Neurosurgery has been considered a high–risk specialty. According to judicial precedents, the cerebral aneurysm and other cerebrovascular disorder have the majority to the number of the malpractice litigations, and the head injury is 20% or less. The purpose of this study was the analysis of diagnostic and therapeutic malpractice litigation in the field of neurotraumatology. Five litigation cases were assessed using recent judgments of Japanese courts. Two cases were sued despite defensible managements at the acute stage of trauma. Other 3 cases were suits for inadequate treatment based on failed diagnosis at the chronic stage. On the basis of previous judgments, some considerations and recommendations are suggested for subsequent litigation.

To clarify the clinical characteristics of definite and non-definite diagnosis groups in intracranial hypotension accompanied by trauma (IHAT), we undertook investigations of registered patients (n=23) prospectively. The results revealed the following features of IHAT: 1) definite diagnosis group, 4 cases; 2) they had long periods from injury to onset (5.5±5.7 days), but these were markedly shorter than in the non-definite group; 3) 75% of definite cases showed typical postural headache; 4) 75% of definite cases showed dural enhancement on Gd-MRI; 5) all 4 cases had confirmed CFS leakage based on imaging diagnosis with cervical lesions in 2 cases and cervical-thoracic lesions in 2 cases; and 6) good recovery was achieved in them by conservative therapy and blood patch, with a cure rate of 100%. These findings suggest that confirmed CFS leakage is indispensable for reaching definite diagnosis of IHAT.

Kirara Club opened in 2001 as a rehabilitation facility for people with higher brain functional disorders.

Currently, a total of 38 people with higher brain functional disorders are participating in the job training support program. Among them, 29 are males, which is 76.3% of all participants.

The people with higher brain functional disorders, who come to Kirara Club, go through “Life Model Rehabilitation.” We developed the “Life Model Rehabilitation” based on the social work practice model.

More than 10 people have been employed as regular workers in the last 9 years, since 2001. Additionally, more than 15 people were qualified as care workers, and two people obtained chef licenses.

From now on, it is essential to have more facilities that support people with higher brain functional disorders, and a system where handicapped people can work more in society.

Study to higher cortical dysfunction after traumatic brain injury in children has hardly been carried out though such area has already been arranged in adults.

We investigated higher cortical dysfunction in children with traumatic brain injury who were achieved rehabilitation in our hospital during recent 5 years. The objects were 88 children average age 8 years 2 month at brain injury, and average age 13 years 6 months at present. The causes of brain injury were traffic accidents 76 cases, falls 8 cases etc. The types of injury were duffuse brain injury 37 cases, contusion 24 cases, acute subdural hematoma 19 cases etc. The types of higher cortical dysfunction were attention deficit 61 cases, memory disturbance 59 cases, poor emotion regulation, poor exective processes, poor social relationship etc.

The first step for dealing with higher cortical dysfunction should be correct assessment by observation and neuropsychologic examinations. The basic way for intervention is to make suitable programs through suficient understunding to his/her own problems according to the assessment, and continue to achieve them in daily life. Making shot term targets such as for 3 months, and long term targets such as 1 year is useful. Exercises should be practical, clear, interisting, and not too difficult. Training should be gradual and evolutional approach. Envilonment should be arranged properly. Also cooperation between home and school is very important. It is useful for them to be trained by the programs for children with developmental disabilities.

33 patients in chronic phase individuals (26 men, 7 women) with higher cognitive dysfunction (HCD) were administered antidepressants, mood-stabilizers and antipsychotics for the treatment of social behavior disturbance (agitation, depression, etc.). A questionnaire for their caregivers was used to examine effectiveness of these medications retrospectively. As a result, antidepressants and mood-stabilizers were effective in reducing agitation and anger. In addition, antidepressants were effective in improving depression. In the future, prospective studies are needed to determine the usefulness of each drug alone, and to establish administration procedures specialized for the treatment of HCD.

