In the Japan Neurotrauma Data Bank, Project Study (PRJ) and One Week Study (OWS) were performed. This study was conducted to clarify the recent trends of head injury in the aged patients. The data in the PRJ 2009 and the OWS 2012 were compared with those in the PRJ 2004 and OWS 2005, respectively.

The aged was defined as 65 years of age or older. The number of the aged patients was 253 in OWS 2005, and 319 in OWS 2012, 383 in PRJ 2004 and 479 in PRJ 2009. The following factors were analyzed: age, cause of injury, alcohol intake before injury, Glasgow Coma Scale (GCS) score, CT findings, incidence of multiple systemic injury (abbreviated injury score 3 or more), treatment and outcome at discharge.

Results: The recent treads of geriatric head injury were as below: 1) Age was relatively higher, 2) Fall or tumble was more common, 3) Alcohol intake was more frequent in the bicycle group of the PRJ 2009, 4) The proportion of combination of focal and diffuse injuries was increased in OWS 2012, and the rate of nonevacuated mass was decreased in PRJ 2009. Acute subdura hematoma was increased in percentage in both the OWS and the PRJ, 5) Treatment; Neurosurgical operation was unchanged in the OWS, but increased in the PRJ. In addition, the administration of hyperosmotic agent was less frequent in the PRJ 2009, 6) Outcomes at discharge were unchanged in the PRJ.

These results suggested that the outcomes of geriatric head injury had not been improved, even though the treatment had been more active and reasonable. The prevention of head injury is indispensable in the aged population.

Severe head injuries with organic lesions in skiing were characterized. We reviewed the patients, backgrounds, the situations of 30 head traumas (6.0%) with organic lesions, out of 504 skiing-related head injuries from 2004/05 to 2012/13 winter seasons in Niigata, Japan. The patient ages were from 8 to 75 (average 37.0 ± 19.0). They were 27 men and 3 women. 30 lesions consisted of 16 cranio-facial fractures, 7 acute subdural hematomas, 3 subarachnoid hemorrhages, 2 brain contusions, an epidural hematoma and a chronic subdural hematoma.

The predominant feature of ski-related severe head injuries in this period is that expert or intermediate skier hit forehead by fall or jump or collision at a gentle slope. Craniotomies were performed in 2 subdural hematomas and the outcome was GR in 59-year-old woman and was MD in 75-year-old man, respectively.

In comparison with the past nine seasons (1994/95-2003/04) study in this area, the characteristics in this period is that the number of patients, the number of severe head injuries, the number of operation were decreased. The average age of the patients increased. The predominant feature of ski-related severe head injury in the past period is that intermediate skier hit a forehead by collision at a middle slope. There were differences in the pattern, situation and mechanism between those two periods. Greater awareness may be needed to ensure safety, especially helmet use and manner observance.

Background: Traumatic optic neuropathy (TON) is an important cause of severe visual loss following head trauma. TON occurs in the setting of head injury, often as a consequence of road traffic accidents or falls. Most TON patients are young males. TON is rare event overall but has a large effect on QOL. Decompression surgery and steroid therapy are both effective in improving visual acuity after TON. Difficulty in choosing between these treatments for individual patients has hindered the establishment of a standard strategy for managing TON. This paper reports how we selected between surgery and steroid treatment for TON at our institute, and the results we accordingly attained.

Methods: Twenty-two patients treated at the emergency department of our hospital were studied. The visual prognosis was assessed for TON patients undergoing de­compression surgery and TON patients undergoing steroid. The patients who underwent surgery were selected based on the guideline for severe brain injury issued by the Japan Society of Neurotraumatology.

Results: On admission, 22 patients had light perception and 5 of 22 patients had optic canal fracture on CT. Four of the 5 patients with optic canal fracture underwent decompres­sion surgery and all 18 of the remaining patients received steroid therapy. Eleven of the 18 (61%) steroid-treated patients recovered visual acuity and 4 of 4 (100%) surgical patients had good outcome.

Conclusion: Decompression surgery was effective on strictly selected cases. On the other hand, the steroid therapy also had a good outcome. The choice between these treatments remains difficult, as both treatments are effective for TON. We need to carefully consider each patient and conduct a larger study to establish a standard strategy for TON.

