The aim of this study was to investigate the diagnostic categories of types of intracranial abnormalities in patients with severe traumatic brain injury (TBI), and the influence of age and mechanism of injury on intracranial pathology. One thousand and two patients, aged 6 years or older, with severe TBI who registered to the Japan Neurotrauma Data Bank from 1998 to 2001 were target population for the data collection. Of these, the 115 patients with cardiopulmonary arrest on arrival and 81 patients with Glasgow Coma Scale score of 9 or more were excluded, leaving 799 patients in this study. Intracranial diagnosis was determined according to the Traumatic Coma Data Bank computerized tomography classification. Diagnosis of Diffuse Injury III, IV, evacuated subdural hematoma, or nonevacuated mass lesions was associated with unfavorable outcome. The proportion of Diffuse Injury was 52% in the patients under 40 years, while only 27% in those over 40 years of age. The proportion of evacuated subdural hematoma or nonevacuated mass lesions significantly increased with patient age. However, regardless of the intracranial diagnosis, older patients had poorer outcomes. Relatively high proportion of patients with Diffuse Injury was seen in traffic accidents. This can be explained, in part, by the greater proportion of young patients injured by traffic accidents. Different occurrence of intracranial lesion types according to age is likely caused by the disparity between the young and aged brain in the progression of secondary brain injury. Alteration in the pathophysiological response may contribute to more severe and irreversible brain damage in older patients, and associates with worse outcome.

This study was conducted to elucidate the relation of cause of injury to extracranial injury and outcome, and to analyze the effectiveness of safety devices in traffic accident group of the Japan Neurotrauma Data Bank. Five hundred and thirty-eight cases with Glasgow Coma Scale score (GCS) 8 or less were injured by traffic accident and enrolled. Those were divided into 4 groups: four wheel vehicle (4WV) group in 101 cases, motorcycle (MC) group in 163, bicycle (BC) group in 118, and pedestrian (P) group in 150. The extracranial injury were classified into 7 categories: cervical spine/cord, face, chest, abdomen, pelvis, extremities, and multiple injuries.

The extracranial injury was most common in the 4WV group, followed by the P group. As for the distribution of extracranial injury, multiple injury was less frequent in the BC group. The Injury Severity Score (ISS) of 31 points or more was most common in the 4WV group. The ISS was quite correlated with the GCS. The outcome at discharge was relatively better in the MC group.

The information about the safety devices was not sufficiently obtained. The effectiveness of the safety devices was not proved in regard to the extracranial injury and the outcome. Furthermore, the relation of seat position to the extracranial injury and the outcome was also unclear. These results did not coincident with the estimated data. The reason of these differences might not be explained in the sole clinical investigation.

“Disasters strike when you least expect them.” Japan has experienced many unexpected earthquakes, typhoons, volcanic eruptions, and other disasters, and has learned many lessons from them. We have been strengthening the immediate response structures such as DMAT since the Great Hanshin-Awaji Earthquake in 1995.

The Japanese Red Cross Society (JRCS) started their disaster relief in 1888. The JRCS has also been developing their disaster relief system and has dispatched ERU (Emergency Response Unit) Team to not only domestic but also international disasters in cooperation with the International Red Cross.

Once the disaster occurs, the gaps between medical needs and supply increase immediately and dramatically. To provide proper medical service to the victims, medical staff should initiate disaster medicine such as triage, treatment and transportation from just after the disaster has occurred. The aim of triage is to get the right patient to the right place at the right time with the right care provider. Then they treat post-triage victims at the health posts in the affected area or transport severely injured patients to proper hospitals outside the affected area.

The most common diseases for several days after the disaster are disaster-related injuries (Phase 1). Then the number of chronically ill patients increases gradually in the following several weeks (Phase 2). We should evaluate the needs of victims in each post-disaster phase, and provide proper services such as emergency medicine, treatment of chronic diseases, public health activity and mental health care.

The more the magnitude of the disaster increases, the more the medical staff has to be involved in relief activities. Whether or not neurosurgeons are inside or outside the affected area, we should always be ready to offer disaster relief according to the best of our ability and assignment. Neurosurgeons outside the affected area should be prepared to accept victims transported from the affected area.

The important issues of disaster preparedness for us are to prepare the disaster management plan before the disaster, and to train relief staffs regularly. When the disaster occurs, we should execute disaster management plan immediately and precisely as prepared. “There is no anxiety if we are prepared.”