In patients with mild traumatic brain injury (MTBI), higher brain dysfunctions which consist of cognitive impairments such as memory, attention, performance and social behavioral disturbances could be rarely apparent. However, higher brain dysfunctions should be identified by neuropsychological tests and supported by a social welfare for handicapped patients. Acknowledgement of higher brain dysfunctions after MTBI without obvious brain damages on morphological neuroimagings could be a social issue under controversy. An imaging of cortical neuron damages in patients with higher brain dysfunctions after MTBI was studied by functional neuroimaging using ¹²³I-Iomazenil (IMZ) SPECT.

Statistical imaging analyses using 3 dimensional stereotactic surface projections (3D-SSP) for ¹²³I-IMZ SPECT and ¹²³I-IMP SPECT as CBF studies were performed in 11 patients with higher brain dysfunctions after MTBI. In all patients with higher brain dysfunctions defined by neuropsychological tests, cortical neuron damages were observed in bilateral medial frontal lobes, but reduction of CBF in bilateral medial frontal lobes were less obviously showed in 8 patients (apparent in 3 and little in 5). Group comparison of 3D-SSP of ¹²³I-IMZ SPECT between 11 patients and 18 normal controls demonstrated significant selective loss of cortical neuron in bilateral medial frontal gyrus (MFG). Extent of abnormal pixels on each cortical gyrus using stereotactic extraction estimation (SEE) for 3D-SSP of ¹²³I-IMZ SPECT confirmed that 8 patients had abnormal pixel extent >10% in bilateral MFG and 5 patients had abnormal pixel extent >10% in bilateral anterior cingulate gyrus.

In patients with MTBI, higher brain dysfunctions seems to correlate with selective loss of cortical neuron within bilateral MFG which could be caused by Wallerian degeneration as secondary phenomena after diffuse axonal injury within corpus callosum. Statistical imaging analysis using 3D-SSP for ¹²³I-IMZ SPECT could be valuable for diagnosis of higher brain dysfunctions without obvious brain damages on morphological neuroimagings in patients with MTBI.

This study was conducted to identify the regional neuronal loss in patients with neuropsychological impairment following traumatic brain injury (TBI) compared with normal control subjects. We performed ¹¹C-flumazenil positron emission tomo­graphy (FMZ-PET) study using 3D stereotactic surface projection (3D-SSP) statistical image analysis in 5 patients with diffuse brain injury and 2 patients with evacuated mass lesion (mean 24.5±6.3, range 19 – 36 years). Nineteen healthy control sub­jects (mean 24.9 ± 4.0, range 20 – 34 years) were studied to obtain the normal data base for 3D-SSP. Group comparison between 5 diffuse TBI patients and 19 control subjects showed a significant regional low FMZ uptake in the bilateral medial frontal gyri, the anterior cingulate gyri, and the thalamus. Individual analysis also showed decreased FMZ uptake in these regions; however, the distribution and degree of low FMZ uptake were different in each individual case. On the other hand, patients with evacuated mass lesion showed severe focal low FMZ uptake comparable to the area of cortical damage. Diffuse TBI uniformly induces neuronal loss or decreased neuronal density in the medial frontal cortex and the thalamus, which may be related to underlying cognitive impairment after TBI. Future studies to confirm a common area of focal neuronal loss and a direct correlation to the neuropsychological test may validate the use of FMZ-PET for the functional diagnosis of neuropsychological impairment after TBI.

Objective: This study investigated longitudinal changes in cognitive dysfunction in patients with traumatic brain injury (TBI).

Methods: Ninety five patients with TBI of variable Glasgow Coma Scale (GCS) scores initially underwent examinations within three months of the TBI (early stage; mean 1.9±1.6 months). They underwent follow-up examinations within 36 months of the TBI (late stage; mean 16.9±6.9 months). The 95 patients were divided into two groups by GCS, the mild TBI (GCS 13 – 15, 57 patients) and the non-mild TBI (GCS 3 – 12, 38 patients) groups. The following neuropsychological tests were used to evaluate the cognitive dysfunction: the Wechsler Adult Intelligence Scale-Revised (WAIS-R) evaluating intelligence, the Wechsler Memory Scale-Revised (WMS-R) evaluating memory, and the Wisconsin Card Sorting Test Keio version (KWCST) evaluating executive dysfunction.

