In 2005, one week study of the Japan Neurotrauma Data Bank was conducted to elucidate the actual status of head injury in our country. Enrolled here were the patients who admitted to the hospitals because of head injury.
Eight hundred and two patients were registered from 321 institutes. Those were divided into two groups: severe head injury (Group S, GCS 3 – 8 on admission) and moderate to mild head injury (Group M, GCS 9 – 15).
The number of the patients was 105 (13.1%) in Group S, and 645 (80.4%) in Group M. The age distribution was different between Group S and Group M. Male was dominant in both groups. As for cause of injury, traffic accident was more common in Group S, but fall or tumble was more frequent in Group M (p=0.0054). The incidence of CT abnormality was 88.0% in Group S, whereas 55.1% in Group M. This difference was statistically significant (p<0.0001). Diffuse brain injury was more common in Group S (p<0.0001). The incidence of multiple systemic injury and neurosurgical decompression was more frequent in Group S (p<0.0001, p<0.0001, respectively).
This is the first nationwide study of head injury in our country, and may play a role as the basic data of future study. The next one week study will be planned in 2012.
Severe head injured patients presenting with Glasgow Coma Scale (GCS) score of 3 have been hesitated to treat aggressively. We analyzed present status of patients with GCS score of 3 from the Project 2004 in the Japan Neurotrauma Data Bank.
Among 1,101 cases registered, 805 cases with GCS score of 8 or less on admission. Of those, 215 cases with GCS score of 3 were classified the survival group (51 cases) and the dead group (164 cases) and compared each group.
These results showed that the characteristics associated with favorable outcome including absence of cardiopulmonary arrest, no abnormality of pupil findings, stable condition of respiration and circulation, serum glucose level (less than 184 mg/dl), absence of initial CT findings including skull base fracture, pneumocephalus and subarachnoid hemorrhage, no serious extracranial injures including Injury Severity Scale score of less than 25, critical care including intracranial pressure monitoring and temperature management.
We suggest that it is important to treat brain and systemic problems aggressively in severe head injured patients with GCS score of 3.
Objective: Despite neurotrauma treatment practices comprising a significant amount of neurosurgical work for secondary medical service centers, little attention has been placed on neurotrauma cases and evaluation of current neurotrauma treatment practices is limited. Therefore we investigated current neurotrauma practices in our hospital located in a Japanese suburban city.
Method: We analyzed 439 patients with traumatic brain injury (TBI) admitted to our hospital between April 2004 and October 2010. Patients were divided into three groups based on the Glasgow Coma Scale (GCS) score on admission: mild TBI (GCS 14 – 15) in 252 patients (57.4%), moderate TBI (GCS 9 – 13) in 116 patients (26.4%), and severe TBI (GCS 3 – 8) in 71 patients (16.2%). Age, gender, alcohol consumption, cause of injury, cranial CT findings, neurosurgical procedure, length of hospital stay, and clinical outcome were analyzed.
Results: The average age of the patients was 59.2 years old. Male patients comprised 65%. Alcohol consumption was reported in 81 cases (18.5%), most of them with moderate TBI. Fall (208 cases, 47.4%) was the most frequent cause of injury, followed by traffic accident (115 cases, 26.2%) and high fall (73 cases, 16.6%). Acute subdural hematoma (174 cases, 39.6%) was most frequently seen in cranial CT findings on admission, which significantly increased with severity. A neurosurgical procedure was performed for 70 cases (15.9%), of which 15 (6.0%) were mild TBI and 18 (15.5%) were moderate TBI. The average hospital stay was 20.8 days, which significantly increased with severity. The overall rate of favorable outcome was 82.7%, and mortality was 8.2%; outcome deteriorated with severity.
Conclusion: Some mild and moderate TBI cases had deteriorated and required surgery or resulted in death. These findings suggest that cautious treatment is necessary even in mild to moderate TBI cases which are often encountered in secondary medical service centers.