In mammalian brain, young neurons generated from the subventricular zone of the lateral ventricle migrate tangentially along the rostral migratory stream (RMS) toward the olfactory bulb (OB), where they differentiate into mature neurons. In order to evaluate an initiation of neurogenesis induced by traumatic brain injury (TBI) in the rats, the response of neural precursors was investigated. The cortical contusion was induced by the controlled cortical impact device (CCI). The rats were injected bromodeoxyuridine (BrdU) intraperitoneally to label proliferating cells. The newly-generated neurons were visualized by doublecortin (DCX) immunohitsochemistry. Within several hours, the DCX expression appeared to be increased throughout the RMS. In such short periods, the upregulated DCX-expression was not accompanying increase in the number of BrdU-positive proliferating cells, suggesting that post-mitotic neural precursors could re-express developmental characteristics. Following transection of the OB, however, although a contusion existed beside the RMS, the DCX expressing young neurons appeared to remain in the RMS and never move to the injury sites. In addition, in order to examine a period of DCX expression in newly-generated neurons, an anti-proliferating agent, Ara-C was administered continuously into the lateral ventricle, the DCX immunoreactivity was disappeared completely within 14 days, indicating that the DCX could exist in the first 2 weeks from the beginning of neuronal proliferation. The results of the present study indicate that, although the neurogenesis in the SVZ-RMS-OB pathway can be enhanced readily in response to TBI, the most of newly-generated neurons do not contribute to the repair of trauma-induced tissue damages. Further study will be necessary to elucidate precise mechanism which regulates the migration and differentiation of endogenous neural precursors, which may lead to a novel therapy which improves functional outcome of the patients suffered from TBI.

Introduction: It has been known that the patients with ossification of the longitudinal ligament (OPLL) of the cervical spine sometimes present with acute spinal cord injury (SCI) after minor trauma. The purpose of this retrospective study is to clarify the role of the spinal canal stenosis by OPLL in the pathomechanisms of acute SCI associated with OPLL.

Materials: Twenty-five OPLL patients presenting with acute SCI treated in our hospitals were reviewed. Sagittal spinal canal diameters were measured using bone-window CT of the cervical spine. Frankel grade on admission ranged from A to D (A: 2, B: 1, C: 13, D: 9). As a control, 62 OPLL patients without SCI that were treated surgically or conservatively (anterior decompression 16, laminoplasty 26, conservative treatment 20) in our hospitals were similarly analyzed.

Results: The sagittal diameter of the spinal canal was reduced to 4.1–10.0 mm in the SCI patients. The Frankel A-C patients had significantly narrowed sagittal diameter than the Frankel D patients (6.4 ± 1.6 mm and 7.6 ± 0.8 mm, p=0.047). In the control OPLL patients, the sagittal diameter was reduced to 2.9 – 10.0 mm by OPLL. The degree of spinal canal narrowing was correlated with the neurological state of the patients. For example, 91% of the patients presented with motor deficits of lower extremities when the sagittal diameter became less than 5 mm. However, only 16% of the patients showed motor deficits of legs if the diameter was more than 8.0 mm.

Conclusions: This study demonstrates critical values and clinical importance of the spinal canal diameters in OPLL patients. Narrowed spinal canal by OPLL is one of important factors determining the severity of SCI. Surgical decompression in the acute stage will be a reasonable treatment option if the OPLL patient with SCI shows marked spinal canal stenosis.

Background and Propose: The initial assessment and early establishment of the goals of therapy remain of extreme important in the management of severe acute head traumas. The aim of this study is to determine the characteristics of the intracranial circulation by assessing the CPP and ICP in correlation with the CT findings. Based on this information, we sought to determine for each group of patients the appropriate choice of therapy along with the prognosis.

Methods: Retrospective study based on the medical records of 33 patients admitted with the diagnosis of severe head trauma with an initial GCS score of 8 or below. The results of the CT scan and the time courses of the CPP and ICP were assessed. All patients were categorized into three groups base on the CT scan findings: 1) patients with focal contusions (FC), 2) patients with a severe shift (more than 10 mm shifting of the mid cerebral structures) (SS), 3) patients with diffuse swelling and damage (DS).