Results: The verbal intelligence quotient (IQ) and the performance IQ were evaluated. The average IQ of the mild TBI group was within the normal range, but the average IQ of the non-mild TBI group was lower at the early stage. Both averages recovered to the normal range at the late stage. The logical memory and the visual reproduction from the WMS-R subtests were evaluated. The averages of the mild TBI group and of the non-mild TBI group were within the normal range at the early stage, and both averages also recovered to normal at the late stage. Both average KWCST scores of the mild TBI group and of the non-mild TBI group were lower at an early stage. They also recovered, but they remained abnormal at the late stage.

Conclusions: These findings suggest that neuropsychological tests of executive dysfunction, i.e. the KWCST, may provide more sensitivity for the diagnosis of cognitive dysfunction and may lead to early rehabilitation and support for more patients.

Blast wave (BW) is generated by explosion and is comprised of lead shock wave followed by subsequent supersonic flow. In addition to civilian traumatic brain injury (TBI) mechanisms, pressure induced damage accounts for the occurrence of blast-induced TBI (bTBI). Fracture, hemorrhage, massive and rapid edema progression, and cerebral vasospasm characterize clinical findings of bTBI in the acute phase, whereas cognitive dysfunction and posttraumatic disorder does in the chronic period. Since BW is invisible, and impacts brain in extremely short period of time in contrast to direct impact and penetrating mechanism injury, it is difficult to recognize for the victim to being suffered clinically. In addition, there have been few animal model that can be conducted in the laboratory and validated in terms of SW physics, which precluded us from understanding mechanism and pathophysiology of bTBI.

On the other hands, we have successfully formed organized infrastructures and accumulating knowledge of SW and BW at Institute of Fluid Science since 1980s both for engineering issues and medical application. Our translational research platform now covers broad range of issues related to SW (BW) and brain injury, including development of clinically relevant bTBI model as a bedside to bench approach, development of surgical instrument applying shock bubble interaction (one of the mechanism of SW-induced tissue injury) as a bench to bed­side approach. The medical instrument is now clinically ap­plied in neurosurgery as laser-induced liquid jet, and showed certain advantage over conventional surgical instruments. Efforts to bring the system into minimally invasive surgery and to expand the application in endoscopic surgery became our current steps.

In the present article, we describe the mechanism of bTBI and current research problems from the perspectives of SW physics. We also describe our translational research platform aiming to facilitate understanding of TBI and improvement in clinical practice of TBI.

Objectives: It is important to provide treatment that cor­responds to changes in intracranial pathophysiology after traumatic brain injury (TBI). Neuromonitoring as a means to understand such changes was examined in this study.

Method: Severe TBI patients with Glasgow Coma Scale scores of 8 or less on admission underwent hypothermia while monitoring intracranial pressure (ICP), jugular venous oxygen saturation (SjO₂), and brain temperature. Management of the TBI patients conformed to guidelines. The difference between brain and bladder temperature was defined as ∆T.

Results: During hypothermia the value of SjO2 in diffuse brain injury patients significantly decreased to 56.6 ± 9.3 (%) in com­parison to evacuated mass patients (75.4 ± 6.4). The average tem­perature when ICP reached its highest value during the re-warming period was 34.9 ± 0.2˚C. Although the required time for re-warming from 34˚C to 35˚C was 56.3 hours, the required time from 35˚C to 36˚C was extended to 75.4 hours. The SjO₂ values (%) in three cases in which ICP was 30 mmHg or more during the re-warming period were, respectively, 95, 90 and 48. ICP was controllable after correspondence with hyperemia or ischemia was determined. A significant correlation between ∆T and SjO₂ was seen in patients with closed craniums.

Conclusion: SjO₂ measurement in TBI patients is useful for understanding abnormalities in cerebral blood flow and metabolism without high ICP. ICP could be controlled after appropriate treatment that conformed to SjO2 values. The brain and bladder temperature monitoring can provide an index of cerebral blood flow.

