We attempted to construct a new supporting model starting at emergency medical center for disabled patients follow­ing traumatic brain injury (TBI). The goal of the model was the establishment of a system for regional coordination and cooperation among acute phase hospitals, rehabilitation institutes, and life and vocational training facilities.

Chiba prefecture with a population of 6 million people is divided into 9 so-called second medical areas (areas of health­care administration). There was no emergency medical center in 2 second medical areas where were adjacent to Chiba-city, one on the west and the other on the south. The Chiba Emergency Medical Center (CEMC) is located northwest in Chiba-city that is one of 9 second medical areas. First a mini-model was made that was targeted at patients with cognitive dysfunction but independent after TBI. The mini-model consisted of one acute hospital (CEMC) and 3 rehabilitation institutes (one at Chiba-city, 2 at neighboring second medical area). In the next step, the mini-model was also intended for more unfavorable patients including vegetative state ones. We performed a preliminary trial on the basis of the mini-model for 167 patients admitted to CEMC from November 2009 to August 2011. Fifty-seven of 167 patients were dis­charged home, and 110 were transferred to other hospitals or institutes. Twenty-nine (for the mini-model) of 110 patients, including unfavorable elderly patients were transferred to cooperative rehabilitation institutes. Eighty-one patients (not for the mini-model) were transferred to various hospitals or institutes as follows: rehabilitation institutes, 12; hospitals with neurosurgical department, 29; general hospitals without rehabilitation and neurosurgical departments, 38; institutes for the patients in a vegetative state or minimally conscious state, 2. The problems of the construction of the regional co­ordination and cooperation system for TBI were discussed, with particular emphasis on a progressive increase of post-TBI elderly patients with unfavorable outcomes.

Background: Sport-related concussion should be taken more seriously. Repetitive concussion in a short period is likely to worsen a player's injury. To immediately remove players who have concussion, or are suspected of having concus­sion, is the safest way to protect them from a more serious state. Graduated Return to Play (GRTP) after having concus­sion is essential.

Objective: To ascertain the level of understanding of concus­sion among high school rugby players.

Method: We investigated with a questionnaire on concus­sion to 396 high school rugby players who participated in a Tokai District tournament in March 2013. The questionnaire contained the following: knowledge of symptoms and signs of concussion (S&S); knowledge of GRTP; personal experience of concussion (Experience); participation in sports concussion lectures (Lecture); observance of GRTP; and reasons for the non-observance of GRTP. The S&S and GRTP were taken from the International Rugby Board Concussion Guidelines.

Results: The players knew around 70% of S&S and GRTP procedures. Experience, Lecture, GRTP observance, and non-observance were 39%, 56%, 34%, and 38% respectively. The most common reasons for non-observance of GRTP were ignorance of its importance and not knowing of it. The most common S&S they had were dizziness, poor attention, loss of consciousness, and headache (66%, 59%, 48%, and 38% respectively). Players were less aware of inappropriate playing behavior, irritability, and feeling nervous or anxious as symptoms of concussion.

Conclusion: The results of this study showed the high school rugby players had some knowledge of concussion, but it wasn't sufficient and they didn't all complete GRTP. Recognition of concussion, removing the players from the field, and observance of GRTP prevent further injuries. Teachers, coaches, and others concerned with rugby, as well as the players themselves, should know about and practice correct concussion management.

Background: The previous data of Japan Neurotrauma Data Bank collecting head injury was almost enrolled in the urban area. However, head injuries also happen in the mountain area. We analyzed the patients in our hospital located in mountain area in Tokushima prefecture, Japan to find the characteristics of the head injury in mountain area.

Methods: From April 2009 to September 2013, 285 patients with head injury were hospitalized and 10 patients with head injury who were already cardio pulmonary arrest on arrival were transported in our hospital. We researched all these patients and examined characteristics of the patients and mechanism of the injury.

