In recent years, with the aging of Japanese society, there has been a sharp increase in the number of patients taking antithrombotic drugs, underscoring their growing importance. The efficacy of antithrombotic drugs in the treatment and prevention of ischemic diseases is well-documented. However, it is essential to remember the risk of bleeding complications associated with these drugs. Our research has shown that traumatic intracranial hemorrhage due to low-energy trauma is common among elderly individuals with head injuries who are undergoing antithrombotic therapy, and symptoms tend to progressively worsen. According to guidelines for the treatment and management of head injuries, discontinuation or reversal of antithrombotic drugs may be considered for elderly patients with head injuries on such medication. This however requires careful risk assessment. A multicenter observational study was conducted to investigate the use of reversal drugs in elderly head injury cases in Japan. Reversal therapy has been primarily administered for severe head injuries requiring craniotomy, without a demonstrated improvement in outcomes. However, early administration of reversal drugs has been suggested as a key to improving outcomes. I will review the indications and methods for reversal therapy in elderly patients with head injuries on antithrombotic therapy, an area where consensus has not yet been reached, by utilizing the results of observational studies and reviewing the literature.

  Chronic subdural hematoma (CSDH) is a major challenge for neurosurgeons, and its prevalence has increased worldwide in recent years. Burr hole surgery has long been the traditional treatment of CSDH. In recent studies, various new surgical techniques and the efficacy of some oral medications have been reported. This review discusses the history and transition of CSDH and its treatments. In addition, the important topic of recurrence factors and future prospects are addressed.

  Although the prognosis for severe head trauma is gradually improving, it remains poor. For patients with multiple traumas, especially those experiencing severe complications such as hemorrhagic shock, the establishment of a treatment plan can be challenging. Multiple trauma is defined as having two or more injuries with an Abbreviated Injury Scale (AIS) score of 3 or higher. Trauma care follows the ABCDE approach, as described in the Guidelines for the Japan Advanced Trauma Evaluation and Care (JATEC), evaluating and stabilizing Airway (A), Breathing (B), Circulation (C), Disfunction of CNS (D), and Exposure (E), in that order. It is challenging to save a patient's life if the treatment of intracranial lesions is prioritized over stabilizing the ABCs. However, it is common for intracranial lesions to worsen during resuscitation efforts for abnormal ABCs, leading to poor outcomes. Although there is extensive literature on treatment strategies and their efficacy in patients with multiple traumatic injuries and hemorrhagic shock, many studies exclude those with severe head trauma. At our hospital, we have been advocating for and practicing an “All-in-One” therapy for severe head trauma, where all possible treatments are consistently applied from the time of initial treatment. While the number of cases with good outcomes has been increasing, the effectiveness of this treatment approach has not yet been fully demonstrated. In this article, we report on our approach to treating patients with multiple traumatic injuries, including head trauma.

  The first clinical description of second impact syndrome (SIS) was provided by Bollinger (1881). Schneider (1973) updated this condition. The term SIS was first used by Saunders (1984). Saunders (1984) defined it as a catastrophic brain injury following a minor impact. An initial minor head injury is often diagnosed as a concussion. After 0-30 days (average 1-2 weeks), the patient suffers a second trauma and develops a serious condition. A second trauma is often less severe than a single trauma that could cause fatal brain damage. One possible mechanism underlying SIS is acute cerebral swelling due to impaired cerebrovascular autoregulation. Most cases are reportedly associated with acute subdural hematomas, suggesting that these may be the true pathology of SIS. The unique presentation scheme of the SIS was insufficient to support a standardized WHO case definition ; however, the pathogenesis remains unclear. Severe head trauma with diffuse brain swelling can occur following minor injuries. Currently, the SIS expresses only one concept and should not be feasible for diagnosis. In all operated-on or autopsied SIS cases, the volume of the acute subdural hematoma was low and was not considered to be a cause of brain swelling. Whether fatal brain swelling is due to dysautoregulation, vasogenic edema, venous insufficiency, cortical spreading depolarization, trigeminocardiac reflex, or a combination of some or all of these remains disputable. If SIS occurs, there is nothing to do. The only way to prevent SIS is to ensure its nonoccurrence. This study aimed to clarify whether the fatal cerebral swelling associated with repeated sports-related concussions (SRC) should be classified as SIS or “post-traumatic diffuse cerebral swelling.” Further, regardless of its specific designation, this study will explore whether the underlying mechanism impacting this condition ultimately alters the essential principles of managing SRC and the criticality of implementing a graduated return-to-play protocol. Because some National Federations of the Japanese Olympic Committee and lecture materials for sports instructors refer to SIS, the mechanism of this phenomenon requires clarification from neurosurgeons.

