Judo-related severe head injury in children and adolescents is a hot topic in the media and in society. Neurosurgeons are often involved in many other sports-related head injuries. The Committee of Sport Head Injury in the Japan Society of Neurotraumatology has studied to develop guideline for neurosurgeons how to manage the athletes with sports-related concussion or an intracranial structural lesion, and how to allow them to return to play.
Sports-related concussion includes not only transient unconsciousness and amnesia but also various somatic (e.g. headache), cognitive and emotional symptoms. The most concussions typically resolve in a short time, although the recovery may be longer over a week in children and adolescents. The Sports Concussion Assessment Tool (SCAT) is the standard method for evaluation of concussion. Repeated concussions may produce rapid catastrophic deterioration (second impact syndrome) or chronic traumatic encephalopathy presenting with cognitive dysfunction. Second impact syndrome may occur in association with acute subdural hematoma. In concussion patients with prolonged symptoms (e.g. headache), brain CT or MRI should be recommended to exclude an intracranial structural lesion such as thin subdural hematoma. Once concussion is diagnosed, an athlete should not be return to play in the same day. An athlete must be asymptomatic prior to return to play, and should take a graduated return to play protocol lasting around one week. Once an intracranial structural lesion (e.g. subdural hematoma) has been found after sport head injury, the athlete should not be allowed principally to return to play contact sports.
One Week Study (OWS) of the Japan Neurotrauma Data Bank was conducted to elucidate the actual status of head injury in our country in both 2005 and 2012. In this article, the data in OWS 2012 was compared with those in OWS 2005, to clarify the recent state of head injury.
All the patients, who admitted to the hospitals due to head injury, were enrolled. Eight hundred and two patients were registered from 321 institutes in OWS 2005, and 682 from 297 institutes in OWS 2012. Analyzed factors were age, cause of injury, Glasgow Coma Scale (GCS) score, CT findings, Incidence of multiple systemic injury and neurosurgical operation.
Results: In OWS 2012; The patients were older (p<0.0001), and traffic accident was less frequent (p<0.0001). Four wheel vehicle and bicycle accidents were more frequent and pedestrian accident was reduced in traffic accident group (p=0.0373). GCS score did not differ significantly between two groups. The abnormal CT findings were more frequent (p=0.0373). Focal injury was most common, followed by combination of focal and diffuse injuries. Multiple systemic injury was more often, but the percentage of neurosurgical operation was not increased significantly.
These results indicated that the aged patients injured by fall or tumble has increased recently. The complicated intracranial lesion and multiple injury also have increased in rate, despite the clinical severity was unchanged.
Intellectual and emotional disorders persisting as long-term problems after head injury have increasingly been highlighted with higher brain dysfunction caused by brain damage. More effective chronic medical intervention is expected for residual disabilities. In order to respond to these expectations, long-term follow-ups of head-injury survivors as well as collection and analysis of comprehensive medical information, including daily living functions and quality of life (QOL), are needed. In this study, an overview was introduced of the long-term natural course of a 47-year-old patient who became a physician after incurring a severe traumatic brain injury (TBI) at age 16 and who has continuously participated in society, and the methods and requirements for long-term prognosis studies in adult survivors of severe childhood TBI was outlined. In addition, the methodologies of cohort studies as a method of longitudinal epidemiological studies in the management of prognoses for disabilities were demonstrated, and the concept and significance of epidemiological studies on long-term prognoses of head-injury survivors, for which the establishment of the system is expected in the future, were organized and explained.
Objective: To investigate the clinical characteristics of intracerebellar contusions (ICC), we retrospectively analyzed our own cases of this traumatic brain injury.
Materials & Methods: From January 2004 to November 2012 we experienced 6 cases with ICC at our institution. Frequency, patient's age, gender, the cause of injury, absence or presence of skull fracture, co-existing lesions, treatment and outcomes were reviewed.