Objective: To establish an accurate and comprehensive incidence report of head injuries and to propose safety measures in Japanese rugby football.

Methods: We reviewed the injury reports of the Japan Rugby Football Union between April 1996 and December 2013, and picked out the catastrophic brain injuries, which is defined by the World Rugby as 12 or less in Glasgow Coma Scale after 48 hours after the incident. Annual numbers of injured players, their ages, phase of play where the injuries occurred and diagnoses on the reports were analyzed.

Results: There were 80 catastrophic brain injuries, including 15 fatalities, in those 17.8 years, averaging 4.5 cases per year. Five injuries happened in junior high-school students, 40 in high school, 16 in college, and 20 in adult players mostly belonging to local amateur club teams. One injury case occurred in a scrum, 23 resulted from being tackled, 42 while tackling, 7 due to ruck, 5 by collision whereas 2 cases were referred to unknown cases. Reported diagnoses included 47 acute subdural hematomas, 13 intra­cerebral hemorrhages, 6 cerebral contusions but 14 cases were not specified.

Conclusion: Tackle-related plays are the most predominant cause of catastrophic brain injuries in Japanese rugby football. Because of their higher incidence in high school and college players, it is essential to educate all of these team leaders about safety measures for reducing catastrophic injuries. Players as well as coaches should also understand the risk concerning possible recurrence of acute subdural hematoma, which requires further investigation and study.

Background: Chronic subdural hematoma (CSDH) is a benign entity and can be treated surgically in most cases. In recent years, the number of patients has been increasing with the aging population and appropriate treatment is required in terms of health economics.

Materials and Methods: In 2007 a clinical pathway (CP) for surgical treatment of CSDH was developed in our department. Most of the patients underwent craniostomy and drainage of hematoma via small skin incision on the forehead without hair removal on the day of admission, and were discharged the next day with a small adhesive plaster over the operative scar. Sixty-one CSDH patients were admitted to our department between 2007 and 2011. Fifty-one patients were included in the CP while the remaining 10 patients were excluded for various reasons, including bad general and/or neurological conditions, inconvenience in revisits to the hospital from a remote place, and family's dissent. In 15 patients out of the 51 included patients, variances in clinical pathway were observed due to surgical and/or systemic complications, delayed recovery of ADL, or family refusal of discharge.

Results: Most of the patients showed quick recovery after surgery, except for a patient in the excluded group who suffered a femoral fracture as a complication from delirium and wandering on Day 12, which resulted in poor outcome. Recurrence occurred in 3 of the 61 patients (4.9%), which compares favorably with previous reports. The mean number of hospitalization days was 7.1. It was significantly shorter than that of 53 patients treated between 2001 and 2006 before CP had been developed.

Conclusion: Reduction of hospital stay after the implementation of CP was achieved without deterioration in quality of medical care. Shorter hospital stay may possibly reduce major complications due to dementia.

Accident is a major cause of death in children. In pediatric head trauma, there are some patients with skull fractures which might originate from familial carelessness. Here, we investigated the characteristics of the pediatric skull fracture patients who were admitted to our hospital emergency department. From April 2009 to September 2013, 94 patient under 15 years old with skull fractures were studied. The each number of patient was 46 (0 – 2 y.o.), 23 (3 – 6 y.o.), 17 (7 – 12 y.o.), and 8 (13 – 15 y.o.), and the rate of boys were 63%. According to mechanism of injuries, there were 64 patients in falls, 11 in pedestrian vs. vehicle, and 1 in abuse. Parietal bone fractures were frequently observed in falls, and many patients showed multiple skull fractures in accidents and depressed fracture in direct hit of things. Almost patients (86%) were treated conservatively, while a surgical intervention was more needed to the patients in traffic accidents. Good prognosis accounted for 90%, although increased poor prognosis was observed in the traffic accident cases. Because epidemiology of pediatric head trauma in Japan is less, it was considered necessary to continue the future investigation.

