Acute subdural hematoma (ASDH) represents a major clinical entity in severe traumatic brain injury (sTBI). sTBI is reported to cause cerebral circulatory disturbances at the acute stage. Here we focused on the cerebral circulation of ASDH patients, evaluated the absolute left‒right difference between cerebral hemispheres, and compared the cerebral circulation between groups with and without favorable outcomes. We retrospectively reviewed the cases of 31 patients with ASDH. Xenon‒computed tomography (Xe‒CT) and perfusion CT had been performed simultaneously in each patient to evaluate the cerebral circulation on post‒injury days 1‒3. The cerebral blood flow (CBF) was measured by Xe‒CT and the mean transit time (MTT) was measured by perfusion CT, and the cerebral blood volume (CBV) was calculated. A significant absolute difference in cerebral circulation between the hemispheres among different types of TBI was observed in the patients’ MTT values. There was no significant difference in these parameters between left‒right hemispheres with ASDH among the favorable outcome group and unfavorable group. There were no significant differences in age, Glasgow Coma Scale score at the onset of treatment, CBF, or CBV. Only the MTT was significantly different between the favorable outcome and unfavorable outcome groups. The circulatory disturbance in ASDH patients occurs diffusely despite the focal injury. Additionally, in patients with unfavorable outcomes, the circulatory disturbance is worse than that in favorable patients. We must adopt a treatment strategy appropriate to the pathophysiology of the different TBI types.

  The effects of dental therapeutic intervention in stroke treatment are still unclear. In this study we clarify its effectiveness in the acute stage of stroke care, especially for the prevention of aspiration pneumonia. We also describe our experience in constructing the prototype of a seamless system for collaborating on medical and dental interventions for stroke patients. A multi‒disciplinary oral function management group was established in our hospital. The group provided the first dental intervention for stroke patients within 3 days after stroke onset. To cooperate more closely with rehabilitation hospitals, we conducted human interactions aimed at standardizing methods of evaluation and care and shared both medical and dental information when the patients were transferred from our hospital to the rehabilitation phase. Recognizing that it is difficult for dental physicians to perform direct interventions at the maintenance phase facility, we taught the oral care method using a prepared oral care manual. Our hospital succeeded in providing not only oral care, but also expert dental treatments such as denture adjustment, tooth extraction, and evaluation of swallowing by VE, all starting from the very acute stage. We also found that dental intervention reduced the prevalence of pneumonia from 3 days after onset. Through cooperation with the rehabilitation hospitals, some cases received continuous dental treatment after their hospital transfer. Dental intervention in stroke patients seemed to be useful for improving both oral hygiene and swallowing function. Meanwhile, there was a limitation to the degree of inter‒facility cooperation that could be achieved through the efforts of the participating facilities alone. To achieve dental intervention nationwide, institutional changes, such as changes in the “stroke path” and medical treatment fees, are needed.

  Acute subdural hematoma (ASDH) in children indicates different pathophysiology from adult ASDH. Children with ASDHs who were injured by minor head trauma occasionally show unfavorable outcomes. A clarification of the clinical factors related to the outcomes of child ASDH could lead to improved prognoses of child ASDH patients. This study was conducted to evaluate predictors of unfavorable outcomes in child ASDH patients and to investigate clinical factors affecting the predictors of unfavorable outcomes. The cases of the children aged ≤ 6 years old with ASDH admitted to Tokai University Hospital from 2000 to 2016 were retrospectively evaluated. During the 17‒year period, 70 children with ASDH were treated. Unfavorable outcomes occurred in 21 children (30%). A multivariate analysis revealed the occurrence of ischemic lesions on neuroimages (cerebral infarction following ASDH: CIASDH) as the only predictor for unfavorable outcomes (p＜0.05). Clinical factors related to the occurrence of CIASDH were convulsion, consciousness disturbance at admission, and a midline shift ≥ 3 mm on computed tomography (CT) (p＜0.05). The occurrence of CIASDH gravely affected the outcomes of children with ASDHs. When a child with an ASDH shows convulsion, consciousness disturbance, and/or a midline shift on CT, the possibility of a CIASDH should be taken into account in the treatment of the child.

