Despite its arsenal of traditional techniques and devices, surgery for traumatic brain injury (TBI) could well be the last field standing against the global storm of minimal invasiveness and other innovations that is rapidly transforming modern medicine. In the world of TBI, neurosurgeons are still required to deal with various unexpected circumstances on the fly, a situation that had once been considered the norm in most surgical procedures but has since been supplanted by modern-era procedures.

  Still, new waves have recently been observed in this field, such as the new approach for acute traumatic coagulopathy and the paradigm shift of systemic trauma treatment in conjunction with interventional radiology that are rapidly prevailing in the field of emergency medicine, and thus major treatment breakthroughs can soon be expected for TBI.

  The One Week Study 2012 (Japan Neurotrauma Data Bank) showed that mild or moderate traumatic brain injury accounted for 86% of neurotrauma cases requiring admission. Thus, mild or moderate traumatic brain injury are a relatively common pathological condition. The condition aggravated to a serious state and required surgical treatment in 15% of moderate cases and 7.6% of mild cases, indicating that careful judgment and management of these cases are important. After admission, it is important to maintain a resting state based on risk factors for aggravation. Blood biomarkers such as S-100B protein and D-dimer may be useful for predicting the presence of intracranial lesions and aggravation to a serious state, and we will introduce a result of our research about blood biomarkers in mild traumatic brain injury patients. The severity of neurotrauma may initially be mild or moderate, but can aggravate to a serious state that may lead to a poor outcome.

  Social problems, such as higher brain dysfunction and postconcussional syndrome, also accompany neurotrauma, which makes treatment of this injury of particular importance for neurosurgeons.

  Neuropsychological impairment after traumatic brain injury (TBI) is sometimes difficult to identify and is therefore called an “invisible or hidden impairment”, especially when the physical impairment is mild. Even when the patients recover well physically, their adaptation back to their normal social life is sometimes impaired. Furthermore, many problems are only actualized once they return to their real lives and society, and thus, these patients often cannot return to their previous schools and the workplace. This article describes the characteristics and tips to diagnose neuropsychological impairment after TBI that are essential knowledge for the clinical neurosurgeon. 1) In the acute phase after TBI, detailed record of consciousness status and early radiological examination including MRI are important for later diagnosis. 2) Functional imaging tools such as SPECT or PET may sometimes detect silent brain lesions where the chronic morphological diagnosis including MRI has failed. 3) Granting a patient’s permission for a driving license is an important role of the neurosurgeon as it impacts both personal and social issues. Neurosurgeons should diagnose their patients and plan treatment strategies based on an accurate understanding of each patient’s neuropsychological impairment reached using all the available tools after TBI. Moreover, appropriately judging each patient’s abilities and guiding them back to social participation will become an increasingly important role for clinical neurosurgeons in the future.

  Sports related head injuries, especially concussion, commonly recur because athletes generally want to return to play promptly. Recurrent concussions may lead to acute brain swelling (aka second impact syndrome) and/or chronic traumatic encephalopathy. Management should be referred to international consensus, such as the Statement of the Conference on Concussion in Sports, the guideline update by the American Academy of Neurology, etc. All these recommendations do not allow the injured athletes to return to play on the same day rather in a stepwise manner. Our present consensus in Japan is described in the article, Neurosurgical management of sports-related head injuries, published in Neurotraumatology, 2013.

  All of us should precisely understand the contents of these publications and give appropriate advise to athletes, coaches, and their family members. A continued knowledge transfer aimed at educating the general public is also essential in this field.

  The key points in managing the acute phase of spinal cord injury are ensuring that the patient can leave bed and start on the path of independence as soon as possible, and beginning rehabilitation at the earliest opportunity. Also, in the early acute phase it is imperative to decompress and fix the responsible lesions and any highly unstable lesions that are found. And it should also be noted that by using spinal instrumentation, the postoperative bedtime period can be shortened. In Japan, the number of elderly cases is increasing and measures to meet this increase are necessary.

  Additionally, we should be aware of vertebral artery injuries that may accompany cases of cervical spine trauma. Finally, addressing the needs of transplantation medical care will be a problem in the very near future. In summary, it will become increasingly necessary to understand the basis of spinal cord trauma cases and to increase the number of neurosurgeons who can take the initiative for their treatment.

  Acute subdural hematoma (ASDH) has a high mortality and poor prognosis despite intensive treatments including surgery. Although some prognostic factors have been reported, predicting outcomes in ASDH patients remains difficult. In traumatic brain injury (TBI), there is a short time window for initial management and the treatment methods are often left to the surgeon’s discretion. It is also important to assess prognostic factors for ASDH to obtain informed consent. Our institution is the only tertiary emergency institution in the district (population 430,000), and all cases of severe TBI come to our department. The aims of this study were to investigate the prognostic factors and complications in ASDH cases in our institution and assess the state of treatment for ASDH in the district.

  Two hundred and forty-four operations for ASDH, acute epidural hematoma and cerebral contusion were performed in our department between January 2005 and December 2015. Cases who received craniotomy for ASDH were included in this study. Exclusion criteria included presence of contralateral ASDH or acute epidural hematoma with mass effect, cases who received burr-hole surgery before craniotomy and with a modified Rankin Scale before occurrence of ASDH of ≧3, and children under 6 years of age. Eighty-eight cases were registered and investigated with respect to prognostic factors and complications.

  Seventy cases (79.5%) were over 60 years of age. According to the Glasgow Outcome Scale score at discharge, only 22 cases (25.0%) had a favorable outcome composed of ‘good recovery’ and ‘moderate disability’, while 35 cases (39.8%) had complications following surgery. There was a significant correlation of prognostic factors with clinical parameters including Glasgow Coma Scale, pupillary status, hematoma thickness, midline shift, compression of basal cisterns, and presence of cortical subarachnoid hemorrhage. Complications were also related to the outcome of ASDH.

  Most cases of ASDH in the district were elderly people, while treatment for severe TBI was only available at our institution. Because many severe cases and elderly people were included this study, only 22 cases (25.0%) had a favorable outcome, while 35 cases (39.8%) had complications following surgery. Glasgow Coma Scale, pupillary status, hematoma thickness, midline shift, compression of basal cisterns, and presence of cortical subarachnoid hemorrhage were prognostic factors for ASDH. The management of complications following surgery is also critical for improved outcomes.

  Brain stem cavernous malformations (BSCMs) are associated with a high rate of hemorrhagic events. Though BSCMs that bleed or grow in size are indicated for resection, the surgical procedure usually involves a high risk of damage to the normal brain. We successfully achieved total resection, in two cases of symptomatic BSCMs, using a neuroendoscope. The BSCM was localized in the ventral part of the pons in the first case and in the middle cerebellar peduncle in the second case. In both cases, diffusion tensor images (DTI) were taken with an MRI to confirm the localization of the BSCM in relation to the pyramidal tracts. We resected the BSCMs using a ‘wet field method’ which renders the surgical fields clear without using suction tubes. The wet field provides the operator with an increased range of manipulation even in a tight space.

  With our technique, the indications of endoscopic surgery have widened. We have shown that neuroendoscopic surgery can safely and effectively replace conventional craniotomy for certain brain stem lesions.