This study was conducted to elucidate the recent trend of geriatric head injury in the Japan Neurotrauma Data Bank.

Three hundred and eighty patients and 479 over 65 years of age were enrolled in Project 2004 and Project 2009, respectively. Those were divided into 2 groups: aged (65 to 74 years of age) and highly aged (75 years of age or more) groups. Analyzed issues were distribu­tion of the patients, cause of injury, incidence of alcohol intake, Glasgow Coma Scale (GCS) score, CT findings, incidence of multiple systemic injury, treatment and outcomes at discharge after injury. The out­comes were evaluated using Glasgow Outcome Scale.

Results: As for the recent trends: 1) Highly aged patients had been increased, 2) Cause of injury: Fall or tumble was more frequent, especially in the highly aged group, 3) GCS score: rate of GCS 3 to 8 was higher in the highly aged. 4) CT findings: Percentage of diffuse injury was lower in the highly aged. In the mass lesion, acute subdural hematoma was more in­creased in the highly aged. 5) Surgical treatment: neuro­surgical operation was less frequent in the highly aged, and rate of operation had been more increased in both the aged and the highly aged groups. 6) Medical treatment: Temperature management was less common in the highly aged. 7) Outcomes at discharge were worse in the highly aged, but no serial change was observed in both age groups.

These results indicated that the clinical features, treatment and outcomes were different between the aged and the highly aged groups. These two age groups could be considered as the different clinical entity. The outcomes had not been improved despite the rate of surgical treatment had been increased in both two age groups.

Background: Spinal cord injury (SCI) is one of the poor prognostic factors in relation to head trauma. There are few reports on neurological functional prognosis in patients with cervical SCI. We retrospectively studied the prog­nos­tic factors in mild to moderate cervical SCI (AIS D, E).

Objective: Fifty-nine patients admitted to our department from August 2008 to May 2014 were evaluated in this study, comprising 53 men and 6 women with an age range from 25 to 84 years old (average 62.7 years). Age, sex, high-dose steroid therapy, surgical inter­vention, pain at the time of admission and discharge (evaluated by numeri­cal rating scale [NRS]), and functional evaluation at the time of admission and dis­charge (Functional Independence Measure [FIM]) were evaluated as prognosis-related factors.

Result: In terms of improvement of NRS <3 or >3 points, a significant difference was observed between patients aged <60 years old and those aged ≥70 years. Specifically, NRS improvement was good in patients ≤60 years of age (p=0.003). Pain on admission was higher in patients at 70 years of age (p<0.0001). In patients aged ≥70 years with improvement of <3 points after admission, the FIM scores on admission and at discharge were low (Mann–Whitney U test, p<0.05). Based on these results, in the elderly >70 years old with mild to moderate cervical SCI, improvement of pain might be a significant factor for neurological functional recovery. In other words, pain control is an important factor influencing prognosis. Prognosis was not related to the use of high-dose steroid therapy, surgery, and height of cervical spinal cord damage.

Conclusion: Pain relief in mild to moderate cervical SCI cases will encourage functional recovery, leading to im­prove­ment of FIM. Pain relief, especially in elderly patients >70 years old, is thought to be extremely im­portant.

Objectives: While some studies have compared the bodily injuries suffered by snowboarders, alpine skiers, and skiers who only ski short distances (short skiers), few studies have examined the head injuries that can occur during these activities. Therefore, we investi­gated the differences between the head injuries caused by these three activities.

Methods: The 3,581 individuals who suffered head injuries at ski resorts during the 13 winter seasons from 2000 ⁄ 2001 to 2012 ⁄ 2013 and visited our hospital were included in this study. We investigated their age, sex, skill level, neurological findings, imaging findings, surgical treatment, and outcomes as well the circumstances of their injuries, what head protection they were wearing, and the locations of their head injuries using information obtained from questionnaires and the patients’ medical records. During the statistical analyses, the χ² test was used, and the level of significance was set at p<0.05.