  Acute hyperthermia after severe traumatic brain injury (sTBI) can lead to secondary brain damage and a significantly poor outcome for patients. We report the efficacy and problems of a novel intravascular cooling system, the Thermogard XP/ COOL LINE^® catheter, for temperature control in cases of acute hyperthermia after sTBI. The participants were 7 patients who underwent intentional normothermia therapy for acute hyperthermia after sTBI at our hospital from June 2016 to December 2016. All patients underwent decompressive craniectomy within 24 hours of the sTBI. All cases exhibited fever with temperatures above 38℃ within 72 hours of the injury. Five cases were controlled by a Thermogard XP/ COOL LINE^® catheter (CL group) and 2 cases were controlled by a surface cooling water cooling blanket (BL group). The time taken to reach the target temperature in the CL group was significantly faster than that in the BL group (151.2±48.6 [37‒211] vs. 765.0±75.0 [690‒840] minutes: P＜0.05). Furthermore, temperatures in the CL group were stable during normothermia therapy. The Glasgow Outcome Scale (GOS) showed no significant difference between the CL and BL groups (2.8±0.7 vs. 3.5±0.5). It should be noted that the Thermogard XP/ COOL LINE^® catheter involves a risk of deep vein thrombosis and catheter‒related infection. Nevertheless, our study suggests that the new intravascular cooling system is a useful device to rapidly control and stabilize body temperature. Further study is required to confirm the efficacy of this intravascular cooling system in controlling acute hyperthermia after sTBI.

  Chronic subdural hematoma (CSDH) with brain herniation signs is rarely seen in emergency departments, and there are few cumulative data to analyze such cases. Here we evaluated the clinical features, risk factors, and rates of completion of CSDH patients with impending brain herniation on arrival in a cohort study. The cases of 492 consecutive patients with CSDH between January 2010 and October 2015 were retrospectively evaluated. We first analyzed the clinical factors and compared them between the patients with and without brain herniation signs on admission. Among the patients who had brain herniation signs on arrival, we then compared clinical factors between the patients with and without completion of brain herniation post-surgery. Eleven (2.2%) patients showed brain herniation signs on arrival, and six patients (1.2%) progressed to complete brain herniation. The patients with brain herniation signs on arrival were significantly older (p=0.03) and more frequently hospitalized with a concomitant illness (p=0.004). A multivariate logistic regression analysis showed that admission to another hospital was the only independent risk factor for having had brain herniation signs on arrival. Having a history of head injury (p=0.02) and disappearance of the ambient cistern (p=0.0009) were significantly associated with the completion of brain herniation. The prognosis was generally poor when the patient presented with brain herniation signs on admission. Our results demonstrate that the diagnosis of CSDH is often made late, despite patients’ hospitalization for a concomitant illness. When an elderly patient shows mild disturbance of consciousness, non-neurosurgeon physicians should consider the possibility of CSDH regardless of a recent history of head injury.

  A good outcome can be expected for patients who achieve recanalization earlier with intravenous recombinant tissue plasminogen activator (rt‒PA) therapy and endovascular mechanical thrombectomy even within the treatable period. It is important for patients who present with acute ischemic stroke to visit the hospital for intravenous rt‒PA therapy and/or endovascular mechanical thrombectomy. Due to the strict criteria for administering these treatments, many patients are unable to benefit from them. In order to shorten the time from symptom onset to visiting the hospital, the time from symptom onset to visiting the hospital was reviewed in patients admitted to our hospital from 2014 to 2015 and delays in visiting the hospital were assessed using medical records.

  From October 1, 2014 to September 30, 2015, 384 patients were admitted to our hospital, 69% of which presented with cerebral infarction. A total of 51% had visited the hospital more than 8 hours after onset, and only 30% had visited within 4.5 hours. rt‒PA therapy and/or endovascular mechanical thrombectomy were given in only 11% of patients. The use of an ambulance was more frequent in those with a shorter delay between onset and admission, and the ambulance use rate overall was 63%. In 45 to 60% of patients their condition was found and they were taken to the hospital not by themselves but their family members or others. It is important that citizens increase their knowledge of stroke symptoms and their status as a medical emergency.