Results: During the same period described above we treated 391 patients with acute head trauma, thus frequency of ICC accounted for 1.5%. The patient’s ages ranged from 18 to 84 years with a mean age of 59.5 years. All patients but one included in the study were women. The cause of injury was traffic accidents in 4 patients, fall in 2. In each instance the patient had received a direct blow on the back of his ⁄ her head from coup injury. Skull fractures and co-existing supratentorial lesions were detected in all cases on CT scan, namely cerebral contusions in 5, acute subdural hematoma in 1, corpus callosum injury in 1. Three patients were managed conservatively and other 3 patients were managed surgically. In the surgically treated patients suboccipital craniectomies were performed in 2 patients and bowth supratentorial and suboccipital craniectomies were performed in 1. Outcomes at discharge were moderately disabled in 5 and dead in 1.
Conclusions: Due to its rarity there has been limited experience in treating ICC at a single institution. Based on our series of 6 cases and review of the literature the clinical characteristics of this rare traumatic brain injury were presented.
Introduction: Recent clinical studies failed to show efficacy of recombinant factor (rFVIIa) and tranexamic acid in traumatic brain injury (TBI) treatment. This failure may be caused by the pathophysiological diversity of TBI. Moreover, there is still little information on the different coagulopathic mechanisms underlying different type of TBI. The aim of this study is thus to clarify the coagulopathic mechanisms in different "pure" TBI rat models with thromboelastography (TEG), which can provide quick, simultaneous estimation of multiple coagulopathic mechanisms.
Materials and Methods: Sprague-Dawley rats (300 – 350 g) were subjected to one of three different injuries: penetrating ballistic brain injury (PBBI), lateral fluid percussion injury (FPI), and acute subdural hematoma (ASDH). In each TBI model, non-heparinized blood samples were collected at different time points (PreTBI, 2.5 h, 24 h, 7 days after TBI). TEG parameters were compared among the three TBI models, and at different time points.
Results: In the early phase (2.5 h) after injury, K-value, which indicates impairment of fibrinogenesis, was significantly higher in ASDH than in FPI (p<0.01). Moreover, MA (Maximal amplitude) and G value, which indicate the strength of platelet-fibrin interaction, were significantly lower in ASDH than FPI (p<0.05, respectively). Moreover, the Coagulation Index (CI), which indicates overall status of coagulation was the lowest in ASDH. Blood coagulation profiles of PBBI were similar to ASDH, although less severe. On the other hand, the peak of coagulopathy in FPI existed on later phase (24 h) after injury, and continued by the 7th day.
Conclusion: Our study clarified 1) The presence of acute-severe coagulopathy in ASDH, 2) gradually worsening coagulopathy in FPI, 3) acute-milder coagulopathy in PBBI. The pathophysiology and severity of coagulopathy was specific to the type of injury and the duration after injury. These results warrant a future clinical study to profile the coagulation disorders after TBI, and possibly of "TEG derived" treatment for coagulation disorder in TBI.
Background and Purpose: The risk factors in post-operative brain edema in acute subdural hematoma have not been understood clearly. After evacuating masses, the indication of decompressive craniotomy (DC) is determined by the surgeons, based on the pre- and intra-operative condition. For suitable indications for DC, we evaluated the risk factors of post-operative brain edema in our surgical cases including hemodialysis patients.
Method and Patients: Thirty four acute subdural patients’ age, sex, Glasgow coma scale (GCS) scores in pre-operation and the presence of hemodialysis were checked retrospectively. Post-operative brain edema was evaluated in computed tomography (CT). Univariate and multivariate analysis were underwent in SPSS.
Results: The average age was 77.0 years old in 34 patients (male 17, female 17). Twenty patients were in GCS score in pre-operation 3 – 8, 6 patients were in 9 – 13, and 8 patients were in 14 – 15. In univariate analysis, patients over 75 years old were lower risk in post-operative brain edema than younger group significantly (p=0.017). In multivariate analysis, older than 75 years were lower risk than youngers (p=0.032), too. Other factors did not have significant differences.
Conclusions: Lower age was the only significant risk factor in post-operative brain edema. The presence of hemodialysis did not have statistical differences.
