The removal of hematomas using single burr hole emergent surgery was performed in 52 patients between January 1996 and April 2002. The main symptoms of the patients were a traumatic acute subdural hematoma (ASDH) at the time of the initial CT observation, a shift in the midline structures of 10mm or more, and/or a Glasgow coma scale (GCS) score of 10 or less. Cerebral herniation with pupillary abnormalities were observed in 42 out of 52 patients with ASDH upon their arrival at the hospital. The average hematoma extraction rate using only a single burr hole was 69%. The extraction rate was particularly high for patients exhibiting mixed low density hematoma areas on their CT images. Improvement in pupillary findings or in the level of consciousness was observed in 36 patients immediately after hematoma extraction using single burr hole surgery. Postoperative control of intracranial pressure (ICP) was successfully performed in 13 patients. The overall clinical outcomes consisted of good recovery (GR) in 6, moderate disability (MD) in 6, severe disability (SD) in 4, persistent vegetative state (PVS) in 4 and death (D) in 32 patients. The clinical outcomes of patients who underwent single burr hole surgery consisted of GR in 6, MD in 4, SD in 1 and D in 22 patients. Furthermore, an additional craniotomy resulted in MD in 2, SD in 3, PVS in 4 and D in 10 patients. Single burr hole surgery is a quick and effective method for extracting ASDH, and favorable results can be expected even in patients with serious head injuries. Active single burr hole surgery in the emergency room is recommended for severe cases of ASDH.

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We reviewed the clinical results of patients treated for subarachnoid hemorrhages (SAH) between 1996 and 2000 at the Emergency Department and Critical Care Unit of Tama-Nagayama Hospital, Nippon Medical School. One-hundred and fifteen consecutive cases of SAH between January 1996 and December 2000 (latter group) were studied, and the results were compared with those of 124 SAH cases treated between January 1991 and December 1995 (former group). Neurological grades were classified according to the World Federation of Neurological Surgeons (WFNS) grading scale, and the outcome of SAH was determined using the Glasgow Outcome Scale (GOS). Coil embolization and induced mild hypothermia therapy were performed as additional treatments in the latter group. The WFNS grades of the former group were I (8 cases), I (13 cases), III (6 cases), IV (41 cases) and V (55 cases), while those of the latter group were I (6 cases), II (21 cases), III (4 cases), IV (34 cases) and V (50 cases). The number of cases that experienced radical obliteration of the ruptured aneurysms were 6 (I), 9 (II), 3 (III), 22 (IV) and 10 (V) in the former group and 5 (I), 20 (III), 3 (III), 33 (IV) and 22 (V) in the latter group. The outcomes of the SAH in the former group were a good recovery (GR) in 22 cases, moderate disability (MD) in 8 cases, severe disability (SD) in 13 cases, persistent vegetative state (PVS) in 6 cases, and death (D) in 75 cases. On the other hand, the outcomes of SAH in the latter group were GR in 42 cases, MD in 12 cases, SD in 9 cases, PVS in 9 cases, and D in 43 cases. Regarding the overall outcome of SAH cases in the two groups, the latter group fared better than the former group (p<0.01). The improvement in the latter group was due to the higher rate of surgical intervention in cases with a WFNS grade of IV or V. In addition, the frequency of deterioration in cases with WFNS grades of I, II or III was smaller in the latter group (2 out of 31 cases) compared to the former group (9 out of 27 cases). When only the surgically treated cases were compared, the differences in outcome were not statistically significant. We conclude that an early estimation of the severity grade, preoperative deep sedation, and radical treatment, even in severe cases (with the exception of completely contraindicated cases, such as those with a loss of brain stem reaction) may prevent death and improve the outcome of SAH.

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Systemic organ dysfunction in patients with severe subarachnoid hemorrhage was evaluated using the SOFA score throughout the follow-up period to characterize organ dysfunction resulting from neuroendocrine reactions during the acute stage of subarachnoid hemorrhage. Of the 194 patients with subarachnoid hemorrhages resulting from a ruptured cerebral aneurysm who were admitted to our department between 1996 and 2000, 100 patients whose SOFA scores could be calculated over a follow-up period after their admission (WFNS grade IV, V: poor grade group [n=79]; WFNS grade I, II, III: non-poor grade group [n=21]) were enrolled in the study. The SOFA scores at the time of admission (day 0), after 24 hours (day 1), 48 hours (day 2), 72 hours (day 3) and 96 hours (day 4) were compared in the poor and non-poor grade groups. The SOFA score on day 0 was significantly (p<0.05) higher in the poor grade group (poor grade group, 5.89±2.040; nonpoor grade group, 1.71±0.960). The SOFA score continued to be higher in the poor grade group throught the entire observation period; the SOFA score excluding the GCS score was also significantly higher (p<0.05) in the poor grade group. The SOFA score in the poor grade group increased significantly (p<0.0001) on day 1, compared with its value on day 0, and the increase continued until day 4. The respiratory dysfunction score, determined by the P/F ratio, was slightly higher in both groups at the time of admission, compared to normal, and this increase continued until day 4, although the difference between the groups was not statistically significant. The coagulation dysfunction score, determined by the platelet count, was significantly higher (p<0.05) in the poor grade group on day 1 and day 4. The circulatory dysfunction score was significantly higher in the poor grade group from day 1 to day 4. The liver dysfunction and renal dysfunction scores did not increase significantly in either group. The possibility of organ dysfunctions, especially coagulation and circulatory dysfunctions should be considered at an early stage in the clinical course of patients with subarachnoid hemorrhages of a severe neurological grade. Appropriate pre- and post-operative intensive care is important when planning direct surgery for cerebral aneurysms.