Results: There were 190 men and 105 women, and the mean age was 65.7 years. The head injuries were caused by fall (35.6%), followed by tumble (29.2%) and traffic accident (26.8%). The most frequent cause in the falls was mountain slope (23.8%), followed by stairs (20.0%) and cliff (13.3%). The fall-rerated head injuries sometimes included subarachnoid hemorrhage, acute subdural hematoma and brain con­tusion at once. The most common trauma-related complication about the fall injury was the spinal injury and followed by the lung injury. The most common fatal case of the fall injuries was acute subdural hematoma. Physiological abnormality on arrival, Glasgow Coma Scale score ≦8, diabetes mellitus, dialysis, and anticoagulant or antiplatelet drug were significant factors of the outcome (p<0.05).

Conclusion: In the mountain area of the country, the elder­lies frequently got injured with head and the most common cause of the head injury was fall. Especially, the fall from mountain slope and cliff were very dangerous and these injuries could become the high energy injury for the elderly.

Objective: The Cerebrospinal Fluid Hypovolemia Research Group beneficiary of a scientific research grant from the Ministry of Health, Labour and Welfare (MHLW) has so far adopted a very strict image diagnostic criteria. The purpose of this study is to weigh the MHLW criteria against the existing image diagnostics from the aspect of therapeutic response to epidural blood patch (EBP).

Materials and Methods: Between March 2011 and January 2013, 178 patients suspected with spinal CSF leak underwent combined radioisotope cisternography (RIC) and computed tomography myelography (CTM). A total of 99 patients, 47 patients with RIC direct leak sign (Group P), and 52 patients with indirect findings (Group I), were diagnosed as having spinal CSF leak. 30 patients out of these 99 patients fulfilled the MHLW criteria. Outcomes after epidural blood patch treat­ments were divided into four categories, Excellent (Ex): no symptoms remained, Good (G): returned to premorbid life with minor symptoms, Fair (F): apparent improvement but partially restricted ADL, and No response (NR): no or minimum improvement with severely restricted ADL. Relationships between outcomes and image findings, such as the compatibility with MHLW criteria, patterns of RIC findings (existence or absence of direct leak signs), were analyzed.

Results: 86 patients underwent a total of 141 EBP treatments (average 1.6 times). Overall outcomes were as follows, Ex: 24, G: 25, F: 26, and NR: 11. Approximately 60% of treated patients returned to premorbid life (Ex+G). The compatibility with MHLW criteria did not affect outcomes. Normalization or sufficient reduction of RI clearance after EBP treatments was a significant factor for favorable outcomes.

Conclusion: This study confirmed the reliability of RIC in the diagnosis of spinal CSF leak from the aspect of thera­peutic response. In addition, RIC is a reliable method to confirm the cessation of CSF leak after treatment.

In Japan the number of child abuse cases increases gradual­ly and approaches about 60,000 cases fiscal 2011. A number of neurosurgeons have an experience to child abuse head trauma cases. Since the child abuse prevention law was established fiscal 2000, the opportunity that neurosurgeons were pressed to make the decision against discrimination abuse head trauma case from accidental head trauma case is expanded.

The cause of over 95% severe head injury cases until one-year-old children is abuse. If we do not take counter measure about these abuse cases and discharge these children from hospital to their house, 5% cases will be dead and 25% cases will be come back to the hospital as same situation. Not only neurosurgeons but also pediatricians, medical social workers, and the child consultation center staff deal with the abuse cases together.

At out hospital from November 2001 to April 2014, 72 child abuse cases were reported and 19 cases were involved with neurosurgical problems. In these 19 cases, 8 cases were treated at intensive care unit, and 4 cases were dead within two weeks from admission. 9 cases were acute subdural hematoma, 2 cases were chronic subdural hematoma, 1 case was diffuse axonal injury, and 7 cases were skull bone frac­ture or concussion. 4 cases were needed the surgical treatment.

In our hospital, the child abuse team including neurosurgeons, pediatricians, and medical social workers intervene directly in these abuse cases as soon as possible. But after discharge, we cannot follow up all cases because there are some cases not returning for outpatient clinic. So we should establish the social and medical structure needed to support abused children and their family.

