【 解　説 】 「スポーツにおける脳振盪に関する国際会議」 はおよそ4年に一度開催される。2001年にウィーンで第１回会議が開かれ，第2回 （プラハ，2004年），第3回 （チューリッヒ，2008年） を経て，2012年には再びチューリッヒにて 「第4回国際スポーツ脳振盪会議」 が開催された。この4回にわたる国際会議の目的は，選手の安全確保と健康改善であり，プロフェッショナル，アマチュアを問わず，スポーツで脳振盪を負った選手の状態を正しく評価し，安全にスポーツに復帰させることを目指すものである。さまざまな分野のエキスパートが討論を重ねて 「共同声明 （consensus statement）」 を発表する一方，脳振盪を負った選手の臨床所見を競技場内外で明らかにする評価ツール 「Sport Concussion Assessment Tool （SCAT）」 が作成された。

SCAT2からSCAT3への改訂にあたって変更されたのは，重症な状態を早期に評価できるようにしたことである。はじめに救急対応を取るべき状態 （Glasgow Coma Scaleが15点未満，精神状態の悪化，脊髄損傷の可能性，症状の進行 ・ 悪化あるいは新たな神経症状の出現） が記載された。そのため，SCAT2では3番目の評価項目であったGlasgow Coma Scaleが1番目に変更され，意識状態の評価を早期に行うことを重視している。さらに5項目目に頚部の評価が加えられ，脊髄損傷などの重症外傷を評価できるよう改訂された。バランステストの項目では，SCAT2ではModified Balance Error Scoring System （BESS） を用いて評価していたが，SCAT3ではBESSとつぎ足歩行の両方か，もしくはどちらか一方を選択できるようになっている。またSCAT2は10歳以上を対象にしていたため，SCAT3では13歳未満の選手用にChild SCAT3が追加された。

以下は，

McCrory P. Consensus Statement on Concussion in Sport: The 4th international Conference on Concussion in Sport, Zurich, November 2012. BJSM 47（5）: 250-258, 2013.の翻訳である。

Introduction: We retrospectively analyzed surgically treated “talk and deteriorate (T&D)” patients at our institution to find an appropriate management of this potentially preventable poor outcome head injury.

Materials and Methods: From January 1996 to November 2014, a total of 468 patients with mild head injuries (GCS≧13) were admitted to our institution. Among these, 16 patients were identified as T&D. We defined T&D as a patient who utters comprehensible speech at some time after head injury and then deteriorates to a severe state (GCS score 8 or less) within 24 hours after injury. Clinical characteristics of these patients were analyzed.

Results: Of the 16 T&D patients, 10 were men, and 6 were women, aged 16–89 years (mean ± standard deviation (SD) = 65 ± 19). Thirteen patients were injured in non high energy trauma. All deterioration was due to intra-cranial hematomas, mostly acute subdural hematoma. Time interval from accident to deterioration was 1–15 hours (mean ± SD ＝ 4.4 ± 4.0). All patients underwent craniotomy, two of these craniectoy and 5 indwelled intracranial pressure monitoring. Two died and 6 were left in moderate disability or severe disability status. The remaining 8 patients had good outcome.

Conclusion: The most important factors in saving these patients are rapid diagnosis and immediate surgical decompression before irreversible brain damage sets in.

Background: Standard surgical treatment for traumatic intracranial hemorrhage such as acute subdural hematoma and brain contusion is craniotomy or craniectomy with general anesthesia. However, we offen hesitate surgery for patients who have severe general state or elderly. For these patients, endoscopic surgery is performed in our hospital. In this study, we investigated cases of traumatic intracranial hemorrhage treated with endoscopic surgery and its surgical results retrospectively.

Methods: Thirteen patients with traumatic intracranial hemorrhage were admitted to our hospital and treated with endoscopic surgery from April 2008 to August 2015. Nine patients with brain contusion and 4 patients with acute subdural hematoma was included. We investigated following factor: age, sex, pre-operative consciousness, hematoma volume and thickness, evacuation rate of hematoma, complication and modified Rankin Scale (mRS) at discharge.

Results: All cases were treated with endoscopic surgery only without decompressive craniectomy. In cases of brain contusion, mRS at discharge was 0–2: 4 cases (44%), 3–5: 3 cases (33%), 6: 2 cases (22%). In cases of mRS 6, cause of mortality was myocardial infarction and sepsis, respectively, and no case died of brain trauma. In cases of acute subdural hematoma, mRS at discharge was, 3–5: 3 cases (75%), 6: 1 case (25%). Cause of mortality was rebleeding.

Conclusion: Endoscopic surgery for traumatic intracranial hemorrhage is a treatment option if its indication is considered carefully. While it is not sufficient for hemostasis, endoscopic surgery is less invasive and possible to perform sufficient decrease of intracranial pressure com­pared with craniotomy or craniectomy. The number of endoscopic surgery for traumatic intracranial hemor­rhage is still small, further studies are needed.

