An increase in the number of a person of advanced age in Japan, corresponding to the super-aging society world-wide, has become an urgent medical issue in Japan. According to the Japan Neurotrauma Data Bank (JNTDB) project 2015, the percentage of patients older than 65 years with severe traumatic brain injury (TBI) is 51.7%. Just more than half of the severe TBI patients in Japan are geriatric. While geriatric patients with acute subdural hematoma or delayed exacerbation are often seen, a high proportion of these geriatric TBI patients taking anti-thrombotic drugs are receiving attension in recent years. The data from the JNTDB project 2015 (n=1,345, April 2015-March 2017) were evaluated in this study. The geriatric TBI patients taking anti-platelet drugs had a significantly higher prevalence of fall as a mechanism of injury, intracranial bleeding and “talk & deteriorate” when compared with that of the patients not taking anti-platelet drugs. Similarly, the geriatric patients taking anti-coagulants had a significantly higher prevalence of fall as a mechanism of injury, intracranial bleeding and “talk & deteriorate”. It is important to appropriately respond to those patients before deterioration, specifically diagnosis with head CT scan, and to neutralize the anti-thrombotic drugs.

  The treatment approaches for severe head injury have not drastically improved in the last 20 years. Various treatment techniques such as hypothermia therapy and progesterone administration have been evaluated, albeit without drastic improvement. Severe head injury is a heterogeneous clinical presentation in which diffuse and focal brain injury coexist, thereby often complicating multiple trauma. Thus, there is minimal higher-level evidence by randomized controlled trials on head injury. Currently, treatment guidelines have been supported by expert opinions. In this article, we introduce the revisions and updates in the fourth edition of the United States serious head trauma guidelines and the goal-directed approach from the Trauma Quality Improvement Program of the American College of Surgeons. In addition, we introduce several remarkable ongoing randomized controlled trials and overview new treatment trends.

  We examined the criteria for acquiring computed tomography (CT) for mild head injury in Japan, where the number of CT scanner is higher than other countries. CT acquisition should be mandatory in adults with a Glasgow Coma Scale (GCS) score<14, those older than 60 years, and those presenting with any symptoms. If none of these criteria are satisfies, CT is recommended in the presence of trauma findings in the head and in patients with dangerous injuries. CT examination should be performed in children with a GCS score<14, those with altered mental status, and those with palpable skull fractures. Otherwise, the criteria for those older and younger than 2 years are different, and children are hospitalized for observation if it the score falls under the standard threshold. In children for whom the effects of radiation exposure is a concern, the protocol should be reconsidered to substitute CT with magnetic resonance imaging.

  Hypertrophic pachymeningitis (HP) is a rare inflammatory disorder presenting with thickening of the dura mater. In patients with idiopathic hypertrophic pachymeningitis (IHP) presenting with tumor-like lesions, discrimination between HP and en-plaque meningioma using magnetic resonance imaging (MRI) is difficult. Here we report an extremely rare case of IHP in the clival region in a patient presenting with hypoglossal nerve palsy who was diagnosed by surgical biopsy.

  In the current case, biopsy was necessary for the definitive diagnosis because MRI revealed an extra-axial mass lesion mimicking meningioma. The treatment for IHP is different from that for meningioma ; therefore, it is critical to confirm a definitive diagnosis with biopsy.

  Here, we present a case of acute middle cerebral artery (MCA) embolic occlusion caused by thrombus from the left superior pulmonary vein after lung lobectomy. A 72-year-old woman presenting with right hemiparesis and aphasia six days after left upper lobectomy for lung cancer was transferred to our hospital. Magnetic resonance imaging showed MCA occlusion and acute large cerebral infarction. The thrombus in the stump of the left superior pulmonary vein was detected by contrast-enhanced chest computed tomography. She was treated with rivaroxaban, and her pulmonary vein thrombus dissolved.

  Based on previous reports, left upper lobectomy is a risk factor for pulmonary vein thrombus and embolic brain infarction. In our opinion, we neurosurgeons need to understand that pulmonary thrombus may cause large vessel occlusion after lung surgery.