Objective: To determine the usefulness of plasma thrombin-antithrombin complex (TAT) level as early prognostic indicator in patients with isolated traumatic brain injury.

Methods: Fifty patients with isolated traumatic brain injury, who were measured TAT on admission, were included in this study. The Grasgow Coma Scale (GCS) score on admission, Glasgow Outcome Scale (GOS) score at discharge, plasma TAT level on admission were measured.

Results: Regardless of their GCS score on admission, plasma TAT levels on admission in patients with poor outcome were elevated significantly beyond their TAT levels in patients with good outcome. Moreover, patients with plasma TAT level on admission more than 800 ng/ml will have a poor outcome, and who would be likely to have a good outcome when their plasma TAT level on admission less than 400 ng/ml.

Conclusion: Plasma TAT level on admission may be used as predictors of outcome in patients with isolated traumatic brain injury irrespective of GCS score on admission.

Background: Traumatic brain injury (TBI) patients need repeat head computed tomography (CT) in many cases. But the necessity and factor of repeat head CT is unclear. The purpose of the present study is to assess the necessity and factor of repeat head CT in TBI patients.

Methods: A retrospective study performed in an emergency medical center between April 2010 and November 2011. The TBI patients who dead the first 24 hours, directly operat­ed and did not follow repeat head CT were excluded. Clinical data collected included age, sex, time between onset and first head CT, type of head trauma, injury severity score (ISS) on admission, Glasgow coma scale, and function of coagulation.

Result: 104 patients were assessed within 20 months. The necessary factors of repeat head CT were hematoma volume in first CT, ISS on admission and soluble fibrin. Positive predictive rate was 75% and negative predictive rate was 83% in the prediction formula with these parameters.

Conclusion: It is possible to predict the progression of TBI in part with these parameters.

We have been taking the form of day care for group training of individuals with traumatic brain injury in chronic phase. 23 cases attended the six months group training in these four years.

In this form, we could be allowed medical insurance billing, so that we could have full-time staffs consisting of occupational therapist, nurse, clinical psychologist. We could teach these cases various practical training and interpersonal coping of communication in long time schedule.

Uncomfortable sentiment (depressed mood and irritability) and inappropriate behavior (untidy appearance and not understanding of other's emotion) reduced. They improved the motivation and the ability for self-expression.

Before the training, only 4 cases were employed, in the other hand 19 cases were not employed. After six months training, 8 cases would be employed, 8 cases could join welfare work or general group participation, 7 cases continued the day care schedule.

Day care formed group training could be useful for individuals with cognitive dysfunction in chronic phase．

Chronic subdural hematoma is one of the most common diseases encountered in neurosurgical practices. The relationship between the case number of chronic subdural hematoma and seasons has not been reported until now. The relationship between recurrence rate of chronic sub­dural hematoma and seasons has not been reported, too. We examined the monthly case number of and recurrence case number of chronic subdural hematoma in our hospital.

The examination included 769 adult patients who had undergone the first one burr-hole surgery between January 2000 and December 2010. We examined the monthly number of cases (recurrence cases and non-recurrence cases), recurrence rate, and recurrence risk factor.

The number of cases was higher in August, April, July and September. November and March had few cases. Recurrence rate was highest in July and lowest in December. We found an association between age and monthly recurrence rate among a recurrence risk factor.

We think that there is an association between the daily life activity of the elderly person and case number of chronic subdural hematoma. The daily life activity of elderly persons shows seasonality. Therefore, we think that the case number of chronic subdural hematoma shows seasonality. To decrease the recurrence rate, examination of the post­operative volume of infusion and an appropriate rest period are necessary.

Posttraumatic syringomyelia (PTS) is the main cause of delayed neurological deterioration after spinal cord injury. However, management principles of PTS have not been well established. We performed a retrospective study of 38 con­secu­tive patients with PTS (male : female = 31 : 7). Patients were divided into 2 groups: with complete (ASIA A, n=23) and incomplete spinal cord injury (ASIA B to E, n=15). All of 38 patients were surgically treated because of progressive neurological symptoms related with PTS. The prominent syringomyelia symptom was progressive upper limb sensory disturbance, but 6 out of 15 incomplete spinal cord injury patients presented with lower limb symptoms alone.