A patient over 60 years old who had suffered gunshot wound to the head was transported to our hospital by emergency medical helicopter service. Computed tomography (CT) revealed the bullet had entered from the right parietal region, penetrated the brain, and lodged in the left parietal bone, leaving numerous bone and metal fragments scat-tered within the brain. Acute subdural hematoma (ASDH) on the left side had caused midline shift. Emergency decompressive craniectomy was performed to remove the hematoma and extract the bullet. Acute brain swelling occurred during dural closure, so evacuation of the necrotic brain and extensive duroplasty with artificial dura were also performed. Unfortunately, the patient died of central herniation the day after surgery. As gun ownership is strictly regulated under the Firearms and Swords Law, gunshot wounds are extremely rare in Japan. In particular, treatment of gunshot wounds to the head is hardly ever experienced. ASDH is rare after gunshot wound to the head, with only one case on the entry side, but the present case occurred on the opposite side to the point of entry. In general, ASDH is caused by tearing of the bridging veins in the subdural space and/or bleeding from the contusional brain. In the present case, the subdural hematoma on the opposite side to the point of entry was caused by continuous bleeding from the left parietal bone fracture extending into the subdural space through the dura tear.

Knowledge of the treatment of patients with gunshot wounds to the head may become more important in the future in Japan. We report this case along with a review of the pertinent literature.

We experienced a case of acute epidural and subdural hematoma associated with superior sagittal sinus injury. Large laceration of the sinus sometimes induces huge bleed-ing with subsequent miserable outcome. The handling of the injured sinus depends on time and situation of the fracture.

An iron plate weighing 200 kg hit the head of 62-year-old man without a helmet. He was referred to our hospital with mild conscious disturbance (JCS: I-3) and right hemparesis. CT images revealed the left acute epidural hematoma, intracranial air, depressed fractures and sagittal suture diastases. His level of consciousness was deteriorated (JCS: II-30) and emergent surgery was performed. First, the craniectomy with the fractured bone on the injured sinus untouched to achieve the decompression of the brain tissue. Next, craniectomy was added to stop bleeding from the injured sinus. Huge bleeding was seen via the torn venous sinus, in spite of the elevated head position. TachoSil^® tissue sealing sheet was applied manually to the injured outer wall of the sinus. Then, brain swelling was seen after stopping bleeding from the outer wall of the sinus. Immediately after that, dura was cut with subsequent hemostasis. After complete hemostasis from the injured sinus, dural plasty with fascia was performed. Fortunately the therapeutic course of the patient was excellent. At 3 months after injury, he received cranio-plasty with custom-made titanium mesh. He returned to his daily life without any neurological deficits. In order to obtain good hemostasis from the injured sinus, TachoSil^® tissue sealing sheet is effective.

77 year-old woman had a traffic accident. When she was taken to our hospital, she had no neurological deficit. Computed tomography (CT) scan on adimission showed acute subdural hematoma, and we selected conservative management. On the following morning, CT scan showed spontaneous remission of the hematoma and she had no symptom. However in the night at the same day, she presented with severe consiousness disturbance and CT scan revealed significant expansion of the hematoma. Hematoma removal was performed immedeately, and we found intraoperatively that the bleeding point was a peripheral branch of the cortical artery. This is a rare case which having both two phenomenons; spontaneous remission and rapid expansion of the subdural hematoma in the acute phase. We considered the mechanism of this clinical condition with some review of the literature.

Background: Subdural hygroma can be treated by sub­dural drainage. However, if it is associated with normal pressure hydrocephalus, a ventriculoperitoneal (VP) shunt is effective. Herewith we report the case of an elderly patient with traumatic subdural hygroma which improved after a VP shunt, and review the relevant previously published literature.

Case presentation: An 85-year-old woman with bilateral acute and chronic subdural hematoma was referred to our hospital. After burr hole irrigation of the right sub­dural hematoma, the subdural hygroma and ventriculo­megaly worsened. We performed VP shunting via the left anterior horn and both findings resolved dramatically. The patient was discharged with moderate disability.

Discussion: Subdural hygroma associated with subarachnoid hemorrhage is usually caused by the laceration of the arachnoid membrane and disturbed absorption of cerebro­spinal fluid. A VP shunt was effective in this traumatic case on the similar mechanism. Prior to surgery, it is important to differentiate the phenomenon from brain atrophy fol­low­ing diffuse axonal injury.

Conclusion: We encountered a case of subdural hygroma treated by a VP shunt. A VP shunt can be effectively used instead of subdural drainage for selective cases.

We report a case of the infant head injury that the seamless emergency system led to lifesaving. The case is a 1.5-year-old boy. He fell to the asphalt parking lot from the window of his apartment on the second floor. Doctor ambulance car was called by the request from the emer­gency services because of his poor conscious level, a right conjugate deviation, and anisocoria. Intratracheal intuba­tion was enforced in the ambulance car by doctor. After confirming stability of the ABC, a head CT scan revealed acute subdural hematoma and brain contusion in his left frontal lobe. An emergency surgery was started at 49 minutes after hospital arrival. We eliminate contusional brain and hematoma and sacrificed damaged bridging vein. Because brain swelling was strong, I finished an operation with taking off the skull. Repeat CT showed acute epidural hematoma in his posterior cranial fossa. We came back to the operating room and evacuated hematoma. He was induced mild hypothermia therapy for 72 hours. His conscious was completely recovered after one week. He had right hemiparesis (MMT 2/5) immediately after rewarming but his hemiparesis im­proved to MMT 4/5. He discharged on his foot on the 33rd day of accident. He had slight right hand skilled act disturbance but good afterwards in progress.