Treatment of severe head injury is still controversial despite various treatment modality has been conducted. In this study, the recent status of the treatment for the severe head injury was analyzed from the data of the Project 2004 (P2004) in the Japan Neurotrauma Data Bank (JNTDB).

Among 912 cases registered in the P2004, 696 cases (76%) with a Glasgow Coma Scale (GCS) score 8 or less on admission were enrolled in this study. Those were divided into 3 groups, according to the CT findings of the Traumatic Coma Data Bank: Diffuse injury (DI) in 293 cases, mass lesion (ML) in 385 cases, and unknown in 8. The clinical features, the treatment and the outcome were compared with those in the Project 1998 (P1998).

Results: 1) Patient's age was older in the P2004, but GCS score, injury severity score, and the proportion of DI and ML did not differ significantly between two groups. 2) Prescription of hyperosmotic agent and anticonvulsants, and barbiturate therapy were less frequent in the DI group of the P2004. On the other hand, hyperosmotic agent was less frequently given and hypothermia was less conducted in the ML group. 3) Evacuated mass was significantly decreased in the P2004. In addition, both internal or external decompression and ventricular drainage were less performed in the P2004. Placement of an intracranial pressure sensor was also less common in the P2004. 4) Outcome at discharge: Mortality rate was reduced in both the DI and the ML groups of the P2004.

These results suggested that the active treatment for the severe head injury had been reduced recently, but the mortality had been also decreased. The reason of these data was unable to be interpreted, so that further study will be necessary to establish the recent trend of the treatment.

Spontaneous intracranial hypotension (SIH) has become a well-recognized syndrome. However, diagnosis of SIH is still challenging. The problem with SIH is that the precise mechanism of cerebrospinal fluid (CSF) leakage remains largely unknown and there is no only definite criterion in the diagnostic imaging.

In this report, the author reviews on the pathophysiology of CSF leakage, clinical symptoms, findings of imaging studies, diagnostic criteria, and management of SIH.

The author mentions current controversy about the diagnostic criteria for patients managed as a posttraumatic CSF hypovolemia in Japan, and proposes the most adequate diagnostic criteria for CSF leaks and SIH.

Intracranial hypotension (IH) is a rare condition caused by leakage of cerebrospinal fluid (CSF). Recently, a small number of clinicians have proposed a new concept about IH following minor head injury. They suggest that many of their patients with IH can be successfully treated with epidural blood patch therapy. They also argue that some patients with post-traumatic cervical syndrome and general fatigue syndrome suffer from IH following minor head injury. Consequently, IH following minor head injury was widely recognized and dealt with as a social problem in Japan. On the other hand, pathophysiological aspects of the condition as well as the provisional criteria to describe this clinical entity remain to be elucidated. In 2006, the Japan Society of Neurotraumatology performed a questionnaire survey asking 44 hospitals belonging to trustees of this society about IH following minor head injury. This paper provides a report of the outcomes of this survey.

The response rate to this questionnaire was 57% (25/44). Fifty-six percent of respondents did not have experience of IH following minor head injury. Moreover, respondents' criteria for describing this disease differed greatly, especially in the radiological examinations and symptoms for the diagnosis of this entity which showed significant variation. These problems might originate from the general features of this disease. With the exception of postural headache, the symptoms of this disease varied enormously. This wide range of symptoms confused with the pathophysiolosies of a great many similar conditions. As such, clarifications of the pathophysiological characteristics of IH following minor head injury, together with consensus on specific criteria to describe the condition, are required.

In conclusion, the results of this survey revealed many serious scientific and social problems associated with the diagnosis and treatment of intracranial hypotension following minor head injury. Scientific study including the performing of randomized controlled trials, is important if agreement is to be reached on the proper identification of this clinical entity.

In order to clarify clinical characteristics of "traumatic" intracranial hypotension (TIH) treated in Japan, 100 Japanese articles were reviewed and compared to 201 foreign articles. The results revealed the features of TIH in Japan as follows; 1) prolific numbers of the reported cases (227 cases) (foreign cases; 15 cases), 2) high incidence (69%) of traffic accident as a cause of injury (foreign cases; 20%), 3) long periods from injury to diagnosis; more than 1 year in many cases, 4) CSF leakage from lumber regions in vast majority cases (foreign cases: cervicothoracic regions; 91%), 5) fewer cases (55%) showing postural headache (foreign cases; 86%), 6) fewer cases (49%) showing dural enhancement on Gd-MRI (foreign cases; 93%), 7) fewer cases treated conservatively (foreign cases; 71%), 8) high numbers of blood patch procedure per patient, 9) lower cure rate (22%) by blood patch procedure (foreign cases; 100%). These results suggest that the clinical entity of TIH treated in Japan differs from that treated in foreign countries.

The role of diagnostic imaging for intracranial hypotension consists of definitive diagnosis of intracranial hypotension and detection of cerebral spinal fluid (CSF) leakage. Magnetic resonance imaging (MR) is the initial modality of choice for patients with symptoms suggesting intracranial hypotesion. Dural enhancement on postcontrast spin-echo T1-weighted imaging and subdural effusion on fluid attenuated inversion recovery are essential findings of the diagnostic criteria. MR myelography is a noninvasive method to detect CSF leakage; however, extradural hyperintensity on MR myelography is non-specific for CSF. Fat-saturated axial T2-weighted imaging and postcontrast axial T1-weighted imaging should be added to confirm CSF leakage.