Objectives: In recent years, traumatic care in Japan was advanced as standardized methodology was adopted in many hospitals including rural regions, where our hospital (Kumamoto Rosai Hospital) was not exception. To improve traumatic care, we adopted Japan advanced trauma evaluation and care (JATEC) as a standard following national guidelines. However, honest reports with respect to traumatic care actually being implemented in rural hospital was still rare, so that it was very much expected to highlight the true nature of traumatic care in Japan. We report the review of 263 cases treated as high-energy trauma that our hospital experienced from January 2009 to August 2010.
Results: We categorized those traumatic cases according to affected body parts, severity, and clinical outcomes. We especially focused on the evaluation of the dead cases and multiple injuries based upon abbreviated injury score (AIS) by calculating probability of survival (Ps) yielded by trauma and injury severity score (TRISS). The dead cases were consisted of 8% (21 cases) of total. The result showed there were only five cases that we considered as unexpected deaths with Ps over 0.5, among which four cases were regarded as preventable trauma death (PTD). The number of PTD among treated death cases (15 cases) consisted of 26.7%, which was still higher than recent average in Japan. Peer review attributed the four PTD cases to severe bleeding after whole body CT as secondary survey and enlargement of subdural hematoma after other department than neurosurgery. Evaluation of 21 cases with multiple traumas demonstrated high mortality rate of 61.9% (13 cases), the majority of those had composition of severe head injury, hemopneumothorax and/or pulmonary contusion, and pelvic fracture.
Conclusion: Shortage of manpower and lack of intensive-care setting which imposed upon rural hospital very much like ours may be responsible for this results. However, further improvement of co-operation between different department as well as professional training for trauma care might overcome those shortcomings.
Our hospital is located between Tsugaru and Shimokita Peninsulas that are wide medically depopulated areas. The depopulated Tsugaru District has only 2 neurosurgical units, and many patients have to be transferred from the district general hospitals. Since 1989, we have been using an image transfer system that is useful for accurately diagnosing patients with head injury. Between January 2005 and September 2010, 644 patients with head injury were admitted to our hospital. The patients who used and did not use telemedicine were 78 and 566, respectively. In both groups, the background (age, gender, and type of head injury), surgery rate, and time of entry into the operating room were analyzed. There were no significant differences in the age, gender, and type of head injuries between the 2 groups. The surgery rate was 25.6% (28 patients) in the telemedicine group and 12.4% (70 patients) in the direct admission group. The average amount of time between admission and entry into the operating room was 2 h and 13 min in the telemedicine group and 2 h and 57 min in the direct admission group. There were significant differences between the telemedicine and direct admission groups (p<0.05). These results suggest that telemedicine is useful in the treatment of patients with head injuries in a widely depopulated area.
Age may be an independent predictor of outcome in traumatic brain injury (TBI). However, predictors of positive outcomes in the elderly remain unclear. The purpose of this study was to assess our current treatment for severe TBI in elderly patients, and to examine the problem. Between April 2006 and September 2011, 108 patients with severe TBI were enrolled. Of these, 44 patients over 65 years of age were classified into the Elderly group (E group) and the remaining 64 patients under 64 years of age were classified into the Non-Elderly group (N-E group). Age, sex, cause of TBI, Glasgow coma scale (GCS), injury severity, the existence of talk and deteriorate (T&D), the existence of pupil abnormalities, and the kind of TBI were compared between groups. As for the cause of TBI, pedestrian traffic accidents and accidental falls accounted for three-quarters of all patients in the E group. With respect to treatment, there was no significant difference in terms of frequency of craniotomy between the E group and the N-E group. Intracranial pressure (ICP) monitoring was enforced more often in the E group. As a result, poor outcome remains significantly higher in the E group. However, the mortality rate for patients with T&D was significantly lower than in patients without T&D in the E group (p=0.0037). In today's aging society, medical decisions should not be made on the basis of age. The pathophysiology and severity of TBI should be considered in order to determine the possibility of lifesaving.
Object. Previous studies have shown a relationship between a patient's stage of diffuse axonal injury (DAI) and outcome. However, few studies have assessed whether a specific lesion or type of corpus callosum injury (CCI) influences outcome in patients with DAI. We investigated the effect of various DAI and CCI lesions on outcome in patients with traumatic brain injury (TBI).