We performed 35 internal syrinx drainage surgeries (25 syrinx-subarachnoid shunts and 10 syringo-cisternal shunts) as initial treatment. Though in 8 patients syrinx re-expansion was observed, in 34 of 38 patients syrinx reduction was achieved as final result in the follow up period. Recurrence seen in 8 patients, was more frequent in cervical injury and rapid syrinx growth group. As an overall outcome in 38 patients, neurological improvement or stabilization after syrinx reduction was obtained in 33 patients (87%). Within this group, 17 patients (45%) improved neurologically with most remarkable recovery in the upper extremities motor function (15 of 17 patients). Despite of multiple shunt sur­geries, 5 patients (13%) neurologically deteriorated. In those cases untreated CSF blockage may have caused repeated spinal cord cavitation.

In conclusion, internal syrinx shunt technique provides favorable outcome for preventing neurological deterioration in posttraumatic syringomyelia patients especially in upper limb motor function. But shunt surgery may not improve intractable PTS patients in whom CSF circulation at spinal cord injury site still remains impaired.

The characteristics of 50 cases aged 85 years and older that admitted to our institute because of head injury were analyzed. Chronic phase admissions were excluded.

Thirty-one cases were female, while male dominancy was noticed considering sex ratio of 85 years and older population in our area. Thirty cases were injured by ground-level fall. Modified Rankin Scale (mRS) at discharge worsened compared with pre-injury status in 17 of 19 acute subdural hematoma (ASDH), 15 of 19 brain contusion and 2 of 5 traumatic subarachnoid hemorrhage cases. Four brain con­cussion, 2 skull fracture and one acute epidural hematoma cases did not deteriorate. 8 cases of ASDH and 6 cases of contusion died. Four cases of acute subdural hematoma underwent surgery, but their outcomes were mRS 5 or 6. A half of cases took antiplatelet and/or anticoagulation therapy before injury. Low-dose aspirin alone did not have influence on prognosis, while anticoagulant or multiple anti­platelet medication induced worse prognosis.

Post-traumatic epilepsy is one of the most important com­plications of traumatic brain injury (TBI), which influences the quality of life in patients with TBI. We evaluated the actual condition of use of anti-epileptic drugs (AEDs) and effects of treatment with AEDs in patients with TBI. We retrospectively examined a series of 76 patients with TBI admitted to our rehabilitation hospital. Twenty-nine (38.2%) of them had been prescribed AEDs in previous hospitals, and 47 (61.8%) had been prescribed no AEDs. Twenty-two of the 29 patients with AEDs were administered AEDs with­out seizures as a prophylactic, and seven were taking AEDs after the initial seizure. The AEDs used as first-line therapy were sodium valporate (VPA) (48.3%), phenytoin (20.9%), carbamazepine (13.8%), and others. The tendency toward a high-frequency use of VPA as a first choice AED in patients with TBI was marked in the prophylactic group. In the prophylactic group, 54.8% of patients used VPA as the first-line treatment. Four of the 29 patients with pro­phylactic use had seizures after the administration of AEDs. Three of the four patients took VPA. Six of the seven patients with AEDs after seizures had recurrent attacks. Three of them had discontinued AEDs previously. Two of the other three patients had been taking VPA. It has been reported that VPA is not suitable for post-traumatic epilepsy, but VPA was in fact the most frequently used in our study. We must reconsider the choice of AEDs for post-traumatic epilepsy in Japan. The standard treatment for post-traumatic epilepsy has not been indicated. There is no standard method of prophylactic AED use for patients with TBI. Regarding the prophylactic use of AEDs, it is necessary to identify which patients should be administered AEDs, what AEDs should be used, and how long these should be con­tinued. Treatment for post-traumatic epilepsy including the choice of AEDs also has not been clearly indicated. The use of AEDs after TBI should be standardized in guidelines in the near future.