  In 228 aneurysm cases, we assessed the relation of ischemic and hemorrhagic complications with age, sex, location, size, ruptured vs. unruptured status, WFNS (World Federation of Neurological Surgeons Committee) grade of ruptured cases and use of neck plasty. Of these 228 cases, 10 had ischemic complications (4.3%) and six had hemorrhagic complications (2.6%). Cases with ischemic complications were significantly correlated with those involving neck plasty. However, no permanent complications were identified. All hemorrhagic complications occurred in cases with ruptured aneurysms. In two cases with hemorrhagic complications, bleeding occurred at the end of coil insertion and the bleeding was stopped with the dilation of the balloon alone, which resulted in good prognosis. Excluding these cases, hemorrhage‒complicated cases tended to have a serious prognosis. Administering argatroban and performing high‒quality endovascular surgery is important for reducing complications. Improvements are also required for reducing the ischemic complications caused by neck plasty. There may be a need to administer dual antiplatelet therapy or perform reinforced heparinization.

  The neck clipping of a large aneurysm of the internal carotid artery (ICA) or a para‒clinoid aneurysm may require flow control achieved by manipulation of the cervical ICA. However, the height of the carotid bifurcation is reported to be one vertebral body‒length higher in Japanese compared to Caucasian patients. Neurosurgeons in Japan are thus more likely to encounter a high‒position ICA, which is difficult to dissect. Herein we describe the safe and cosmetic method that we use for securing the cervical ICA during aneurysm clipping. For Japanese patients with a high‒position ICA, the head is placed in a suitable position for clipping. The pillow that is usually used for the elevation of the ipsilateral shoulder is not used to create tension in the cervical skin. The skin incision follows the skin wrinkle just above the thyroid cartilage, which usually points to the mastoid tip. The transverse skin incision is initiated at 2 cm medial from the anterior border of the sternocleidomastoid muscle and extended posteriorly to 5 cm length. The skin flap is then formed along the great auricular nerve to reach the anterior border of the sternocleidomastoid muscle. The posterior belly of the digastric muscle is dissected as far as possible. The carotid triangle is identified and the bifurcation is dissected to reveal the ICA. We have performed this method in 20 patients. No episodes of cranial nerve palsy, including the facial nerve, recurrent nerve, and hypoglossal nerve, were observed after the surgery. A transverse skin incision for cervical carotid artery dissection can thus achieve good cosmetic results.

  We herein report a 13‒year‒old female patient who presented with moyamoya disease (MMD) with intracerebral hemorrhage (ICH). This pediatric patient was transferred to our emergency center with a sudden headache and general seizure. On admission, her Glasgow Coma Scale (GCS) score was 6 (E1V1M4) with anisocoria. Cranial computed tomography (CT) showed ICH in the right frontal lobe with intraventricular hemorrhaging. A CT angiogram revealed a steno‒occlusive state in the bilateral anterior and middle cerebral arteries, indicating MMD. Immediately after CT angiography, we performed neuroendoscopic surgery to rapidly remove the intracerebral and intraventricular hematoma and to preserve the superficial temporal artery for subsequent bypass surgery. On both the 38th and 58th days, we performed bilateral encephalo‒dura‒arterio‒synangiosis. Her GCS score improved from 6 to 15 and her modified ranking scale score improved from 5 to 3. No rebleeding or ischemic symptoms occurred thereafter. Neuroendoscopic surgery may therefore be useful for the treatment of pediatric MMD presenting with ICH.

  We report a case of prolonged unconsciousness and progressive brain swelling due to a diffuse brain tissue injury caused by a surface flashover and blast injury.

  A 48‒year‒old man was struck by lightning while cycling. At the accident site, he was unconscious, but his breathing and cardiac rhythm were regular. On admission, he had left ear bleeding and belt‒like superficial dermal burns extending from his left ear to the left arm and to the genital area. Imaging examinations of his head revealed diffuse brain swelling with a left‒sided subdural hematoma and subarachnoid hemorrhage, and bilateral intracerebral hemorrhage. His brain swelling was progressive and intractable, and he died 11 days after the injury.

  The cause of his brain swelling was considered attributable not only to the rupture of brain vessels due to Joule heating and electric energy caused by the electric current, but also to diffuse brain tissue injury caused by the surface flashover and blast injury since the patient’s skin on the head was wet. Clinicians should note that in patients with a lightning injury whose skin is wet, intracranial injury and progressive brain swelling caused by a surface flashover and blast injury can be fatal.