Objective: The intracranial pressure (ICP) monitoring has been recommended in Japan Society of Neurotraumatology (JSNT) Guidelines, and the cerebral perfusion pressure (CPP) oriented therapy has been performing to prevent the secondary ischemic brain damage in many institutions for the management of severe head injury. Although the optimal CPP value is recommended as over 60 – 70 mmHg in JSNT guidelines, there is no clear evidence. To determine the optimal CPP level in severely head-injured patients, the cerebral perfusion and brain metabolism were measured with microdialysis.

Methods: In severe head injury patients (GCS≦8), the value of ICP and CPP were monitored hourly for 7 days. Glucose, lactate, pyruvate, glycerol, and glutamate in dialysate were analyzed hourly with the microdialysis method. And the lactate/pyruvate (L/P) ratio which indicated the degree of ischemic brain damage was calculated in each case.　 Moreover, the values of these biochemical parameters were compared between groups divided by CPP value.

Results: The value of glucose was highest in the group of 71 – 80 mmHg of CPP group. The value of lactate, glycerol, and glutamate decreased according with the increasing of CPP value. When the CPP value decreased below 60 mmHg, the value of lactate, glycerol, and glutamate increased abruptly. These result suggests that the optimal CPP level seemed to be over 60 mmHg. However, with the evaluation of the optimal CPP value by analyzing the relationship between CPP and L/P ratio, the optimal value was different individually in each case. In addition, the pressure reactivity index (PRx) and the CPP/glucose slope, which should express the degree of impaired autoreguration, also varied in each case.

Conclusion: Our study suggested that the optimal CPP level is different in each case, and the variously impaired autoregulation is one of the factors which largely affect optimal CPP value. The direct monitoring of cerebral perfusion and brain metabolism with the microdialysis method might be useful to determine the optimal CPP levels in severely head-injured patients.

Objective: In our country the spinal injury of the thoracolumbar region are not rare. We report our experiences of spinal surgery for thoracolumbar spinal injury.

Methods: Eighteen cases of thoracolumbar spine injury treated in our hospital between November 2006 and October 2009 were analyzed retrospectively. Their average age was 67.5 years old (ranging 28 – 90). There were twelve males and six females. Two groups were further classified as osteoporotic vertebral body fracture, twelve cases and non-osteoporotic fresh spinal injury, six cases. Osteoporotic type were treated with vertebroplasty and/or posterior decompression and fixation using in­stru­mentation. Fresh non-osteoporotic type were treated with posterior decompression and fixation using instrumentation.

Result: There were no surgical complications such as neural or vascular injury, or infection.

Conclusion: Authors presented the surgical method and advantages of vertebroplasty and instrumentation surgery in the treatment of patients with thoracolumbar spinal injury. Careful definition of the bony injury and instability and acknowledgment of instrumentation surgery is crucial for correct surgical planning and satisfactory outcome.

Object: Previous studies have shown a relationship between lesions and clinical outcome among patients with diffuse axonal injury. However, there have been a few numbers of data about insulted anatomical points of corpus callosum. The aim of this study is to know the clinical characteristics and outcome were affected by the type of lesion of the corpus callosum in patients with diffuse axonal injury.

Methods: A retrospective, single-institution study involving 37 Japanese patients with diffuse axonal injury among 304 patients with blunt head trauma was conducted between July 2003 and May 2009. Bivariate analyses were performed to evaluate clinical characteristics and outcome according to each type of lesion of the corpus callosum in patients with diffuse axonal injury.

Results: Among the 37 patients with diffuse axonal injury, 19 had corpus callosum injury. Patients with lesion of corpus callosum had a lower one-year extended Glasgow outcome scale in patients with diffuse axonal injury. There were five, seven, and seven patients, with lesions of genu, body, and splenium of the corpus callosum, respectively. Patients with lesion of the genu were significantly older, and had a lower one-year extended Glasgow outcome scale in patients with corpus callosum injury (P<0.05) by bivariate analysis.

Conclusions: Lesion of the genu of the corpus callosum may be related to poor 1-year clinical outcome in patients with diffuse axonal injury.