Object. Intraventricular bleeding (IVB) is widely regarded as one element of a complex involving severe blunt traumatic brain injury (TBI) and corpus callosum injury (CCI) is recently considered to be one of factors related to poor outcome in patients with TBI. Although postmortem studies have focused on the relationship between IVB and CCI, there have been few investigations of IVB on CT as a predictor of CCI on MRI in patients with mild to moderate isolated blunt TBI.

Methods. We reviewed 332 mild to moderate isolated blunt TBI patients, to investigate whether IVB on CT predicts CCI on MRI. First, we classified patients into groups with and without CCI and compared clinical and radiological findings between them. Then, we investigated prognostic factors that were related to the development of disability at 6 months after injury. The outcome at 6 months after injury was evaluated using the Extended Glasgow Outcome Scale (EGOS). Finally, we evaluated correlation between the severity of the IVB on CT and the number of CCI lesions on MRI. The sever­ity of the IVB was defined by number of ventricles in which IVB was seen, and number of CCI lesions was counted.

Results. On multivariate logistic regression analysis, Glasgow Coma Scale Score 9 – 12, traffic accident, and IVB on CT were significantly related to CCI. Multivariate analysis also showed that advanced age, male gender, Glasgow Coma Scale Score 9 – 12, IVB on CT, and CCI on MRI were associated with the future development of disability (EGOS ≤ 6). Furthermore, simple regression analysis revealed the existence of a strong correlation between the severity of IVB and the number of CCI lesions.

Conclusions. Our results suggest that evidence of IVB on CT may indicate CCI, which lead to disability, in patients with mild to moderate isolated blunt TBI.

The case was 80 year old male. The patient presented gait disturbance, disorientation and dysarthria. CT scan revealed chronic subdural hematoma on the left side and he was treated with trepanation operation. Ordinary thin outer membrane was found on operation. Thereafter, the remaining hematoma was frequently tapped through the burr hole.

High density area was found on the lateral side of the hematoma cavity 7 weeks after operation. 14 weeks after operation, motor aphasia and behavior abnormality happened. CT revealed marked rebleeding, so the second operation (trepanation and drainage) was performed. On operation, ordinary outer mem­brane was found. Even after the operation, the hematoma still remained with the high density area on the lateral side of hematoma cavity. So the recurrence of hematoma was treated by the repeated tap through the burr hole. Even 2 weeks after the second operation, the air bubble remained to be trapped along septum of the hematoma cavity.

The disorientation happened 22 weeks after the first opera­tion (8 weeks after the second operation). The eighth tap was tried, but the hematoma could not aspirated adequately. So the third trepanation and drainage operation was performed. The hematoma was organized. After operation, the size of hematoma decreased to some degree, but the symptom did not change. The hematoma was cultured and Propionibacterium sp was found to exist in hematoma cavity.

Gait disturbance and aphasia happened 24 weeks after the first operation (2 weeks after the third operation). Ultimately, the hematoma was removed by craniotomy. Organized hematoma was found in the subdural space. Although the cultured hematoma showed Propionibacterium sp, the bacteria could not found on Gram stain. The symptom improved after the craniotomy operation. The compression of the brain almosy completely disappeared 26 weeks after the first operation (2 weeks after the cranioto­my operation). No recurrence of chronic subdural hematoma was found 35 weeks after the first operation (11 weeks after the craniotomy).

We report a case of repeated recurrence of chronic subdural hematoma in a very elderly patient, presenting a therapeutic challenge. The patient was a 104-year-old man who developed consciousness disturbance (Japan coma scale [JCS] 10) and left hemiparesis 3 months after head trauma. Computed tomography (CT) showed bilateral (predominantly right-sided) chronic subdural hematoma. At the first visit, he underwent burr-hole ir­rigation, and became neurologically clear the next day. However, he subsequently experienced repeated recurrence of chronic subdural hematoma, and underwent burr-hole irrigation a total of four times. In the mean time, he received the Japanese traditional medicine Goreisan and underwent middle meningeal artery embolo­therapy for the prevention of recurrence of chronic subdural hematoma, but had a recurrence. Finally, after the evaluation of his general condition, he underwent capsulectomy under general anesthesia, and was cured. Very elderly patients with recurrent chronic subdural hematoma should undergo less-invasive treatment first, then more invasive treatment in a step-by-step fashion, and, finally, capsulectomy as an option under general anesthes­ia if their general condition allows.