Object: Acute subdural hematoma has been recognized as a devastating injury. The aim of this study was to assess the factors contributing to outcome of the patients who underwent surgery for acute subdural hematomas.
Materials and Methods: We conducted retrospective analysis of 337 consecutive patients who admitted our hospital for acute traumatic brain injury. We found 123 patients with acute subdural hematoma on CT scan. We analyzed the risk factors of poor outcome at discharge or at 3 months after admission among the patient who underwent surgical interventions, by calculating odds ratio with corresponding 95% CIs and adjusting for patient age, sex, injury mechanism, Glasgow coma scale, Rotterdam CT score, time interval from injury to operation and surgical intervention at admission.
Result: Four cases (9.1%) underwent emergency burr-hole surgery before craniotomy, and 22 patients underwent decompressive craniectomy. GCS at admission was correlated with unfavorable outcome, and Rotterdam CT score showed a significant correlation with death (odds ratio 5.4, p=0.02). There was no relevance between prognosis and surgical method (odds ratio 3.6, p=0.32). However, the elder patients with decompressive craniectomy tended to have higher mortality, but were not significantly different.
Conclusion: It is still difficult to predict the prognosis of severe acute subdural hematoma before surgical interventions. Both craniotomy and decompressive craniectomy were feasible strategies for acute subdural hematoma, but we need more study in order to provide a good indication for surgery.
Introduction: Support services for patients with higher brain dysfunction following head trauma have been expanded nationwide, but examination methods appropriate for diagnosis and quantitative evaluation of rehabilitation efficacy have not been established. We developed a screening test for patients with higher brain dysfunction and examined its usefulness in association with support facilities for patients with higher brain dysfunction in Tokushima.
Test Contents, Subjects, and Methods: The screening test consisted of 21 items, including orientation, short-term memory, visual perception ⁄ situational cognition, and attention ⁄ executive function; these items were evaluated on a 50-point scale. Initially, the screening test was performed for healthy person of different age groups, and the mean scores for each test item were obtained. The screening test and Hasegawa Dementia Scale-Revised (HDS-R) were successively administered after rehabilitation intervention in patients with higher brain dysfunction. Subjects were patients undergoing rehabilitation for higher brain dysfunction due to head trauma and stroke.
Results: All patients with higher brain dysfunction (11 persons) at the time of rehabilitation intervention had abnormal scores (0 – 36 points; mean, 22 points) in the screening test, and the items showing abnormal scores were consistent with clinical symptoms of the patients. The screening test performed 3 months after rehabilitation intervention showed improvement of scores in 7 of the 11 patients.
Conclusion: Although the results of our screening test partially correlated with those of HDS-R, our screening test could evaluate higher brain dysfunction according to its elements, even in patients with normal scores on HDS-R, and was useful for screening patients. Moreover, this screening test may be useful for quantitative determination of rehabilitation efficacy in patients with higher brain dysfunction. We intend to accumulate further data on cases and verify the results of this screening test.
Chronic subdural hematoma is one of the most common diseases encountered in neurosurgical practice. Although its treatment method is well established, the best irrigation solution for burr-hole surgery to treat this disease is not clear.
To identify the best irrigation solution, we compared recurrence rates and complications for 3 different solutions: the lactated ringer, saline, and artificial cerebrospinal fluid. The study included 864 cases that had undergone burr-hole surgery between January 2000 and December 2011. The study was retrospectively analyzed. Recurrence was defined as the time at which recurrence warranted re-drainage. We examined the patients for complications of intracranial hemorrhage, cerebral infarction, postoperative infection, and postoperative convulsion.