Methods. We retrospectively reviewed 89 consecutive patients with DAI who were seen between May 2004 and May 2010. Outcome was evaluated with the Extended Glasgow Outcome Scale (EGOS) 1 year after TBI. Cases with single-DAI had only one of the 3 lesions (lobar, corpus callosum, or brainstem). Dual-DAI cases had 2 of these lesions, and triple-DAI cases had all these lesions. Furthermore, we defined single-CCI, dual-CCI, and triple-CCI using 3 lesions (genu, body, splenium) in the same way among patients with single (corpus callosum)-DAI. Univariate and multivariate logistic regression analyses were performed to evaluate the relationships between these lesions and outcome in patients with DAI.
Results. Fifty seven patients had single-DAI lesions: 40 in the lobar, 12 in the CC, and 5 in the brainstem. Twenty four had dual-DAI lesions, and 8 had triple-DAI lesions. Of the 12 CCI, 9 had single-CCI, and 3 had dual-CCI. Only lesions in genu were related to disability among these lesions. We dichotomized patients into those with and without genu lesions regardless of other lesions. Multinominal logistic regression analysis showed that a genu lesion (OR, 27; 95% CI, 3.4 – 32; p=0.0032) and a pupillary abnormality (OR, 6.2; 95% CI, 1.2 – 21; p=0.0032) were associated with disability (EGOS ≤ 6) in DAI patients.
Conclusions. Regardless of the number of lesions, the existence of a genu lesion suggested disability 1 year after TBI in patients with DAI.
We analyzed the characteristics of patients suffering craniofacial injury. A retorosepective analysis was performed at neurosurgical department of our hospital between January 2000 and December 2009. Our candidates were patients bearing moderate or severe intracranial lesions need to be consulted on experts of another departments related to the facial trauma. During ten years, 2519 patients of head trauma were admitted on neurosurgical department. Of these patients, two hundreds five patients (8.1%) were consulted to each experts. Traffic accident was most commonest cause of craniofacial trauma in this study (n=126; 61%) followed by fall, direct hit of foreign body, violence. Most frequent department available for consultation was otorharyngology (n=131; 63%). Subsequently, Ophthalmology (n=58; 28.3%), Oral surgery (n=34; 16.6%), dermatology (n=25; 12.2%) and plastic surgery (n=6; 3%) had been available for medical consultation. Most frequent symptom was facial fracture. Among theses patients bearing facial fracture, thirty patients get surgical intervention. Most involved cranial nerve disturbance was facial palsy. In this study, most frequent diagnosis of intracranial lesion was cerebral contusion followed by cranial vault fracture, acute subdural hematoma, epidural hematoma. A large fraction of craniofacial injury in this study, degree of intracranial lesion were mild, therefore GOS on discharge was almost favorable. Only eight patients get neurosurgical intervention. Despite a mild intracranial lesion, neurosurgeon plays a role as coordinator in the management of craniofacial trauma in our hospital. And this trend may be under similar circumstances in Japan. Needless to say, most important therapeutic goal to the patients of craniofacial trauma is protection of neurological functions, but injuries of facial comportments decline the QOL of traumatic victims. Close and Effective relationship between neurosurgeon and another experts related to facial injuries is necessary to improve QOL of patients.
This study investigated resumption of motor driving in recovery stage after traumatic brain injury (TBI) in our hospital.
We selected 12 cases based on certain inclusion criteria from 38 patients who had sent to our hospital and received rehabilitative training after TBI since February 2008 until December 2010. We evaluated motor driving skills by driving simulator (DS-2000®, Mitsubishi Precision Incorporated Company), higher brain function by neuropsychological tests (WAIS-III, WMS-R, RBMT, TMT, FAB, BADS, kohs) and ADL by Functional Independence Measure (FIM). On admission driving simulation (DS) was performed, while DS and aptitude test (AT) was respectively performed on discharge. Each episode of dangerous driving was counted and totalized under 10 situations in DS, while capability of motor driving was evaluated from 5 points of view in AT.