Objective: Consistent with a rapidly growing geriatric population, the age distribution of traumatic brain injury (TBI) is dramatically changing. The management of elderly TBI patients is a serious problem for neurosurgeons in charge of their treatment in Japan. In this study, we sought to clarify the characteristics of elderly TBI patients trans­ferred to our tertiary critical care center, to better under­stand the current situation, prognostic factors, and possible therapeutic strategies.

Method: We retrospectively reviewed all TBI patients aged ≥75 years admitted between 2003 and 2012. Demographics, injury mechanism, radiological findings, injury diagnosis, management, and comorbid status information were ob­tained, as well as outcomes assessed by the Glasgow Outcome Scale at 3 months. Univariate and multivariate analyses were used to identify predictors of mortality and independent living status.

Results: Among 628 consecutive TBI patients, 92 (14.7%) were eligible. The elderly TBI patients had a significantly higher incidence of non-traffic accidents (67.4% vs. 31.5%) and death (27.2% vs.11.6%) compared with those younger than 75 years (p<0.0001). Factors concerning favorable ⁄ un­favorable outcome and alive ⁄ dead were statistically ana­lyzed. In univariate analyses, Glasgow Coma Scale (GCS), GCS motor score, dilated pupils, surgical intervention, serum d-dimer level, prothrombin time-international normalized ratio, injury severity score, and head abbreviated injury score (AIS) were significant in both out­come evaluations. Sex, acute subdural hematoma, and “talk and deteriorate” clinical course correlated with favorable ⁄ unfavorable out­come; heart rate, subarachnoid hemor­rhage, and cranial vault fracture correlated with alive ⁄ dead. Multivariate analysis revealed significance in the mecha­nism of injury, GCS, head AIS, and “talk and deteriorate” clinical course for favorable ⁄ unfavorable outcome; heart rate and subarachnoid hemorrhage were significant for alive ⁄ dead.

Conclusion: Our study confirmed poor outcome and treatment difficulties in TBI patients aged 75 years and older. Multi-disciplinary collaboration is warranted to mitigate comorbidities and functional deterioration in the elderly.

Brachial plexus injury is usually very complex, involving both spinal nerve and spinal root ruptures, and accompanied with avulsion of one or several roots from the spinal cord. It occurs mainly in young individuals and may leads to devastating neurological dysfunction in affected patients. Despite the experience with regards to the treatment of brachial plexus injury increases over the last decades, the functional outcome had been quite limited even in healthy young patients. Recently, all reconstructive procedures includ­ing nerve grafting and neurotization have been providing satisfactory results. We analyze various factors in 54 patients with BPI and discuss about treatment and outcome. As a result, acute repair with sharp injury is best and provided good function in 75% of damaged elements. Neurolysis using nerve action potential is credible, can avoid unnecessary nerve repair and provided good outcome (91%) in stretch injury. Useful recovery (87%) in nerve repair was obtained. In this study, favorable outcome in restoration of shoulder and elbow function was obtained by choosing optimal surgical method in some type of brachial plexus injury. In the future, restoration of distal hand function due to C5 – T1 injury and root avulsion is essential.

Intractable oronasal bleeding can be caused by severe craniofacial injury, and its treatment is often difficult. We report six cases of traumatic intractable oronasal bleeding, which were treated with transarterial embolization using Gelfoam or a platinum coil, and evaluate the efficacy of the endovascular treatments. In all six cases, the oronasal bleed­ing was controlled by transarterial embolization of the external carotid artery. There were no embolic complica­tions, and the patients' circulatory dynamics subsequently stabilized. Three cases underwent decompressive craniecto­my and evacuation of hematoma. The outcomes were good recovery (n=1), severe disability (n=1), a vegetative state (n=3), and death (n=1).

Although the neurological prognosis depended on the type of intracranial injury, there were no major complica­tions related to the endovascular treatment, and the bleeding could be controlled. Endovascular treatment is an acceptable treatment for intractable oronasal bleeding due to severe craniofacial injury.