In recent years, attention to sports-related head injuries, especially concussion has been increasing. The main problems faced in sports-related head injuries are severe traumatic brain injury (typified by acute subdural hematoma) or repeated concussion, as conventionally pointed out. This article describes the following management strategies for sports-related head injuries that are essential knowledge for the clinical neurosurgeon : ①The consensus of sports-related head injuries. ②On-field management for sports-related head injuries (include child and/or adolescent athlete). ③The hazards of repeated sports-related head injuries. ④Teaching methods for athletes and stakeholders.
In the future, the role of the neurosurgeon in exercising appropriate judgment and guidance is expected to grow in this field.
The aged population is rapidly growing across the world. Japan is one of the fastest aging societies, in which people over 65 comprise 25% of the general population ; and this figure is expected to rise to 40% in 2060. Recently, the aged have come to pose an increasing problem in the management of traumatic brain injury (TBI). Age is closely associated with an increased poor outcome and mortality following TBI. In fact, according to several studies on TBI, age could be the most significant factor in the prediction of outcome. Although the influence of increasing aged TBI is expected to place severe demands on health care resources, especially in developed countries, there are no randomized studies, or treatment guidelines for the aged group. Poor outcome and mortality following TBI are related to the anatomical and physiological vulnerability of the aged brain. Moreover the taking of anticoagulants and antiplatelet agents has been reported to be one cause of a poor outcome following traumatic intracranial hematoma. In this manuscript, we describe the current situation and important issues regarding the management of TBI in the aged.
Mortality due to trauma is classified as an unexpected accident on the mortality statistics, and it is the fifth cause of death. Especially the first cause of death among young people is an unexpected accident, about half of which are head injuries. Considering that it is presumed that there are 2 to 10 times more serious cases of later obstacles, the loss of head trauma to society is enormous.
At the Japanese Society of Neurotraumatology, in the sense to understand the actual situation of cranial trauma treatment of Japan, as JNTDB P1998, P2004, P2009, has made a statistical survey in a facility of the major nationwide dealing with severe head trauma. In addition, we prepared guidelines for the management of traumatic brain injury and strive to improve treatment level.
From the JNTDB data so far, it can be seen that the number of traffic accidents in the ages of 10 to 20 years has been decreasing as compared with those after the severe punishment of drunk driving and dangerous driving. On the other hand, it can be seen that the number of non-traffic accident patients over the age of 60 is increasing. Therefore, it is necessary to take measures against falling fall of elderly people.
Severe traumatic brain injury has complicated injury form and pathology, and there is very little evidence of aggressive treatment. That is why it is necessary to understand the pathology and to treat individual cases by making use of neurological evaluation, image evaluation, and other intensive care monitors progressing day by day.
In the future, as we revise the guidelines, we will analyze the mechanism of head trauma and hope to improve new head injury prevention and treatment.
The Great East-Japan Earthquake was a complex disaster comprising an earthquake, a tsunami, and radioactive contamination, that caused enormous damage to a wide area. While providing disaster medical treatment in this setting, new problems other than emergency medical care were revealed. In such a scenario, further improvement and strengthening of the medical system are necessary to prevent damage to the victims’ medium- to long-term health. We describe in detail the disaster medical activities in Kesen-numa City Hospital during the Great East Japan Earthquake.
Finally, neurosurgeons are also expected to actively participate in the disaster medical management in addition to their role providing medical treatment for neurological patients.
Combination of systemic administration of high dose methotrexate (HD-MTX) and whole brain radiation therapy (WBRT) has widely been used as the standard treatment modality for primary CNS lymphoma (PCNSL). In this study, we retrospectively analyzed newly diagnosed PCNSL cases treated with different regimens at our institute. First, by comparing the results of our historical data of DeVIC (dexamethasone, etoposide, ifosfamide, carboplatin)/WBRT and HD-MTX/WBRT, we evaluated their strengths and limitations. We then compared the results of RMPV (rituximab, methotrexate, procarbazine, vincristine)/reduce dose WBRT (rd-WBRT) therapy to the historical regimens to examine if RMPV therapy could overcome the drawbacks of the past regimens. We report here our experience with RMPV therapy from Nagoya University where our Department of Neurosurgery carries out all neuro-oncologic duties including systemic chemotherapy.
DeVIC group had a higher response rate compared to HD-MTX group (DeVIC 95%, HD-MTX 50%). One year overall and progression free survival was also longer in DeVIC group. These results highlighted the need to improve the initial response as a major issue to be resolved in HD-MTX therapy. On the other hand, RMPV therapy achieved a much better response (complete remission 86%) with induction chemotherapy alone. One year and two year overall survival after RMPV therapy was 100% and 75% respectively. Moreover, incidence of leukoencephalopathy was lower in RMPV patients, where rd-WBRT of 23.4 Gy was administered, compared to HD-MTX group with WBRT of 40 Gy. There was one case of treatment limiting toxicity in the RMPV group where treatment was discontinued after severe gastro-intestinal hemorrhage. Although RMPV therapy caused more adverse events than HD-MTX in general, there was no significant difference between grade 4 neutropenia requiring G-CSF administration (RMPV 28%, HD-MTX 7.1%, p=0.186).
Our results show that RMPV could overcome the drawbacks of HD-MTX monotherapy. These results are one of the first reports of newly diagnosed PCNSL treated with RMPV/rd-WBRT in a Japanese population. These promising results require further investigation preferably with a prospective trial carried out in an institution with the capacity to properly manage the possible adverse events.
There are few reports of delayed symptomatic complications occurring after coil embolization. A 70-year-old woman underwent coil embolization for subarachnoid hemorrhage due to a ruptured internal carotid artery-posterior communicating artery aneurysm, and was discharged without neurological deficit after 4 weeks. But one month later, she returned to our hospital because of left hemiparesis and gait disturbance. Magnetic resonance imaging (MRI) showed several enhanced lesions in the right cerebral white matter with extensive edema. We started steroid treatment. Three weeks after her second admission, her symptoms improved and the enhanced legions almost completely disappeared on MRI. We speculated these lesions were cause by hydrophilic coatings that had peeled off the various endovascular devices used during, inducing foreign body granulomas in the cerebral parenchyma. Although endovascular treatment has become quite common place, we should still pay careful coil embolization attention to in case there are delayed symptomatic complications such as these.