Vertex epidural hematoma (VEDH) is relatively rare. Several reports have described atypical chronic and non-surgical cases. Because of variations among VEDH, it was difficult to properly diagnose prior to the computed tomography era. We herein describe a case of VEDH with dual suture diastasis. Our search of the literature yielded 39 cases with similar clinical courses. Clinical characteristics of VEDH, including the impact distribution, bone injury and bleeding source, are reported. Important considerations for diagnosis and surgical treatment are also discussed.

A 61-year-old man was aware of serous fluid rhinorrhea fre­quently 6 years after a head injury. However, the rhinorrhea ceased spontaneously in several days. He had meningitis with headache, fever, and neck stiffness 10 years after the head injury. No functional deficit of the cranial nerves was noted except left anosmia. No other neurological deficits was detected. Plain head computerized tomography (CT) scan revealed low density area in the left frontal base. Bone image of the CT scan revealed a fistula at the posterior wall of the frontal sinus and the roof of the ethmoidal sinus. Magnetic resonance imaging (MRI) showed that the brain lesion was low signal intensity on T1-weighted images and high signal intensity on T2-weighted images sus­pecting of old brain contusion. CT cisternography showed the cerebro­spinal fluid (CSF) leakage draining from the subarachnoid space through the roof of the left ethmoid sinus into the nasal cavity. The CSF leakage was noticed when he raised his head or defecated. The CSF leakage could not be stopped by conservative treatment with a spinal drainage for 2 weeks. Duraplasty with pedicled periosteal flap was performed by craniotomy and CSF leakage was completely stopped post­operatively. No further problems occurred in the post­operative follow-up period. Delayed CSF leakage is rare. It often can't be stopped by conservative treatment, and surgical treatment is usually required. This case presentation is followed by the discussion of related reports as well as issues concerning diagnosis and treatment of delayed posttraumatic CSF leakage.

An unusually prolonged course of traumatic encapsulated epidural hematoma was reported.

A 44-year-old man had visited the local hospital with lt. frontal skull fracture on the acute epidural hematoma caused by falling down due to excessive alcohol intake. The conservative observation had been taken because of neither enough volume of the hematoma to do the surgical intervention nor neurological deficit. He was admitted to our hospital on 40th day after the injury with deteriorating headache and dizziness. The CT scan showed slowly developed lt. frontal epidural hematoma. Total extirpation of the epidural hematoma enveloped by thick capsule was performed on post-injury day 47. After surgery, his condition was fully recovered.

Histologically, the hematoma capsule was consisted of fibrous and inflammatory tissues with hemosiderin deposit and partial ossification, which findings might be similar to traumatic chronic subdural hematoma.

The slowly progressed chromic epidural hematoma should be kept in mind during conservative observation for a thin epidural hematoma.

A 14-year-old girl, who experienced a traffic injury and became comatose, was transferred to our hospital. Emergent operations, external decompressive craniectomy, and manual reposition of rotatory atlanto-axial dislocation were per­formed under general anesthesia. She recovered from a dis­turbed consciousness state after operative and medical treat­ments in our ward. However memory disturbance and spastic gait disturbance persisted even 2 months after the injury.

The most important point of discussion in this case is the decision to perform external decompression for diffuse brain injuries without measurement of intracranial cerebral pressure (ICP). In general, continuous ICP measurement is essential for deciding whether to perform external decompression or conservative therapy. Some studies have shown that ex­ternal decompression later leads to ventricular enlargement.

In daily clinical practice, many patients experiencing traffic accidents are transferred to emergency hospitals to have all equipment, e.g., ICP measurement equipment, required to deal with the extreme cases. However, it is very difficult for peripheral hospitals to be ready for all the extremities, like ICP measurement equipment. Herein, we report our experiences and difficulties in such a case.