Recent studies have been shown that levels of matrix metalloproteinase-9 (MMP-9) increase after traumatic brain injury (TBI), degrading components of the basal lamina disrupting the blood-brain barrier. We measured the concentration of MMP-9, tissue inhibitor of matrix metalloproteinase-1 (TIMP-1), and interleukin-6 (IL-6) in blood after TBI. Samples were collected from systemic arterial and jugular venous blood from seven patients with severe TBI on days 0 and 1 post-injury. All patients underwent hypothermia as soon as possible after admission. Before induction of hypothermia, level of MMP-9 exceeded the normal range, however, level of TIMP-1 was below the normal range. On day 1, MMP-9 levels in arterial blood and internal jugular venous blood decreased significantly, to within the normal range. In addition to these changes, a significant correlation was seen between levels of MMP-9 and IL-6 in internal jugular venous blood during the investigation period. These results indicate that imbalance between MMP-9 and TIMP-1 may contributes to the pathophysiology of TBI. MMP-9 is induced by inflammatory events following TBI. Hypothermia may suppress the elevation of MMP-9 with suppression of the inflammatory response.
Back ground: There have been few Japanese literatures or textbooks about the assessment and management of sports-related concussion. The 2nd international conference on concussion in sport was held at Prague in 2004, and the summary and agreement of this meeting was published in many major journals.
Purpose: The authors intended to introduce and summarize the concept of “Summary and agreement of the 2nd international conference on concussion in sport, Prague 2004”. SCAT (Sport concussion assessment tool) was also translated into Japanese in order to distribute to many sports-related fields.
Summary: Back ground issues, a new classification of concussion in sport, clinical issues, investigational issues, concussion management, and other issues were summarized. The SCAT card was found to have some parts which are supposed be modified for adopting in Japanese sport field.
Conclusions: Many issues of sport concussion as well as revised SCAT card should be continually announced and/or distributed to medical doctors, other medical staffs, and coaching staffs in order to promote higher standard of care.
Medical services for trauma patients have been recently promoted to management in emergency medical centers from individual consultation with a doctor on call. In general, in emergency medical centers, emergency doctors and/or trauma surgeons initially treat trauma patients, and then doctors from specialized departments are involved as needed. Here, we address some issues related to the management of trauma patients at emergency medical centers and report the current status of our system.
To manage trauma patients, especially multiple traumas characterized by pathophysiological diversity, we have established the trauma team, to provide comprehensive acute care to trauma patients suffering vital or potentially vital injuries, i.e., head and/or trunk injury. The initiative to establish the trauma team was taken by a trauma surgeon. From the point of view of organ-specific expertise for the surgical treatment, the team includes a trauma surgeon for the surgical management of trunk injuries and a neurosurgeon for the management of brain injuries. Firstly, doctors must be on standby in the Emergency Department at all times to attend to trauma patients. The ER physicians also participate in the initial stabilization and evaluation of trauma patients. At our Emergency Department in 2004, 40% of 3212 outpatients and 45% of 240 inpatients were categorized as trauma patients. Over half (56%) of these trauma inpatients suffered from head injuries. Acute care for the head injury patients with CT abnormalities (34% of the trauma inpatients) was provided by the trauma team which includes neurosurgeons. Neurosurgery for intracranial hematomas was performed in 8% of the trauma inpatients.
Definition of therapeutic plans for patients with multiple traumas is an important issue. To review the acute management in trauma patients with head injury, we applied TRISS as a clinical indicator of the prognosis and the indications for surgery in 30 consecutive cases with severe acute subdural hematoma (ASDH). We evaluated the physiological status of the patients, which was expressed as the Revised Trauma Score, at the time of the neurosurgical consultation. The overall mortality of the cases was 73%, while in the patients with the probability of survival (Ps) score of over 0.5 as calculated by TRISS, it was 50%. Furthermore, there was significant difference in the Ps score between cases who underwent surgical treatment and those who did not, with average Ps scores of 0.56 and 0.39, respectively. Therefore, a cutoff Ps score of 0.5 may be useful for objectively reviewing the indications for neurosurgery in patients with ASDH.
In 5 seasons of the past, 2107 persons visited to our hospital with head injury caused by snowboarding. We analyzed them using questionnaire and findings at examination about the receiving technical guidance and the degree of head injury. Among them, we analyzed 1865 persons, except the cases where others collide during stillness, unrelated to their skill level. We classified them from the slight injury to the serious injury into three stages (Type 1: without neurological deficit, Type 2: transient consciousness disorder or amnesia without organic change, Type 3: organic change). 55% of them were received technical guidance.
The people who have not received technical guidance, had more serious head injury. The significant difference was accepted between receiving of the technical guidance and the degree of head injury (p<0.01 by Wilcoxon rank sum test, p<0.05 by χ2 test). In the examination according to technical level, the beginners' class person without technical guidance were sustained more severe head injury. There was significant difference was accepted (p<0.05 by χ2 test).
In order for receiving of the technical guidance of snowboarding to lead to decrease of severe head injury and to perform a snowboard more safely.
Pulmonary complications are the most common cause of death in patients with acute tetraplegia. However generally, surgeons are cognizance of infection after anterior cervical spine procedures in acute spinal cord injury patients after or immediately before the placement of tracheostomy. Two patients had both anterior cervical spine surgery and tracheostomy performed in this term by using the following devices. No patients had infection after surgery. Our devices are as follows: (1) When the operation area of anterior cervical spine surgery is performed, the pretracheal fascia is not opened. (2) When the anterior cervical spine surgery is performed after tracheostomy, the operation area and the tracheostomy area are isolated by draping. (3) Incisions made must have as maximum a distance as possible between the areas of anterior cervical spine surgery and tracheostomy. If both anterior cervical spine surgery and tracheostomy are performed in short term, it is necessary that the device is implemented for the case of anterior cervical spine surgery with a spinal cord injury requiring tracheostomy.
Recently brainstem lesions after head injuries observed in magnetic resonance (MR) images are considered as not an exceptional phenomenon. Usually most of the cases of brainstem injuries were included with other brain contusions as a result of shearing head injuries. Solitary brainstem injury, however, is still considered as rare event and its developing mechanism remain also unclear.
A 56-year-old-male was involved in an accident collapse of tunnel. Neurological examination on arrival to our hospital revealed mild disorientation without apparent focal deficits. Computed tomography (CT) showed solo small contusion at medial upper pons without skull fracture. Cervical X-ray picture showed tear-drop fracture of C7 vertebral body and fracture of C6 lamina. After a little while, he went into a comatose state, which revealed anisocoric non-reactive pupils, both limitation of ocular movements and tetraparesis. Follow up brain CT showed marked enlargement of the contusional hematoma of pons extended to midbrain. Spinal cord injury could not be observed in cervical MRI. Conservative medical management was performed. Neurological status did not improved significantly after two months.
This rare injury was suggested to be the sole influence of the cervical hyperflexion. Present case implies that stretching force can lead to a solitary brainstem injury.