The case numbers were 207 (24.7%) in the lactated ringer group, 361 (43.1%) in the salne group, and 296 (32.1%) in the artificial cerebrospinal fluid group. The recurrence rate was 9.7% in the lactated ringer group, 10.5% in the saline group, and 9.1% in the artificial cerebrospinal fluid group. There were 2 cases of intracranial hemorrhage in the lactated ringer group, 4 cases in the saline group, and 8 cases in the artificial cerebrospinal fluid group. There were 2 cases of cerebral infarction in the lactated ringer group, 1 case in the saline group, and none in the artificial cerebrospinal fluid groups. Postoperative infection occurred in 2 cases in the saline group and in 0 cases in the lactated ringer or artificial cerebrospinal fluid groups. There were 7 cases of convulsion in the lactated ringer group, 5 cases in the saline group, and 8 cases in the artificial cerebrospinal fluid group. There were 2 cases of heart failure in the artificial cerebrospinal fluid group, 1 case in the saline group, and none in the lactated ringer group. There were no statistically significant differences in the recurrence rates and complications among the groups.
As for the irrigation solution for chronic subdural hematoma, it is thought that there is no problem with the three irrigation solution.
Purpose: We examined the usefulness and limitations of burr-hole surgery in the emergency room by retrospectively investigating the characteristics and outcomes of patients who underwent the burr hole surgery for traumatic severe brain injury.
Methods: A total of 53 patients underwent burr-hole surgery in the emergency room. We analyzed a preoperative factors such as GCS score on admission; systolic blood pressure; pupil findings; blood tests (fibrin degradation product (FDP), D-dimer); morphology of hematoma; ICP immediately after burr-hole surgery; and the mean interval from contact to emergency service to burr-hole surgery. Patients were devided into groups on the basis of diffuse injury (DI) groups and evacuated mass lesion (EM) groups in accordance with National Traumatic Coma Data Bank (TCDB) classification. Student's t-test and Fisher's exact probability test as statistical analysis were conducted with a significance level of p<0.05.
Results: 1) FDP and D-dimer were significant prognostic factors in all patients; 2) survival following burr-hole surgery alone was common among DI group with mild impairment of the coagulopathy and no extensive brain swelling, and in whom ICP could be controlled with subdural drainage; 3) survival following additional craniotomy following burr-hole surgery alone was common among EM group with mild impairment of the coagulopathy and mild brain parenchymal injury; 4) in patients with a GCS score of 3, FDP and D-dimer were significant prognostic factors; and 5) patients with shock, such as complication by pelvic fracture, experienced particularly poor outcomes.
Conclusion: Burr-hole surgery in the emergency room was considered useful for the following purposes: 1) quick reduction of intracranial pressure at an early stage prior to craniotomy in the EM group; and 2) managing hematomas and controlling ICP with cerebrospinal fluid drainage in the DI group. 3) Survival was possible under certain conditions, even in the most severe cases such as GCS score of 3.
Background and Purpose: Chronic hemodialysis (HD) has been known as a risk factor for chronic subdural hematoma (CSH), although clinical characteristics of CSH have not been clarified in HD patients. In this paper, clinical characterisitics of CSH are investigated in HD patients, and clinical problems of those are discussed.
Materials and Methods: Twenty-seven HD patients with CSH are involved in this study. Age, gender, cause of trauma, pre-conditioning with anti-coagulant ⁄ platelet therapy, symptom, Glasgow Coma Scale (GCS) scores, Glasgow Outcome Scale (GOS) scores, recurrence rate, complications are summarized from medical records, to compare with 348 non-HD cases with CSH as control.
Result: Pre-traumatic conditioning with anti-coagulants or -platelets is more frequent in HD than control. Initial symptoms, as well as GCS scores, are more severe in HD than control. GOS scores are significantly worse in HD than control, although more than 85% of patients result in favorable outcome even in HD patients. Mean duration of administration is significantly longer in HD than control. Recurrence rate seems higher in HD than control, but not significant. Main reasons of poor outcome are cerebral infarction, cardiac failure, pneumonia, and so on.
Conclusion: Early diagnosis and treatments may be important to improve outcome of CSH in HD patients, as well as appropriate treatments for both coagulopathy induced by preconditioning with anti-coagulants ⁄ -platelet therapy, and general complications.