Result: The maximum ICP in survival cases within 24 hours was 44.4 mmHg and no higher score patient could not survive. The average CPP in death case whose ICP was more than 45 mmHg was 16.8 mmHg. The mortality of cases with 80 mmHg in CPP higher was 4.8%, following: 40 – 50 mmHg = 45.5%, 30 – 40 mmHg = 28.6%, below 30 mmHg = 100%. ICP of FC group, with early intervention, kept below 34 mmHg and was well controlled. It improved at least 58 mmHg in 24 hours. Five of seven with ICP 35 mmHg higher after 12 hours showed no survival cases. B.P and CPP of those case were also remarkably low. Two of seven survival cases demonstrated to withdraw CPP 40 mmHg in 12 hours. In DS group, only these cases, which showed ICP below 15 mmHg, were survived.

Conclusion: The time course of the CPP and ICP varied with the CT findings. The prognosis of patients whose ICP was more than 40 mmHg was unsatisfactory. This result underlines the importance of the early establishment of the goals of therapy based on the initial CT findings.

In this study, we reviewed the results of treatment in patients with acute subdural hematoma (ASDH) who underwent emergency burr hole surgery in the emergency center, and investigated factors involved in the outcome. The subjects were 108 patients with ASDH who underwent surgery between January 1996 and October 2004, with a Glasgow coma scale (GCS) score of 8 or lower. They were divided into 2 groups: patients who underwent emergency burr hole surgery in the emergency center, and patients who underwent elective craniotomy. We assigned 17 patients who underwent craniotomy after emergency burr hole surgery (16%) to Group A (burr hole surgery + craniotomy), 47 patients who underwent emergency burr hole surgery alone (43%) to Group B (burr hole surgery alone), and 44 patients who underwent elective craniotomy (41%) to Group C (craniotomy alone). In these patients, we investigated age, GCS score at arrival, interval until surgery, mechanism of injury, CT findings, injury severity score (ISS), presence or absence of reflex to light, presence or absence of shock, and treatment results, and analyzed the correlation between technique and each parameter. Subsequently, patients with a good outcome were compared to those with a poor outcome with respect to each factor. The outcome was evaluated based on Glasgow outcome scale (GOS) scores on discharge; patients with good recovery (GR) or moderate disability (MD) were regarded as achieving a favorable outcome, and those with severe disability (SD), vegetative state (VS), or who were dead (D) were regarded as achieving a poor outcome. Of the patients who underwent emergency burr hole surgery (Group A + Group B), 10 (16%) showed good outcomes. The survival rate was 31%. Good outcomes were achieved in 7 patients (41%) in Group A, in 3 patients (6%) in Group B, and in 14 patients (33%) in Group C. The survival rates were 76%, 15%, and 61% in Groups A, B, and C, respectively. Concerning technique, the proportion of patients aged more than 70 years, the proportion of patients with a GCS score of 4 or lower, the proportion of patients with the disappearance of reflex to light, and the incidence of shock in Group B were significantly higher than the values in Group C. In Group A, the number of patients in whom the interval from arrival until the start of surgery was 30 minutes or less was significantly larger than that in Group B. Five factors influenced the outcome: age (patients aged more than 60 years showed poor outcomes), GCS score at arrival (patients with a GCS score of 6 or lower showed poor outcomes) mechanism of injury (patients who were injured in a traffic accident showed poor outcomes), reflex to light (patients with the disappearance of reflex to light showed poor outcomes), and CT findings (patients with t-SAH showed poor outcomes).

A 42-year-old Asian female with known moyamoya disease, clinically revealed as cerebral infarction and had been undergone bilateral EDAS (encephalo-duro-arterio-synangiosis) and single burr-hole operation in her right frontal region 12 years before, developed an acute subdural hematoma after head trauma in a traffic accident. Craniotomy preserving the site of EDAS was performed to remove hematoma. Transcranial anastomosis through a burr hole in her right frontal region for the purpose of neo-vascularization (burr-hole operation) was the main source of bleeding. Angiography performed postoperative day 11 showed that anastomoses of EDAS were preserved. Postoperative course was satisfactorily, she made full recovery and was discharged on postoperative day 22 in good condition as before the traffic accident. Only left side MMT (Manual Motor Testing) 4/5 weakness as before remained. This is the first report of acute subdural hematoma caused by the rupture of a transcranial anastomosis through a burr hole of burr-hole operation as well as the first report of good recovery in a patient with moyamoya disease underwent craniotomy for acute subdural hematoma. In this case, preserving the site of EDAS during the operation resulted in good outcome.