Group was constituted by 11 men and 1 woman, 39 (mean) years old. Initial mean GCS was 9.3 (range 5 – 12), moderate (8 cases) – Severe (4 cases) injury. They were discharged 117.8 days after TBI. Episode of dangerous driving in DS on admission was 25.8 ± 5.9 (mean ± SD), while on discharge was 19.1 ± 4.6 (t-test, p<0.01). AT on discharge indicated two disqualified cases (17%). One of two had no remarkable abnormality in higher brain function but had sensory disturbance in right lower limb, therefore needed visual confirmation in AT. Another had abnormality in most of neuropsychological tests and it suggests certain correlation between motor driving and higher brain function. Eight of 10 qualified cases actually resumed motor driving and no obvious traffic accident was confirmed according to telephone interview 3 months later since discharge.
This study suggested that not a few patients with TBI could actually resume motor driving safely even in recovery stage after TBI under appropriate inclusion criteria, DS, and AT. Further various strategies, however, should be developed to guarantee safe resumption of motor driving.
In contact sports, such as boxing, rugby, American football, and judo, the risk of cerebral concussion or acute subdural hematoma by head blow, remains in high in Japan. The prognosis of an acute subdural hematoma is very poor and the mortality rate reachs to 55%. Dr. Ryo Uchida of Aichi University of Education investigated the fatalities in school judo classes, and clarified that more than 110 students aged 12 to 17 died as a result of judo accident in Japan. The fatalities is more than five times higher in any other sports. According to the investigation of Kobayashi, in Britain, Germany, Canada, the United States, and Australia, where judo population is larger than Japan, fatal accident in judo could not be found. On the judo community in Japan, the high mortality rate of judo is thought to be caused by underestimation of the danger of “concussion” and too hard drill works. Therefore, All Japan Judo Federration should take measures immediately in order to save a precious young life, because of the government plan that new national curriculum reforms will be required in all junior high school students to practice judo or some other “budo” starting along the 2012 school year.
We analized the 51 cases of skull base fracture who were hospitalized in the acute phase for the past 5 years. The sites of the fractured skull base were anterior cranial fossa in 34 cases, middle cranial fossa in 4 cases, spenoidal bone in 2 cases, petrous bone in 18 cases, and occipital bone in 4 cases totally. The fracture of the facial bone was seen in 13 cases. The systemic injuries were chest injury in 9 cases, abdominal injury in 3 cases, pelvic fracture in 3 cases, and spine fracture in 7 cases. The observed intracranial injuries were acute epidural hematoma in 12 cases, brain contusion in 12 cases, acute subdural hematoma in 9 cases, and traumatic subarachnoid hemorrhage in 6 cases. The pneumocephalus happened in 27 cases and the persistent cerebrospinal fluid rhinorrhea was followed in 6 cases. The neurological symptoms of the cranial nerves were observed in 6 cases and septic meningitis happened in 1 case.
The prognosis was independent home life in 38 cases, bed-ridden in 4 cases, vegetative state in 4 cases, and death in 5 cases. The serious head trauma (5 cases), severe chest injury (3 cases) and hemorrhagic shock due to pelvic fracture (1 case) were engaged in the poor prognosis among 9 cases of death or vegetative state. One case of the serious head trauma (5 cases) died of the hemorrhagic shock due to skull base fracture. Two cases became vegetative state following the contusion of the brain stem or cerebellar hemisphere. Among 3 cases of severe chest injury, one case suffered hemorrhagic shock due to hemothorax. Another 2 cases was suffered from respiratory impairment due to bilateral pneumothorax or bilateral lung contusion.
So the prognosis was analized from the viewpoint of chest injury in 51 cases of skull base fracture. Six cases became vegetative state or death among 9 cases who suffered chest injury such as hemothorax, pneumothorax or lung contusion. However, only 3 cases became vegetative state or death among 42 cases without chest injury. The vegetative state or death was observed significantly more frequently in the cases with chest injury than the cases without chest injury.
Skull base fracture can cause serious brain damage. Furthermore, associated systematic injuries can cause the circulatory and respiratory failure.