Background and Purpose: Atlantal arch defects are rare. The purpose of this paper is to investigate the incidence and clinical implications of these, using Cervical CT with traumatic patients.

Methods: A retrospective review of 1,534 cervical spine computed tomography (CT) scans was performed to identify patients with atlantal arch defects. Posterior arch defects of the atlas were grouped in accordance with the classification of Currarino et al.

Results: Posterior arch defects were found in 7 (7/1534, 0.44%) and anterior arch defects were found in 2 (2/1534, 0.13%) of the 1,534 patients. The type A posterior arch defect was found in 5 patients and the type B posterior arch defect was found in 2 patients. No type C, D, or E defects were observed. One patient with a type B posterior arch defect had an anterior atlantal-arch midline cleft. Associated cervical spine anomaly was not observed in our cases. None of the reviewed patients had neurological deficits because of atlantal arch defects.

Conclusions: Most congenital anomalies of the atlantal arch are found incidentally during investigation of neck mass, neck pain, radiculopathy, and after trauma. Almost cases of atlantal arch defects are not need to operate. But it is important to note some cases require surgical treatment.

Hinge craniotomy (HC) is a new technique of decompressive surgery used in our facility for 16 patients from September 2008 to September 2009. Two of the 16 patients were changed to conventional decompressive craniectomy (DC) because intra­cranial pressure (ICP) during operation was over 25 mmHg. Both patients died after surgery and another patient died of pneumonia. Mean ICP of the remaining 13 patients was 13.2 ± 1.0 mmHg before craniotomy and significantly reduced to 5.1 ± 5.7 mmHg at the end of surgery (P<0.05). Two of these 13 pa­tients also received additional DC after HC because brain herniation worsened. Therefore, 11 patients were successfully treated with HC. In contrast, 17 patients underwent DC from August 2007 to August 2008, but 5 of the 17 patients died after surgery. Therefore, 12 patients were treated with DC. Retrospective review was conducted of 11 patients with HC and 12 patients with DC. Mean postoperative ICP was 6.4 ± 6.0 mmHg after HC and 6.3 ± 6.1 mmHg after DC. Postoperative improvement in midline shift on computed tomography showed no statistical difference. Shunt surgery was carried out in 45.5% (5/11 patients) after HC and 58.3% (7/12) after DC, number of additional surgeries was 0.9 ± 0.9 times after HC and 1.75 ± 1.5 times after DC, rate of intracranial infection was 0% (0/11) after HC and 8.3% (1/12) after DC, and length of hospital stay was 58.9 ± 22.7 days after HC and 76.3 ± 39.1 days after DC (all lower after HC but not significant). Two patients showed skin necrosis after HC and required additional debridement. HC does not require additional cranioplasty. Postoperative ICP control and improvement in midline shift were similar for HC and DC, but HC tended to reduce postoperative intracranial infection, need for additional surgery, and length of hospital stay.

We performed a statistical investigation of poor outcome factors for diffuse brain injury using the state of consciousness, age, gender, pupil abnormality, CT, and MRI findings upon arrival of diffuse brain injury patients to the hospital.

We studied 93 diffuse brain injury patients but excluded those with multiple trauma of AIS 3 or above, those who tested positive for alcohol at the time of arrival at the hospital, and those who also exhibited a focal brain injury.

Based on clinical findings made at the time patients arrived at the hospital, being older than 65 years of age, GCS 7 and below, and having abnormal light reflexes were poor outcome factors. Regarding CT findings, being unable to see the suprasellar cistern, poor visualization of the ambient cistern, and SAH on the brain surface were poor outcome factors. Regarding MRI findings, the presence of basal ganglia injury and brainstem injury were poor outcome factors. Based on a stepwise logistic regression analysis of all poor outcome factors, it was revealed that being older than 65 years of age, having light reflex abnormalities, and the existence of brainstem injuries are all poor outcome factors, independent of each other. In addition, regarding injuries to the brain stem, midbrain injuries were the most prevalent and lateral injuries of the midbrain was the most prevalent poor outcome factor. However, in cases of injury to the brainstem only, recovery was good.