Background: Suitable maintenance of cerebral perfusion is important to prevent further brain damage, and previous studies have emphasized an influence of bran ischemia on traumatic brain injuries (TBI). ABCD2 score and CHADS2 score are available for predicting subsequent ischemic events of brain. In this study, we investigate whether these stroke risk scores are useful to predict neurological deterioration of TBI.

Methods: 452 patients with TBI were admitted to our hospital from Oct. 2007 to Mar. 2012. Patients with chronic subdural hematoma, and with low ADL were excluded from this investigation. Finally 272 cases were enrolled in this study. ABCD2 score, CHADS2 score and modified Rankin scale (mRS) of these patients were evaluated.

Results: Patients with ABCD2 score of 1 and over demonstrated poor neurological prognosis. But a correlation between ABCD2 score and mRS are not found. CHADS2 score has a significant correlation with neurological prognosis of TBI. Patients with CHADS2 score of 2 and over demonstrated poor prognosis (mRS 3 – 6). And patients with CHADS2 score of 4 and over demonstrated high mortality rate.

Conclusion: CHADS2 score is useful to predict a neuro­logical prognosis of TBI.

Objective: The Cerebrospinal Fluid Hypovolemia Research Group beneficiary of a scientific research grant from the Ministry of Health, Labour and Welfare (MHLW) has con­cluded, that minor traumas, including motor vehicle accident, may cause spinal CSF leak. Because the first aim of MHLW research group was to confirm the occurrence of spinal CSF leak after minor trauma, very strict image diagnostic criteria were adopted. The purpose of this study is to weigh the MHLW criteria against the existing image diagnostics.

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). Serial spinal MRIs were performed before and after combined RIC ⁄ CTM studies.

Results: RIC revealed overt RI leak in 47 patients (Group P), and CTM confirmed CSF leaks in 27 patients. In 52 patients with indirect RIC findings including early bladder filling and/or accelerated RI clearance (Group I), CTM confirmed CSF leaks in 7 patients. Eleven patients presented with typical clinical and radiological features of spontaneous intracranial hypotension (SIH) (Group P: 7, Group I: 4). Serial spinal MRI after combined RIC ⁄ CTM showed increased CSF leak in 33 ⁄ 47 patients (Group P), and 15 ⁄ 52 patients (Group I). In these patients, most CSF leaks were located at thoracolumbar junction.

Conclusion: This study shows spinal CSF leak is a complication of minor trauma. In the diagnosis of spinal CSF leak, RIC has several advantages in addition to its inherent ability, especially when combined with CTM. Combined RIC ⁄ CTM often increases CSF leak, resulting in the enhanced sensitivity of spinal MRI.

Purpose: The jumping has the potential risk of high energy injury. The characteristics of head injury by jumping were compared with that by simple falling during snowboarding.

Material and Method: 513 snowboarding head injury cases consulted at Saito Memorial Hospital and Yuzawa Health Medical Center, Niigata Prefecture, Japan from 2007/08 to 2010/11. The patient's background, traumatic amnesia/ transient loss of consciousness, injured site, organic traumatic lesions were investigated in 278 cases due to falling and in 135 cases due to jumping in the 513 patients.

Results: Mean age was 24.9 years old in falling group, 24.8 years old in jumping group. Male ratio of jumping group 80.0% was significantly higher than that of falling group 58.6% p<0.001). The ratio of traumatic amnesia was almost same in two groups, but the ratio of transient loss of con­sciousness in jumping group 34.1% was significantly higher than that of falling group 12.9% (p<0.01). Organic traumatic lesions were acute subdural hematoma 11; craniotomy was performed two of 11 cases, skull fracture 1, epidural hematoma 1 and maxillary sinus bleeding 1 in falling group, acute subdural hematoma 3, skull fracture 1 and subarachnoid hemorrhage 2 in jumping group.

Conclusions: The clinical features between the two groups showed the differences. Head injury by jumping might inflict greater damage for the brain.

Background: The indication of radiological examination for head injury in children often discussed. The aim of this study was to identify clinical factors related to abnormal findings on radiological examination.

Methods: We enrolled 565 patients younger than 15 years, who underwent radiological examination for head injury between January 2009 and December 2010. We collect data on 3 parameters: age, subjective symptoms such as nausea, vomiting and headache, and scalp hematoma.

Results: There were no significant differences in abnormal findings on radiological examination between patients aged 0–2 and 3–15 years old, and between those with and without subjective symptoms. Seven of 276 patients without scalp hematoma, 14 of 225 with small scalp hematoma (< 3 cm), and 17 of 26 with large scalp hematoma (> 3 cm) showed ab­normal findings. There was a significant difference between the three groups (p<0.0001).