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Background: Management strategies for aneurysmal subarachnoid hemorrhage (SAH) have undergone radical changes following the development of Guglielmi detachable coils (GDC). However, which treatment option, direct surgical clipping or endovascular coiling, should be the treatment of choice remains debetable. Here, we evaluated and compared the recent outcomes of SAH cases that were treated using these methods. Material & Method: Data on 503 patients who underwent treatment for SAH at the Department of Neurosurgery, Fujita Health University, Japan between 1998 and 2002 were analysed. Out of the 503 patients, 279 patients underwent direct surgery and 95 underwent endovascular coiling. One-hundred and twenty-nine patients received conservative treatment. Results: The pretreatment Hunt & Hess grading scores of the patients who underwent direct surgery was as follows: grade I, 22 (8%); grade II, 57 (20%); grade III, 98 (35%); grade IV, 50 (18%); and grade V, 52 (19%). The scores of the patients who received an endovascular coil were as follows: grade I, 12 (13%); grade II, 19 (20%); grade III, 21 (22%); grade IV, 19 (20%); and grade V, 24 (25%). No statistically significant difference were observed between the two groups (p>0.15). The final treatment outcome was assessed using the Glasgow outcome scale (GOS). In the surgical group, 182 patients (65%) exhibited a good recovery (GR), 24 patients (9%) exhibited moderate disability (MD), 15 patients (5%) exhibited severe disability (SD), and 58 patients (21%) died. In the endovascular coil group, on the other hand 39 patients (41%) exhibited GR, 15 patients (16%) exhibited MD, 18 patients (19%) exhibited SD, and 23 patients (24%) died. These differences were statistically significant (p<0.001). Thus, the outcome was better in the surgical group. Out of the 129 cases treated conservatively, 100 cases had experienced cardiopulmonary arrest on admission and eventually died. The remaining 29 cases with angiographically occult aneurysms, however, exhibited a good recovery. Conclusion: Direct surgery should be considered as the treatment of choice for Grade I-IV SAH patients, while endovascular coiling should be adopted for Grade V SAH patients.

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Thirty-three people (nine groups) ingested fish belonging to the grouper family; eleven people subsequently complained of muscle pain and muscle weakness of the neck, shoulder, hip and thigh 3 to 43 hours after the meal. Rhabdomyolysis was suspected based on the patients'symptoms and the results of blood examinations, and five patients were admitted to hospital. Fluid therapy was administered, and all of the patients recovered and were discharged from ospital on the 4th day of admission. A palytoxin-like substance was detected in the fish and was presumed to be the cause of the rhabdomyolysis. If patients with food poisoning complain of muscle pain and have no symptom of the digestive system, the possibility of poisoning by palytoxin or a palytoxin-like substance should be considered. Although such poisoning is commonly caused by parrotfish, other fish species may also carry these substances.

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A 73-year-old man was admitted to hospital suffering from organophosphate intoxication. On the fourth day of admission, his serum amylase level was elevated (1, 713IU/l), in accordance with a marked elevation in his serum pancreatic phospholipase A₂ (PLA₂) and elastase-1 levels. A diagnosis of acute pancreatitis was made based on the results of an abdominal computed tomography (CT) examination, which revealed edematous swelling in the head of the pancreas. The organophosphate intoxication likely produced an excessive cholinergic effect, inducing a functional obstruction in the pancreatic duct and hyperstimulation of the acinar cells immediately after organophosphate loading. These two effects are likely to have caused the interstitial pancreatitis. The CT findings in this case seem to support this mechanism. The patient's pancreatitis, which occurred soon after hospitalization, improved after several days. Some reports have described the occurrence of necrotizing pancreatitis in cases of organophosphate intoxication. The occurrence of pancreatic involvement in association with organophosphate intoxication is much higher than previously thought, and other serum pancreatic enzymes, in addition to amylase, should be measured shortly after admission. When pancreatitis occurs, proper treatment should be applied according to the severity of the condition.

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We report a very rare case of cervical spinal cord injury in connection with thoracic vertebra arthrodesis following a motor vehicle accident involving a 3-point seat belt. A 36-year-old man napping in the passenger seat was injured by the seat belt when his car ran into a traffic pole. He was diagnosed with anterodislocation of the fifth cervical vertebra and cervical spinal cord injury. Steroid pulse therapy and halo traction therapy moderately improved his neurological abnormality. There was ecchymosis due to shoulder seat belt pressure on the left neck, which was at a higher level than usual. We concluded that the shoulder seat belt injured him directly due to submarining, because he was drowsy at the accident. His history of thoracic vertebra arthrodesis would also be related to the cervical spinal cord injury.

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