Object: Retrospinal C1-C2 fluid collection (C1-C2 sign) is known as a sign on cervical magnetic resonance (MR) imaging in patients with intracranial hypotension. In recent consecutive 7 patients treated in our hospital for intracranial hypotension, 3 patients manifested C1-C2 sign on sagittal T2-weighted fat-suppressed cervical MR imaging. We hereby report these three cases of intracranial hypo­tension manifesting C1-C2 sign with special reference to diagnost­ic imaging and pathophysiological implication.

Methods: The findings of radioisotope cisternography (RIC), cranial MR imaging, spinal MR imaging, MR myelo­graphy, and computed tomography (CT) myelography of 3 patients with C1-C2 sign on cervical MR imaging were retrospectively reviewed.

Result: All three patients developed intracranial hypoten­sion following trauma. The common imaging findings for 3 patients of intracranial hypotension with C1-C2 sign were diffuse dural enhancement on cranial MR imaging, C1-C2 sign on spinal MR imaging and MR myelography, floating dural sac sign (FDSS) on spinal MR imaging, and early bladder radioisotope accumulation on RIC.

Conclusion: Both FDSS and C1-C2 sign on T2-weighted fat-suppressed MR imaging are important findings of intracranial hypotension following trauma. From the imaging findings, we classified spinal cerebrospinal fluid leak into extra spinal canal leak, epidural leak, and enhanced absorption.

We here report a case of organized chronic subdural hematoma radically cured by small craniotomy with neuro­endoscope. A 75-year-old woman presented with right motor weakness and aphasia. Burr hole trepanation surgery was performed, but the hematoma was hardly removed, because of the hardness of the hematoma. Based on the first operation findings, the diagnosis was organized chronic subdural hematoma. We planned the craniotome surgery. However, the general anesthesia seemed to be risky because the patient suffered from cirrhosis of the liver and angina pectoris. That was why we used the rigid neuroendoscope under local anesthesia (1% lidocaine) with propofol and pentazocine providing sedation. Intraoperatively, two burr holes were made and connected. The final opening was approximately 4 cm in diameter. Her symptom was free after this surgery. No recurrence of hematoma was encountered after an operation for two years. This operative method is less invasive than wide-ranging craniotomy to evacuate the hematoma. In addition, advantages of the endoscopic approach include access to the entire hematoma cavity through a small craniotomy and electrical coagulation of active bleeding. Organized chronic subdural hematoma is generally treated by broad craniotomy under general anesthesia. Our case indicates that this method represents a feasible treatment option for elderly patients at high risk for general anesthesia who suffers from organized chronic subdural hematoma.

On baseball with large player population, severe head injuries have frequently occurred as compared with other sports. Since 2009 we treated six patients with severe head injuries on baseball, two of them underwent surgical treatment for the injuries, caused by pitching machine. Although the majority of baseball-related head injuries were caused by direct impact with the ball, the pitching machine that propelled high velocity ball is known to cause severe head injuries. We report here our pitching machine related head injury cases as warning.

A chronic subdural hematoma (CSDH) is a hematoma present in a capsule within the subdural space, which develops in the chronic phase after minimal head trauma. Refractory CSDH, a CSDH that recurs repeatedly after burr-hole drainage, has been reported in some cases. A 76-year-old man who lived alone and had a history of alcoholic liver dysfunction and hypertension presented with left hemi­paresis after head trauma. Computed tomo­graphy (CT) revealed a right CSDH, and he underwent burr-hole drainage. CT performed the next day showed a recurrence of CSDH with slight left hemiparesis, but no surgery was performed. He developed left hemiparesis after l7 days, and CT showed increase of hematoma. He underwent surgery 7 times for 5 recurrences (3 burr-hole drainages, burr-hole drainage after embolization of the middle meningeal artery [MMA], hematoma evacuation with capsulectomy and hematoma evacuation). He had a recurrence of CSDH for about 2 weeks after each operation. CT performed after the last operation showed no recurrence. Several clinical factors could have caused the recurrences in this case. Potential coagulopathy due to alcoholic liver dysfunction may have been the major factor contributing to the recurrences. There are three treatment options conventionally used for CSDH: burr-hole drainage, embolization of the MMA, and capsulectomy. In this case, capsulectomy proved to be effective in preventing recurrence.