Conclusion: Scalp hematoma, especially that more than 3 cm, should be considered as an indication for radiological examination in children with head injury.

Symptomatic chronic subdural hematomas of the posterior fossae are rare, with only 7 surgical cases having been described in the CT era.

Herein, we report a rare case of an 80-year-old female with chronic subdural hematomas of the posterior fossae who complained of headache and vomiting. Hematoma irrigation by burr hole surgery was safely confirmed by intra­operative CT. Her symptoms were relieved immediately by the operation.

The case is a 23-year-old man. He collided into a tree while snow boarding. He was transported to our hospital due to an impaired consciousness. His level of consciousness at admission was E1V2M5/GCS and he suffered from left hemi­plegia. The diagnosis upon admission was “pneumo­cephalus, fracture of the right sphenoid sinus wall, left occipital bone fracture, fracture of the mandible, left pneumo­thorax, bilateral pulmonary contusion”. When intensive care was carried out and neurologic findings were confirmed along with his recovery of consciousness, a diagnosis of Millard-Gubler syndrome was made from the observation of right abducens nerve palsy, right facial paralysis and left hemiplegia. The present case is a rare and independent case of brain stem injury, caused by both hyperextension and hyperflexion of the neck to the mandible bone and occipital bone was considered from the fracture. During follow-up, there was no prominent accelera­tion of ICP and secondary brain injury was ruled out. Although the time of onset of the symptoms is unknown, the prognosis of the nerves was relatively good. Regarding the image findings, MRIT2-weighted imaging and FLAIR imaging showed a pale spotted high-signal area was indicated only in the right central part and basilar part of the pons; however, no low signal region suggesting bleeding was observed upon T2star-weighted imaging.

This case was believed to be a shearing strain injury　because the lesion was in a somewhat deep part of the brain stem and the brain surface was maintained.

We report the case of a penetrating injury due to a pruning shears. A 54-year-old male felt down from a stepladder and a pruning shears stuck his right ear. He was transferred to our emergency room in the state that a pruning shears stuck. At the time of removing another stretcher in our emergency room, a pruning shears was come out. Bloody cerebrospinal fluid (CSF) was flowed out from his right ear. His consciousness was normal and had no neurological deficit. A brain computed tomography (CT) revealed intracranial air in the posterior fossa and penetrating fracture of the right pyramidal bone. Subarachnoid hemorrhage and brain contusion were not recognized. Three dimensional CT angiography (3D-CTA) revealed no damage of the major vessels. Instead of surgical craniotomy, spinal drainage was placed for 24 days. CSF leak was under control and not detected 21 hospital day. Meropenem hydrate (3.0 g/day) was used prophylactically for 28 days and infectious complication was not occurred. Although slight sensorineural hearing loss remained, the patient returned his work. However, surgical operative strategy in penetrating injury cases is usually managed, there are some cases cured by conservative treatment.

A 11-year-old girl suffered a minor head injury during a snowball fight. She showed an abnormal behavior several hours later and consulted our hospital the next day. An acute ischemic lesion was detected in the left caudate head on CT. MRA revealed string sign in the left A1 and A2 segment. A diagnosis of posttraumatic anterior cerebral artery dissection was made. Cerebral angiography per­formed 11 days after head injury revealed occlusion of left anterior cerebral artery. The occlusion of the anterior cerebr­al artery after minor head trauma is extremely rare condition and has not reported so far.

Pseudoaneurysm of the superficial temporal artery (STA) is found as a pulsatile cystic mass in a temporal area, but is rarely reported. We report a case of pseudoaneurysm of the STA in a patient with cirrhosis who has a tendency to bleed.

A 53-year-old man presented with a pulsatile mass in the left temporal region which developed a month after head injury from a bicycle accident after drinking. The mass was 3 cm in diameter and compressible, and decreased in size after manual compression of the proximal STA. 3D-CT Angiography showed a pseudoaneurysm of the left STA. At first, we treated the pseudoaneurysm with conservative treatments because of the tendency to bleed caused by cirrhosis. But the pseudoaneurysm kept growing and formed ulcer in the top of the pseudoaneurysm, therefore we resected the pseudoaneurysm with ligation of the proxim­al and distal ends of the STA. There is no recurrence after the resection of the pseudoaneurysm.

The pseudoaneurysm of STA could not be cured by the conservative treatments in this case. Surgical resection of the pasudoaneurysm of STA should be recommended even though a patient has risk factors such as a tendency to bleed.