  Arteriovenous malformations (AVMs) of head and neck (oropharynx) are relatively rare vascular anomalies that occasionally present with massive bleeding in the oral cavity. The management and treatment for oropharyngeal AVMs are difficult due to their variety and rarity. We herein report a patient with a ruptured AVM of oropharynx, which was successfully occluded by endovascular therapy.

  A 70-years-old man presented with intraoral hemorrhage. A CT scan demonstrated a giant oropharyngeal tumor, and a surgical biopsy was performed. After the procedure, bleeding from the lesion had occurred several times. Digital subtraction angiography (DSA) demonstrated an oropharyngeal AVM, mainly fed from the lingual artery and the facial artery, and drained into the common facial vein. Since there were concerns about dysphasia and mucosal necrosis after surgical resection or sclerotherapy for the AVM, endovascular embolization was performed. The AVM was embolized by injecting 25% to 33% NBCA from the several branches of the lingual artery (deep lingual artery, dorsal lingual artery) and the facial artery (ascending palatine artery). DSA and CT angiography after the endovascular therapy showed complete occlusion of the AVM, and he was discharged 11 days after the treatment without re-bleeding from the lesion.

  Oropharyngeal AVMs treated by endovascular therapy require long-term observation. However, endovascular embolization with NBCA against oropharyngeal AVMs may be safe and effective.

  Although tethered cord syndrome is occasionally associated with Chiari malformation type1, their causative relationship and the order of symptom onset remain to be elucidated. We report the case of an adolescent patient who developed both Chiari malformation type1 and tethered cord syndrome symptoms sequentially. A 12-year-old girl, who underwent foramen magnum decompression for symptomatic Chiari malformation type1 one year before, suffered lumbago, pain of lower extremities, and urinary dysfunction. Her pain was provoked by flexion. As the symptomatology and magnetic resonance imaging findings suggested tethered cord syndrome, sectioning of the tight filum terminale was performed, which resulted in complete resolution of the symptoms. Her body length increased by 6.1cm during the period between foramen magnum decompression and sectioning of the filum terminale. We assumed that the interaction of her crowded posterior fossa, tight filum terminale, and growth of the spinal column during adolescence contributed to the sequential symptom onset of Chiari malformation type1 and tethered cord syndrome.

  Eosinophilic meningitis is a rare complication following brain surgery, often triggered by allergic reactions to foreign materials. A limited number of studies have identified a resorbable collagen dural substitute (RCDS) as a potential cause of eosinophilic meningitis.

  We report the case of a 20-year-old female who underwent duraplasty using RCDS. The patient suffered from hydrocephalus and subsequentially faced repeated ventriculoperitoneal shunt malfunctions of unknown cause. Cerebrospinal fluid eosinophilia was identified, and her symptoms and laboratory findings improved following the administration of high-dose corticosteroids. Additionally, the patient developed progressive syringomyelia and presented symptoms in the delayed postoperative period due to craniocervical junction arachnoiditis obstructing cerebrospinal fluid flow. This underscores the necessity for a follow-up whole spine MRI even after resolution of eosinophilic meningitis.

  This case highlights the potential for eosinophilic meningitis and subsequent complications associated with the use of an RCDS. Thus, we should pay attention to possible early and delayed complications following surgery involving RCDS.