Severe traffic accidents and falls sometimes cause enlargement of the fracture i.e. growing skull fracture (GSF). It is rare complication of head injury and occurring in infants and young children who are in the process of growing. Here we report our consecutive seven cases of GSF, mainly showing the latest case and literature review. Seven cases included four boys and three girls and caused by severe traffic accidents (three cases) and falls (two cases), which was consistent with previous reports. Fractures were located in the occipital (two cases), temporal (two cases), frontal (one case), parieto-occipital (one case) and temporo-parietal region (one case). The mean age in operation for GSF was 25.6 months (7M – 5Y). The mean duration between the accident and the operation for GSF was 9 months (5M – 12M). The latest case was a seven-month-old boy who had a severe traffic accident. Initially, he was conservatively treated for a skull fracture in the left temporo-parieto lesion and contusion in the left temporal lobe. A pulsating cyst was appeared in the bone defect area because of the enlargement of the fracture. Then, he was referred to our hospital for a surgical repair with the diagnosis of GSF. In the operation, duraplasty and cranioplasty were performed. In cranioplasty, the bone defect was replaced by the autologous skull bone graft in the intact area and the donor site was replaced by the autologous particulate bone and hydroxyapatite. At six months post-operation, the boy was stationary and the fracture showed no further enlargement. Although GSF is rare complication of head trauma, we should remember this disease for infants and young children who are in the process of growing. Using the autologous bone graft harvested from the adjacent area would be worth considering in the treatment of GSF, especially for infants.
We report a 55-year-old man with a depressed fracture overlying the superior sagittal sinus (SSS). He was hit by a golf club at the midline of the parietal region, and transferred to our emergency care unit. On admission, his consciousness level was clear and he had no neurological deficit, although he suffered from headache and nausea. A contused wound was debrided and primary sutured. Computed tomography (CT) scans revealed a depressed skull fracture overlying the junction of the middle and posterior part of the SSS, and there was no epidural or subdural hemorrhage and no parenchymal lesion. On CT angiography (CTA) and digital subtraction angiography (DSA) showed the SSS stenosis and the depressed bone fragments compressed the SSS. Although he was initially treated with intravenous glycerol and antibiotic agents, during the next 10 days, his headache, nausea and dizziness remained unresolved. The fundoscopy showed a bilateral chocked disc, and the initial pressure during a lumbar puncture was 25 cm H2O. 13 days after the trauma, elevation of the depressed bone fragments was performed. A small tear in the SSS was treated by head elevation and compression with a fibrin sheet. His symptoms were resolved the day after the surgery, and the post operative CTA and DSA confirmed good patency of the SSS. He was discharged from the hospital on postoperative Day 10 with no neurological deficit.
For a depressed skull fracture overlying the SSS, early cerebral angiography studies and evaluation of benign intracranial hypertension are required.
Intracranial pressure monitoring is recommended for the management of severe traumatic brain injury, and decompressive craniectomy a standard procedure to control intracranial pressure. We report here a case of severe traumatic brain injury with uncontrollable intracranial pressure that required multiple decompression surgeries. A 64-year-old man presented with a head injury after falling from a tree. On admission, the patient's Glasgow Coma Scale was 8. Brain computed tomography revealed multiple skull fractures and biparietal epidural hematoma. Bilateral evacuation of the hematoma, right-side decompressive craniectomy, and placement of an intraparenchymal pressure probe in the left parietal lobe were performed. One day later, intracranial pressure exceeded 30 mmHg and additional right temporal decompressive craniectomy and duraplasty were required. Intracranial pressure decreased to less than 20 mmHg after this second surgery, but increased again 4 days later. Additional right frontal decompressive craniectomy, evacuation of the right parietal lobe hematoma, and internal decompression of the right temporal tip were carried out. Intracranial pressure decreased to less than 20 mmHg postoperatively, but increased again to more than 50 mmHg one day later. In an emergency procedure in which skin and dura sutures were cut, intracranial pressure was decreased to less than 20 mmHg. Decompressive skinplasty was performed with artificial dermis (Pelnac®) to maintain a low intracranial pressure. After this fourth surgery, intracranial pressure remained low, never exceeding 20 mmHg. Decompressive skinplasty with artificial dermis contributed greatly to decreasing the intracranial pressure. More cases are required to investigate the indications for this technique.