Chronic subdural hematoma is one of the most common diseases encountered in neurosurgical practice. Although its treatment method is well established, the recurrence factor is not clear.

To identify the recurrence factor, we compared the clinical features of recurrence cases and non-recurrence cases of the same patients. The study included 87 cases (96 hematomas) that had undergone burr-hole surgery between January 2000 and December 2013. The study was retrospectively analyzed. Recurrence was defined as the time at which recurrence warranted re-drainage.

The recurrence factors were preoperative consciousness, preoperative paralysis, volume of preoperative hematoma, bilateral operation, and volume of postoperative hematoma and air.

We concluded that operation should be performed, before hematoma increases and symptom progresses, for preven­tion of recurrence.

Purpose: The prediction of outcome in patients with diffuse axonal injury (DAI) is usually difficult in the acute phase. Although several prognostic factors of DAI have been reported previously, conventional neuroimaging techniques like computed tomography and magnetic resonance imaging (MRI) are limited in their outcome prediction. The purpose of this study is to determine whether brainstem injury and the number of injured regions identified using susceptibility-weighted imaging (SWI) are useful in predicting the outcome of acute phase DAI patients.

Materials and Methods: Eight patients with DAI (median age 19 years, mean GCS score 8.9) were examined retrospectively with MRI, including fluid-attenuated inversion recovery and SWI, and the number and distribution of injured regions was evaluated. To evaluate injured regions, the brain was divided into 14 regions: brainstem, corpus callosum, bilateral frontal, parietal, temporal, occipital lobe, bilateral basal ganglia, and bilateral cerebellar hemisphere. Patients were divided into three groups, according to the Adams et al. classification. Outcome was assessed at 30 days post-injury using the modified Rankin Scale (mRS).

Results: Grade 3 DAI was found in four patients using SWI and two patients using FLAIR. On SWI only, grade 3 DAI patients showed significantly higher mRS than grades 1 and 2 (p=0.02). A large number of injured regions on SWI correlated significantly with poor mRS (p=0.0004). The median mRS was 3.5.

Conclusion: SWI is useful for evaluating the number and distribution of injured regions in DAI patients, and correlates with mRS 30 days post-injury.

A total of 8 consecutive patients with traumatic optic neuro­pathy (TON) underwent extradural optic canal de­compression via the trans-superior orbital fissure (SOF) approach between September 2009 and August 2014. We retrospectively review medical charts, radiological findings, surgical techniques, complications, and final surgical results. All 8 patients presented with visual disturbance caused by head and/or face injury. Two patients had no light perception, 6 had light perception, and 2 had ophthalmoplegia. All patients underwent extradural optic canal decompression and high-dose steroid administration within 24 hours after injury. Postoperative visual acuity on discharge was im­proved in 6 patients and unchanged in 2 patients with ophthalmoplegia gradually recovered by 3 months after injury. Postoperative outcome was good recovery in 7 patients and moderate disability in one patient. There were no complications related to the surgical procedure. The advantage of this surgical procedure is easy identification of the optic canal, resulting in fewer surgical complications, and this procedure can also achieve intraorbital decompression. We recommend extradural optic canal decompression via the trans-SOF approach as a safe and reliable procedure in patients with TON.

Background: Most patients recover fully from mild traumatic head injury (mTHI), but a few patients have persistent neurocognitive problems. The purpose of this study is to provide whether magnetic resonance imaging (MRI) can provide more detailed information of the mTHI than computed tomography (CT) in the young patients.

Methods: We enrolled 20 patients younger than 20 years with mTHI, who underwent CT and MRI in the acute stage after injury. We compared the intracranial traumatic findings (ITF) of CT with MRI. Furthermore, we compared the depiction ability of ITF on 2D image with 3D image.

Results: One (5%) of 20 patients had ITF with CT (acute sub and epidural hematoma 1). 5 (25%) of 20 had ITF with MRI (acute sub and epidural hematoma 1, brain contusion and acute subdural hematoma 2, and brain contusion 2). There was no significant difference the time needed to MRI scanning form CT scanning between positive group and negative group of ITF with MRI (p<0.07). 3D image of FLAIR was more sensitive for the visualization and detection of ITF than 2D image.

Conclusion: MRI is more sensitive than CT in the detection of ITF with mTHI. Particularly, 3D FLAIR provides detail information of ITF.

Objective: To report an accurate and comprehensive incidence of spinal cord injuries and to propose preventive methods 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 spinal cord injuries, which is defined by the World Rugby as A to D of American Spinal Injuries Association scale after 48 hours after the incident. Annual numbers of injured players, their ages, phase of play where the injuries occurred and injured level were analyzed.

