be an alternative way to shape the future of research in neurotrauma in our country.
Because of the high mortality and the high morbidity rate, the management and the treatment of severe traumatic brain injury is very important and difficult in the field of traumatology. The treatment of patients with multiple injuries complicated with brain injury requires close collaboration between trauma surgeons specializing in the treatment of torso trauma and neurosurgeons. The Japanese trauma care system has progressed remarkably with the advancement of standard procedures to decrease preventable trauma deaths and with the publication of guidelines for the treatment and management for severe traumatic brain injury. And with Japan's aging society, the increase in the number of traumatic brain injuries in older adults is a serious problem. Elderly patients with traumatic brain injuries generally have worse outcomes compared with younger patients due to their weakened physical status and of the presence of other age-related disease. To properly evaluate severe traumatic brain injury, especially in elderly patients, many kinds of intracranial monitoring and biomarker measurements s have been employed. Under a common comprehension of the difficulty faced in the treatment and management of traumatic brain injury, the joint symposium between the annual meeting of Japanese Association of Surgeons of Trauma (JAST) and Japan Society of Neurotraumatology (JNST) was held in 2014. In this symposium, many problems as well as the approaches and trials used for treating traumatic brain injury, including treatments for elderly patients, were discussed in order to improve patient' outcomes.
Due to the rapid aging of the Japanese populace, the age structure and the disease profile of head injury patients have changed greatly. With the revised “Guidelines for the Management of Severe Head Injury” third edition from 2013, the contents were amended to reflect these societal changes. Accordingly, a new chapter, detailing recent progress in imaging diagnosis and an addendum covering sports-related head injury, traumatic cognitive impairment and traumatic low cerebrospinal fluid pressure syndrome were added. There is very little evidence-based treatment for severe head injury, due to the complicated heterogeneous pathophysiology of the disease. Based on this recognition, neurological evaluation, imaging diagnosis, intracranial pressure, ICP and cerebral perfusion pressure, CPP monitoring and other intensive neuro-monitoring methods are very important to formulate a comprehensive strategy.
We review current topics in sports-related head injuries including acute subdural hematoma (ASDH) and cerebral concussion. Sports-related ASDH is a leading cause of death and severe morbidity in popular contact sports like American football in the USA and judo in Japan. It is thought that rotational acceleration is most likely to produce not only cerebral concussion but also ASDH due to rupture of a parasagittal bridging vein, depending on the severity of the rotational acceleration injury. Repeated sports head injuries increase the risk for future concussion, cerebral swelling, or ASDH and chronic traumatic encephalopathy (CTE). To avoid fatal consequences or CTE resulting from repeated concussions, an understanding of the criteria for a safe post-concussion return to play is essential. Once diagnosed with a concussion, the athlete must not be allowed to return to play on the same day and should not resume play before the concussion symptoms have completely resolved. If brain damage has been confirmed or a subdural hematoma is present, the athlete should not be allowed to participate in any contact sports. Information on the risk for and management of head injuries in athletes participating in different sports should be widely disseminated in educational institutions and by public relations campaigns of sports organizations. Efforts must be made to educate not only personnel and parents directly involved in the care of athletes but also the general public.
In recent years, instances of traumatic brain injury (TBI) in the elderly has been increased. This article addresses the clinical characteristics and problems of TBI in the elderly. Either falls to the ground from standing or from heights are the most frequent causes of elderly TBI, since both motor and physiological functions are degraded in the elderly. Acute subdural hematomas (ASDH) are the most frequently encountered acute traumatic intracranial lesions. Their high frequency has been proposed to be associated with the increased volume of the subdural space resulting from atrophy of the brain often found in the elderly. The delayed aggravation of intracranial hematomas has also been explained by such anatomical and physiological changes present in the elderly. Delayed hyperemia/hyperperfusion may also be a characteristic of elderly TBI, although its mechanisms are not fully understood. In addition, widely used pre-injury anticoagulant and antiplatelet therapies may be associated with delayed aggravation, making the management of TBI in the elderly difficult. Establishing preventions and treatments for elderly TBI is an urgent issue since its outcome has remained poor for more than 40 years.
With the innovation of measuring techniques, research into several biomarker has been ongoing in neurocritical care. In addition to the usual biomarkers such as neuron specific enolase, S100β and glutamate, several new biomarkers along with their pathomechanisms have been studied in traumatic brain injury (TBI) patients. These biomarkers are neurofilament families derived from neural cytoskeleton, tau protein derived from dendritic microtubules, microtubule-associated protein 2 derived from dendritic cell body, myelin basic protein from oligodendrocyte and myelin, ubiquitin C-terminal hydrolase-L1 derived from neural cells and glial fibrillary acidic protein from glial cells. In this article, we will review the basic and clinical data of these biomarkers. Then, we will discuss the efficacy of these biomarkers for the “visualization” of TBI pathophysiology.
Cholesterol crystal embolism (CCE) is a severe complication of carotid artery stenting (CAS). Here we describe the occurrence and risk factors for CCE after CAS. We evaluated the 35 patients treated with CAS in our hospital. Of these patients, 1 was diagnosed with CCE, and 3 were possible CCE. In these 4 patients, the postprocedure estimated glomerular filtration rate was lower and blood eosinophil count was higher compared to those in patients without CCE. In addition, all the CCE patients had shaggy aorta at the thoracic region. Multiple regression analysis identified shaggy aorta at the thoracic region as an independent risk factor for CCE (odds ratio 55.2, 95% CI : 1.18-2.586). We should pay attention for CCE, although it is a rare complication of CAS.
A 59-year-old woman presented with ataxia, diplopia, and vomiting. She was transferred to our hospital after magnetic resonance imaging (MRI) showed hydrocephalus. Preoperative cine mode MRI showed a cerebrospinal fluid signal in the area of the fourth ventricle. Accordingly, hydrocephalus caused by occlusion of the foramina of Luschka and Magendie was considered. Observation of the affected ventricle using a neuroendoscope demonstrated many small polypoid lesions on the ventricle wall and ventriculography performed through the endoscopy showed the patency of the cerebral aqueduct and also revealed that contrast agent had stagnated in the fourth ventricle. We diagnosed a disproportionately large communicating fourth ventricle (DLCFV) and performed endoscopic third ventriculostomy. The postoperative course was uneventful, and all symptoms were resolved. Although the mechanisms underlying DLCFV remain unclear, neuroendoscopic observation and treatment may be useful. We report this case along with a review of the pertinent literature.