Results: There were 2,674 subjects (74.7%) in the snow­boarding group, 835 subjects (23.3%) in the alpine skiing group, and 72 subjects (2.0%) in short skiing group. The causes of the patients injuries were categorized into falling on a slope; falling during jumps; colliding with snowboarders, skiers, or obstacles; and unknown. The snowboarders’ injuries were mainly caused by falling on a slope (45.9%), falling during jumps (33.7%), and collisions (17.1%). On the other hand, the alpine skiers’ injuries were mainly caused by falling on a slope (48.7%), collisions (35.8%), and falling during jumps (9.3%), whereas those of the short skiers were mainly caused by collisions (40.3%), falling during jumps (31.9%), and falling on a slope (25.0%). Occipital head injuries were common among all subjects; however, they were significantly more common among the snowboarders and short skiers than among the alpine skiers. About half of the snowboarders and short skiers suffered disturbances or loss of memory or consciousness. On the other hand, less than 30% of the alpine skiers exhibited neurological symptoms. In this study, 52 snowboarders, 9 alpine skiers, and one short skier suffered acute subdural hematomas.

Conclusions: The snowboarders and short skiers fell during jumps, suffered occipital injuries, and experienced memory and consciousness disturbances more often than the alpine skiers. On the other hand, the alpine skiers were more expert and fell on steep slopes more frequently. The snowboarders suffered acute subdural hematomas most often, and it is considered that getting snowboarders to wear a helmet and teaching them to correct their falls before a head injury occurs could help to prevent acute subdural hematomas.

Background: The concussion reporting system be­came part of safe measures in the Japan Rugby Football Union (JRFU) beginning in 1990’s. Only scores of cases had been reported annually until 2011 when the World Rugby Concussion Guideline was published. The JRFU has tried to spread its contents to every player by having safe measuring courses in all regional unions resulting in an increase of 300 reports since 2012.

Objective: To ascertain the present state and propose some strategies of concussion management.

Method: We reviewed the concussion reports be­tween April 2012 and March 2015. Each report was sent to a regional union mainly by the team manager of the injured player. The match doctor and the referee could also report, when a player had concussion. In the case of non-game time concussion, the team manager reported. Annual number of concussed players, their ages, phase of play where the concussion occurred and repetitive injury cases occurring on the same player were analyzed.

Results: There were 1,451 concussions (336 to 388 cases per year) in those 4 years. Eighty five (5.9%) happened to those between 8 and 12 years old, 263 (18.1%) to 13–15, 548 (37.8%) to 16–18, 350 (24.1%) to 19–22, 205 (14.1%) to 23 and over. The phase of play was tackling in 758 cases (52.2%), being tacked in 416 (28.7%), other plays including maul and saving 98 (6.8%) and no-reported incidences in 95 (6.5%). Fifty-five players had two or more concussions for four years, two cases incurred within two weeks.

Conclusion: Young and adolescent ages should be the main target of the safe measures approaches to prevent from concussion especially focusing on tack­ling situations.

Posttraumatic transient subdural fluid collection is occasionally encountered in pediatric patients. 42 pediatric patients with head trauma who detected intra­cranial hemorrhage or skull fracture by neuro­imaging were treated at Hyogo Prefectural Kobe Children’s Hospital between April 2014 and September 2015. Patients underwent acute surgery were excluded. Posttraumatic subdural fluid collection was found in 8 (19.0%) of 42 patients and 7 (87.5%) of 8 were under 2 years old. Chronic subdural hematoma developed in 5 (11.9%) of 42 patients and they were all detected subdural fluid collection before chronic subdural hematoma developed. Our study suggests that posttraumatic transient subdural fluid collection is more common in infants and may later develop chronic subdural hematoma.

Objectives: We aimed to evaluate coagulation-fibrino­lysis abnormalities in patients with severe head trauma according to the age group and focal injury vs diffuse brain injury type.