Background and Purpose: We investigated recent changes in clinical characteristics of acute subdural hematoma (ASDH) in abused infants.

Patients and Methods: In recent 5 years, we experienced 7 abused infants with ASDH (recent group). Clinical characteristics of infants were compared with other 6 abused infants with ASDH who were experienced between 10 and 15 years ago (previous group). Age, gender, assailants, methods of abuse, symptoms, sites of ASDHs, traumatic lesions other than head injuries, treatments, and outcome were reviewed from medical records to compare between groups.

Results: Most patients were male in late period of infancy, and were delayed in consulting to a medical doctor in both previous and recent groups. The most common assailant was mother in the previous group, although they were fathers or mothers' boy friends in the recent group. Being dropped or thrown was the most common cause of injury in the previous group, shaking was the most common in the recent group. Injuries on the body surface were common finding in the previous group, although they were rare in the recent group. As sites of subdural hematomas, supratentorial vault was the most common in the previous group, supratentorial interhemisphere was the most in the recent group. In chronic stage after ASDHs, severe brain atrophy was common in both groups, suggesting poor functional outcome.

Conclusion: Recent clinical characteristics of abused infantile ASDH was different from classical those in Japan, and were similar to those in Western countries.

Objective: The diagnosis and managements of the head injury in battered children are greatly complicated by medical history and the mechanisms of injury. In the present study, we evaluated the clinical features of the head injury in battered children.

Methods: Clinical signs and symptoms, the mechanisms of injury, intracranial pathology, and prognosis of 25 battered children with head injury treated between 1984 and 2003 were retrospectively analyzed.

Results: The age of 25 children was between 1 month and 2 years old. The average of the ages was 7 months old. In 68% of 25 patients, the age was 6 months or less. The medical history of head injury was unclear in 16 children. The chief complains were disturbance of consciousness, convulsion, vomiting and hypothermia. Retinal hemorrhages were recognized in 88% of the patients and these were bilateral in 68%. Acute subdural hematomas (19 cases) and chronic subdural hematomas (6 cases) were shown on CTs or MRIs. In four cases, cerebral contusions were complicated as intracranial pathology. In 44% of the patients, the hypoxic-ischemic injury was confirmed on CTs or MRIs. Fractures of limbs and ribs were recognized on skeletal survey in 40% of the patients. 71% of 17 survival cases had moderate or severe psychomotor disabilities at the end of follow-up periods.

Conclusion: In children under 2 years of age with subdural hematomas, clinical investigations other than CT and MRI, included ophthalmoscopy by opthalmologist and skeletal survey, are crucial and mandatory for early diagnosis of the child abuse.

We investigated the characteristics of types of disability, ways of evaluation, possible age of evaluation, and recommended neuropsychological tests for evaluation after traumatic brain injury in young children. Participants were 40 children under 6 years of age at brain injury. They were divided into 3 groups. Group I: 20 cases with severe disability, group II: 15 cases with mild to moderate disability, group III: 5 cases without disability. After checking both their condition during acute stage and detail of disability at present, each group was compared. Glasgow coma scale was significantly low in group I. Subdural hematoma was frequent in group I and diffuse brain injury was frequent in group II. Diagnosis of disability was almost possible at one year after brain injury in group I and III. It was impossible to diagnose the severity of disability in group II because evaluation of higher cortical dysfunction such as attention deficit, emotional dys-adjustment or memory disturbance was difficult. Wechsler Intelligence Scale for Children-III test and Kaufman Assessment Battery for Children were the most recommended tests for evaluation.

The incidence of child abuse has been increasing recently, and the frequency of clinical encounters with abused children is rising. Shaken baby syndrome (SBS), in which intracranial hemorrhage or eyeground hemorrhage are caused by excessive shaking of infants, is attracting attention as an injury closely related to infant abuse. In this report, a patient with SBS who developed status epilepticus during the course is presented.

Patient: The patient was a 3-month-old male admitted with a primary symptom of convulsion. Disturbance of consciousness (JCS3) was noted on arrival, and head CT disclosed subdural hematoma along the falx cerebri and brain swelling over a wide area of the bilateral occipital lobes. Eyeground hemorrhage was noted bilaterally. The parents' description of the cause of injury was unclear, and imaging and funduscopic findings suggested SBS. Since the patient showed status epilepticus on admission, he was intermittently administered drugs including midazolam, but convulsion was not completely resolved. On the 3rd hospital day, convulsion was finally suppressed by the continuous administration of thiopental after securing the airway by tracheal intubation. However, brain atrophy progressed rapidly thereafter, disturbance of consciousness persisted, and development was delayed. SBS is an injury with a 15% mortality rate, but, as it mostly occurs in infancy, the outcome of the injury is more likely to be affected than those of adult injuries by complications such as secondary hypoxia and convulsion as well as the primary damage to the brain. In this patient, also, increased intracranial pressure due to brain edema and the persistence of status epilepticus are considered to have led to the rapid progression of brain atrophy. Physical abuse is the most frequent form of abuse in victims of child abuse encountered at the outpatient clinic, and, as abused children often sustain head injuries, in particular, opportunities in which neurosurgeons examine abused children are increasing. Therefore, it is important for neurosurgeons to consider SBS due to abuse in examining infants with head injuries. It is also necessary to begin systemic management including respiratory management more resolutely and earlier than in adults.