Results: There were 105 catastrophic spinal cord injuries, including 1 fatalities, in those 17.8 years, averaging 4.5 cases per year. Four injuries happened in junior high-school students, 39 in high school, 26 in college, and 36 in adult players mostly belonging to local amateur club teams. Twenty-eight injuries occurred in scrums, 16 resulted from being tackled, 25 while tackling, 20 due to ruck, 7 in mauls, 7 by collision, whereas 2 cases were referred to unknown causes. Thirty-three injuries of 58 reported diagnoses included the lesion between C4/5 and C5/6.

Conclusion: A certain cases of catastrophic spinal injuries are occurred during rugby football in most of countries where rugby is popular including Japan despite of safety measures. Scrum, ruck, and tackle-related plays are the predominant causes of them. Because of their higher incidence in high school and college players, it is continuously essential to educate all of these team leaders about preventive methods and to enforce laws of the game implementation for reducing catastrophic injuries.

Background: Decompressive craniectomy (DC) is used to improve the brain herniation or increased intracranial pressure caused by brain swelling as the result of severe traumatic brain injury or severe acute stroke. When the intracranial pressure is normalized, cranioplasty is per­formed in a second stage using autologous or artificial bone. Hinge craniotomy (HC) as a one-stage surgery was reported by Schmidt in 2007.

Objective: To examine the merits and detractions of HC compared with conventional DC.

Method: We performed DC for 19 and HC for 9 patients from 29 to 99 years old, between April 2012 and March 2014. We compared outcomes, number of days of hospitalization, and rates of infection between the groups.

Results: DC was performed for infarction (n=2), hemor­rhage (n=3), SAH (n=10), and trauma (n=4); and HC for infarction (n=5), hemorrhage (n=3), and trauma (n=1). The outcomes of DC excluding SAH were GR (n=1), SD (n=1), PVS (n=5), and D (n=2), in which 1 case of death was because of disease other than in the head. The outcomes of HC excluding SAH were MD (n=1), SD (n=3), PVS (n=1), and D (n=4) in which 2 cases of death were because of diseases other than in the head. There were 95.8 days of hospitalization excluding death for DC and 86.8 days for HC. We did not observe infection of wounds in these cases.

Conclusion: The study shows that HC has the effect of reduced intracranial pressure and preventing sinking skin flap syndrome, and may reduce medical costs.

Acute subdural hematoma (ASDH) is classified into simple hematoma type (S-type) and complicated hematoma type (C-type), based upon the presence or absence of brain tissue injury. This study retrospectively examined the clinical characteristics of 72 consecutive patients with ASDH admitted to our institution from January 2008 to October 2014.

Patients were classified into C-type (n=43; 59.7%) or S-type (n=29; 40.3%) groups on the initial CT findings. C-type cases were predominantly caused by traffic accidents (46.5%), whereas S-type cases were caused by falls (75.9%). The percentage of patients with Glasgow Coma Scale (GCS) score of 8 or less was higher among the C-type group than that among the S-type group (54.6% vs. 24.1%; p=0.016). The C-type group also had significantly shorter mean time from injury to surgery (p=0.012) and more frequent performance of targeted temperature management (p=0.021). The percent­age of patients with a favorable outcome on discharge was lower for the C-type group (27.9%) than for the S-type group (48.3%) (p=0.087). These findings demonstrate that trauma severity and urgency are higher for C-type than for S-type.

Despite these differences, patients with C-type and S-type with GCS score of 8 or less showed similar rates of favorable neurological outcome (13.0% vs. 14.3%, respectively). We noted that 4 ⁄ 7 (57%) patients an S-type with GCS score of 8 or less were transferred to our institution after neurological deterioration and subsequently had a poor outcome. It is important to transmit patient’s information to local health facilities and nursing home, and to educate senior family.

Objective: Although several hypotheses regarding the developmental mechanism of arachnoid cyst (AC)-associated chronic subdural hematoma (CSDH) have been proposed, the mechanism has not yet been clarified. We applied burr-hole evacuation to AC-associated CSDH and investigated its developmental mechanism based on the presence or absence of postoperative size reduction of AC.

Subjects and Methods: The subjects were 6 patients with AC-associated CSDH treated at Toho University Omori Medical Center between January 2003 and December 2013 who were followed for 6 months or longer after discharge. Clinical, pre- and postoperative computed tomography (CT), and magnetic resonance imaging (MRI) findings were evaluated.

Results: Hemorrhage was noted in AC in 4 patients. The AC size decreased within one day after surgery on CT, and AC did not expand for 10 months and thereafter in all 4 patients. In contrast, in the remaining 2 patients without hemorrhage, the AC size did not change after surgery.

Conclusion: It was assumed that AC wall breakage was involved in the cases accompanied by hemorrhage in AC. In contrast, AC remained for a prolonged period after surgery for CSDH in the cases without hemorrhage in AC, suggesting that CSDH was caused by damage of vulnerable blood vessels on the AC surface or intracranial imbalance due to the cyst.