Methods: We included 56 patients and divided them into three age groups: the young group comprised 9 patients aged ≤19 years; the middle-aged group, 24 patients aged 20 – 64 years; and the elderly group, 23 patients aged ≥65 years. These three groups were com­pared in terms of the following: level of consciousness on admissioin; imaging findings; hemoglobin (Hb), platelets (Plt), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen, fibrin ⁄ fi­brino­gen degradation products (FDPs) and D-dimer; and mortality rates.

Results: The consciousness level on admission did not differ between the groups. Comparison of imaging findings revealed that the young group had a high proportion of patients with traumatic subarachnoid hemorrhage, while the middle-aged and elderly group had a high proportion of patients with brain contusion and acute subdural hematoma. No significant differ­ences were noted between the groups in Hb, Plt, PT, APTT, or fibrinogen levels. However, FDP and D-dimer levels were significantly higher in the middle-aged and elderly group. The middle-aged and elderly group also showed a significantly higher mortality rate than the young group.

Conclusions: The proportion of patients with focal brain injury was higher in the middle-aged and elderly group than in the young group, and patients in the middle-aged and elderly group developed hyper­fibrinolysis immediately after sustaining injuries. There is no reliable treatment for hyperfibrinolysis. Investigating the effect of treatment of hyper­fibrinolysis in severe head trauma should be a priority for future research.

Complications of surgery for chronic subdural hematoma include such as acute subdural hematoma, pneumocephalus and subdural abscess. We report a case of chronic subdural hematoma that was difficult to diagnose and treat. The patient was an 87-year-old man who had fallen one day. Two months later, he devel­oped right hemiparesis, and was taken to our hospital by ambulance. The diagnosis was chronic subdural hematoma, and he underwent burr-hole irri­ga­tion. Right hemiparesis had improved after the opera­tion, but he became aware of clumsiness of the right hand on the third postoperative day. Subsequently, he addi­tional­ly developed aphasia, and head CT performed on the 6th postoperative day demonstrated a convex lens-shape­d hematoma. Therefore, he underwent cra­niotomy and hematoma evacuation with a diagnosis of acute epidural hematoma. However, no epidural hematoma was observed intraoperatively. When the dura mater was dissected, a chronic subdural hematoma was seen. Beneath the chronic subdural hematoma, there was a previous chronic subdural hematoma. We removed it as much as possible and the operation was finished. One month later, he developed right paresis and aphasia again so we performed burr-hole irrigation. The subsequent progress was good.

On the CT image, subdural hematoma that appeared outside the previous chronic subdural hematoma capsule should be carefully distinguished from acute epidural hematoma and acute subdural hematoma, which is a postoperative complication of chronic subdural hematoma.

We encountered two surgical cases of symptomatic middle cranial fossa arachnoid cysts and will report on the findings in these surgical cases with additional literature review.

Case 1 involved an 11-year-old boy who presented with an arachnoid cyst with chronic subdural hema­toma on CT and MRI after mild head trauma due to soccer. He experienced headache, vomiting, and gait disturbance. Initially, he underwent surgical removal of the hematoma and microscopic fenestration of the cyst wall under general anesthesia, and he recovered. However, he needed re-operation because the subdural hematoma recurred. Re-operation involved membra­nectomy and coagulation of bridging veins running in the septum of the cyst, hema­toma removal, and cyst fenestration. After re-operation, hematoma did not recur for >15 months.

Case 2 involved a 56-year-old man with an arachnoid cyst with subdural hygroma on CT and MRI after a mild head trauma due to falling. The patient reported disturbances in discrete movement of left upper limb. His initial surgical treatment included microscopic fenestration with membranectomy, the hygroma did not recur for >3 months.

Therefore, it is suggested that microscopic fenes­tration with membranectomy and coagulation of bridging veins around the cyst can reduce the postsurgical recurrence rate of symptomatic middle cranial fossa arachnoid cysts.