This report presents a case of medulloblastoma which was identified incidentally at the CT examination for the trauma. A 5 years old male patient consulted the hospital for minor head injury and the CT examination was judged to be normal. The patient consulted our hospital again for the continuous headache. CT scan and gadolinium-enhanced magnetic resonance imaging showed the massive tumor in the posterior fossa. The lesion was subtotally removed and the pathological diagnosis was medulloblastoma. The patient was treated with irradiation and chemotherapy thereafter and no recurrence has been found 2 years and 6 months after the trauma.
In the radiological examination of the traumatic injury, the interpretation of radiogram should be performed in a careful manner bearing in mind the possibility of incidental other lesions such as brain tumor.
Object: The continuous disruption of neovascuralization on outer membrane of subdural hematoma could be concerned in the refractory chronic subdural hematoma (rCSDH). The middle meningeal artery (MMA) mainly supplies to the membrane through the contacted dura matter. We hereby report a case of rCSDH with a risk factor of ischemic complication accompanied by embolization of MMA.
Patient: A 72-year-old female suffered severe headache due to left CSDH. She had been given a 10 mg of rivaroxaban against chronic atrial fibrillation. Twice symptomatic recurrences occurred after simple burrhole surgeries. Finally, embolization of MMA was additionally undergone with using coils following the third burrhole surgery. We chose some coils as an embolic material to avoid ischemic complication due to the migration of liquid embolic material, because recurrent meningeal artery (RMA) was shown on the angiogram prior to embolization. The hematoma disappeared at one month after the embolization.
Discussion: As long as it is easily to access to MMA, embolization of MMA is a simple and less invasive treatment under local anesthesia. However, MMA originated from stapedial artery, has some normal variations and occult anastomosis to internal carotid artery system (ophthalmic artery, inferior-lateral trunk on C4 portion) as known as dangerous anastomosis. RMA, one of these anastomotic arteries, generally connects between MMA at intracranial foramen spinosum and ophthalmic artery in ipsi-lateral orbit through superior orbital fissure. Therefore, the embolization, especially with using liquid embolic materials, should undergo at more distal portion of MMA as possible to avoid the accidental migration.
Conclusion: Deteriorate to rCSDH infrequently occurred in our clinical situation. The embolization was feasible treatment for patients with rCSDH. To recognize the anatomy of microvasculature is the most important for less complication regardless of embolic materials. Further discussion is necessary for both indication and timing of embolization.
Traumatic intracranial aneurysms are rare conditions that can result from non-penetrating head trauma. Because of the significant mortality and morbidity rates associated with this condition, early diagnosis and treatment are highly recommended. Here, we report one case of a traumatic aneurysm of the paraclinoid internal carotid artery (ICA). Briefly, a 23-year-old male was admitted to our hospital with disturbance of consciousness that developed after he fell from a high place. The patient's Glasgow Coma Scale was 8 (E1V2M5), and a computed tomography (CT) scan revealed an acute epidural hematoma, traumatic subarachnoid hemorrhage, and fractures at the anterior cranial base. A craniotomy to surgically remove the hematoma was immediately performed following the trauma; however, magnetic resonance angiography (MRA) on day 9 and CT angiography (CTA) on day 10 showed a wall irregularity of the right paraclinoid ICA. Cerebral angiography (CAG) on day 21 revealed that an aneurysm of the right paraclinoid ICA had developed; therefore, trapping with a high-flow bypass was performed on day 38. The bypass using left radial artery was performed between the right cervical external carotid artery and middle cerebral artery (M3), and trapping was performed between the right cervical and just proximal ICAs to a posterior communicating artery. Postoperative CAG showed no filling of the aneurysm and patency of the bypass, and on day 61, the patient was discharged from the hospital without any surgery-related complications. In conclusion, we recommend repeated CAG or CTA and MRA for the diagnosis of traumatic intracranial aneurysms. Additionally a high-flow bypass prior to aneurysm trapping may be useful in the surgical management of traumatic aneurysms of the paraclinoid ICA.