Prediction of prognosis of patients with traumatic brain injury (TBI) is very important for rehabilitation of the patients. However, the prediction of prognosis of TBI is more difficult than that of other diseases such as cerebro­vascular diseases, because the severity of brain damage of patients with TBI is unclear. We retrospectively investigated efficacy of rehabilitation and clinical outcome of a series of 94 patients with traumatic brain injury (TBI) admitted to our rehabilitation hospital. In-hospital rehabilitation improved both motor and cognitive function of patients with TBI. Motor and cognitive Functional Impairment Measure (FIM) was significantly improved after rehabilitation. In most of the patients, the cause that impaired their activities of daily living was decline of cognitive and neuropsychological function. The good outcome group (Extended Glasgow Outcome Scale was 7 and 8, n=44) is significantly younger and shows high score in Functional Independent Measure and neuropsychological batteries at admission than those of the poor outcome group (Extended Glasgow Outcome Scale was 1–6, n=50). Functional outcome of the patients with TBI depended on the severity of admission in the rehabilitation hospital. But FIM efficacy showed no difference between the good and the poor outcome groups, an appropriate rehabilitation is effective even in severely damaged patients. The age of patients and score of Mini Mental State Examination at admission were significantly related to clinical outcome of patients with TBI in a multivariate analysis.

We report herein the case of a 64-year-old man who presented with bilateral upper limbs neuropathic pain and bilateral lower limbs spasticity and clonus induced by spinal cord injury. The patient underwent spinal cord stimula­tion (SCS) for upper limbs neuropathic pain. Two electrodes were placed in C4–7 level. Visual analog scale was improved 79 to 16. Then, the patient underwent intrathecal baclofen (ITB) therapy for lower limbs spasticity. Ashworth scores were all improved. The combination therapy of SCS and ITB is effective for the case of coexist neuropathic pain and spastici­ty.

Traumatic Middle Meningeal Artery Aneurysm (TMMA) is rare and associated with high mortality (20 – 50%). Skull fracture is usually an associated feature of this entity (70 – 90%). We present two cases of TMMA after head injury with acute epidural hematoma. One case was treated by endovascular therapy before rupture. The other case was conservative therapy because TMMA spontaneously regressed. The both of two cases had good outcome. Only little is known about the natural history of TMMA and the treatment guidelines. However, some authors suggested that TMMAs are more common than the previously thought. It is important to be aware of possible TMMAs in case of head trauma, especially with the fracture of temporal bone near the middle meningeal artery because they can lead to acute or delayed intracranial hemorrhage associated with high mortality. Surgical treatment or endovascular treatment is selected for TMMAs. Recent reports suggested that endovascular treatment is widely used as the first approach for TMMAs because it is minimally invasive, feasible and effective. It is possible that more of TMMAs will be detected with increased use of noninvasive vascular imaging such as 3D-CTA and MRI/A.

The effectiveness of the middle meningeal artery embolization has been reported for chronic subdural hematoma started acute epidural hematoma is trauma disease. In cases of acute epidural hematoma, we want to report a case of a hematoma removal and middle meningeal artery embolization in the small open head was performed in a hybrid operating room.

66-year-old woman was introduced to fall to our department, it was recognized right of acute subdural hematoma, brain contusion and left acute epidural hematoma in CT. General anesthesia is difficult, I went hematoma removed in the small open head. However, since the opposite side of the epidural hematoma has expanded, it went again hematoma removal. For traumatic DIC it was difficult hemostasis. We have added the embolization of the middle meningeal artery in the hybrid operating room. She has passed without postoperative rebleeding.

Using the hybrid operating room, the middle meningeal artery embolization for acute epidural hematoma was safe and effective hemostasis auxiliary.

In the emergency medical field, brain death due to cases such as head trauma or stroke frequently occur. The role of the physician is not only to provide advanced medical care, family care and medical condition description is also re­quired. But, the contents obtained from the brain death determination and subsequent family, sharing of information in the medical staff and co-medical is often inadequate.

Such middle, in July 2010, "Act for Partial Revision of the law on organ transplantation (so-called, the revised Organ Transplant Law)" was enacted. In the low’s contents, even if there is no intention on the organ donation of the person, brain death under organ donation if there is a family consent it was possible. Also it became possible brain death under organ donation from children younger than 15 years. And, because the organ donation case by family hope was in­creased in the later law enforcement, and is forced to respond in the medical institutions in each region. In recent years, medical physicians (particularly, including emergency physicians and neurosurgeons), nurse, and clinical labora­tory technicians, request of advanced knowledge of the correspondence after brain death state and brain death has increased in organ donation medical institutions. Their requests in the emergency medical field is a burden on the organ donation of medical institutions, has increased. Especially in their burden, support from the other hospital for brain death determination, the coroner by the police of the exogenous case, and cooperation with child consultation centers is important for pediatric case.

Therefore, we evaluated the implementation of the simula­tion for the cooperation with the police and child consulta­tion center.