Objectives: With the rapid expansion of the elderly population, there has been an increase of the number of elderly traumatic brain injury (TBI) patients in Japan. In this study, transition of aggressive treatment and patient outcome in geriatric TBI patients were analyzed with the data of Japan Neurotrauma Data Bank Projects (JNTDB) 1998 (P1998), 2004 (P2004), 2009 (P2009), and 2015 (P2015). The prognostic factors in geriatric TBI were also examined.

Methods: Of 4,527 cases registered in the four JNTDB projects, 1,879 geriatric TBI cases (≥65 years old) were enrolled in this study. The clinical features, aggressive treatment defined as surgical procedure and/or inten­sive temperature treatment including intracranial pres­sure monitoring, and outcomes based on Glasgow Outcome Scale on discharge were compared among four study projects. Moreover, to clarify the prognostic factors in geriatric TBI patients, logistic regression analysis was performed.

Results: The percentage of geriatric TBI population was significantly increased throughout three projects (P1998; 30.1%, P2004; 34.6%, P2009; 43.9%, P2015; 53.6%, p<0.0001). Aggressive treatments including sur­gical management and intentional temperature man­agement were performed in 69.3% of geriatric patients in P2015 and this percentage was significantly increased from P1998 to P2015. Less invasive method, like as trephination and mormotermic targeted tem­perature management, were tend to choose for geriatric patients. With these efforts for geriatric TBI care, mortality ratio was significantly decreased (P1998; 62.8%, P2015; 44.7%, p<0.0001). On the other hand, the percentage of severe disability patient was still significantly increased. The percentage of dependent survivors were also increased (P1998; 23.2%, P2015; 39.1%, p<0.0001). Patient Age ≥ 75, Injury Severity Score ≥ 25, Glasgow Coma Scale (GCS) ≤ 8, pupil abnormality, existence of traumatic subarachnoidal hemorrhage (SAH), and existence of intraventricular hemorrhage (IVH) were clarified as the unfavorable prognostic factors. IVH was the strongest unfavorable prognostic factor in geriatric TBI patients (OR 3.99, 95%CI 2.05 – 7.76, p<0.0001).

Conclusion: Our result revealed that the aggressive, less invasive treatments provided less mortality in geriatric TBI patients. On the other hand, these efforts did not result in better outcome in this popula­tion. For the prompt decision making, patient age, initial GCS, and anatomical severity including SAH and IVH should be helpful as the functional prognostic factors.

Reconsideration of multimodal treatment strategy, including rehabilitation, seemed to be established.

The cranioplasty sometimes seems to offer patients clear benefits in terms of not only cosmetic im­provement but also neurological improvement. In this report, we describe the case with acute subdural hematoma after an emergency cesarean section, who was a 34–year–old, pregnant woman. She had con­vulsions accompanied by impaired consciousness following a severe headache the day after tomorrow of cesarean section. Computed tomography scan showed acute subdural hematoma. We transported her to the operative room within half an hour and performed a craniotomy and evacuated hematoma by curettage with a toothbrush following emergency hematoma irrigation with burr hole. Unfortunately, she persisted vegetative state for 14 days. But she recovered dra­matically a few days after we performed cranioplasty. Finally, her outcome was up to Modified Rankin scale 1.

Introduction: Diffuse idiopathic skeletal hyperostosis (DISH) is a distinct clinical entity presenting extreme hyperostosis in vertebral bodies, differentiated from ankylosing spondylosis. We report a case of DISH with delayed thoracic and cervical spinal cord injuries fol­lowi­ng a minor trauma.

Case presentation: A 69–year–old man, with moder­ate mental retardation, fell forward in a street and was taken to a second emergency hospital, without neuro­logical deficits or abnormal findings on brain com­puted tomography. Thirty hours after the injury, he was taken to our hospital presenting urinary and fecal incontinence and total paraplegia. Anal reflex was absent. The neuroradiological findings showed un­stable fracture and spinal injury at T11 level, associated with extensive hyperostosis of anterior longitudinal, supraspinous, and interspinous ligaments, suggesting DISH. His posterior longitudinal ligament was ex­treme­ly ossified, and subarachnoid space was narrowed from the upper cervical to the upper thoracic spine. There was no cervical spinal injury. He underwent posterior fixation from T9 to L2, aiming for his early mobilization, three days after injury. Unfortunately, he got another cervical spinal cord injury, eleven days after the initial injury, causing dyspnea and tetra paresis, and he died of pneumonia fifty one days after the initial injury.

Discussion and Conclusion: DISH may cause de­creased mobility of the spinal column, leading to vertebral body fractures and instabilities followed by delayed neurological deterioration after minor trauma. Fractures in DISH must be carefully assessed for instability. Earlier diagnosis is needed allowing the chance of surgical treatment for unstable fractures to achieve better neurological outcomes. The surgical treatment may be from two to three above and below posterior spinal fixation. However, surgical indications should be carefully considered because of the high incidence of perioperative complications.

Background: Confirmation of consciousness disturbance at the injury and identification of morphological brain damage are essential to authorize the neuro­psychological impairments by traffic accident in the process of compensation for damages. However, com­pensation for damages is sometimes claimed in the cases whose consciousness disturbance is not evident and organic brain damage is not identified in the brain images. In the present study, we analyzed trial cases in which the neuropsychological impair­ments by traffic accident was contended at court, and clarified important factors in the judgment of the com­pen­sation litigation for damages.

Methods: Using precedent search system "Westlaw^Ⓡ Japan" with keywords of "neuropsychological impairments" and "impediment", we extracted trial cases in which approval or non–approval of neuropsycho­logical impairments by traffic accident was judged at court from January, 2013 until December, 2017. We analyzed the reasons for the judgment especially in terms of consciousness disturbance at the injury, morpho­logical brain damage at acute stage and radio­logical findings including advanced MR images and radioisotope examinations. We further analyzed the cases claimed that mild traumatic brain injury (mTBI) causes the neuropsycho­logical impairments.

Results: During this period, 67 trial cases were extracted from the precedent search system. Sixteen cases were judged suffering from the neuropsychological impairments by traffic accident and 51 cases were denied. In 16 approved cases, 10 cases were approved as the neuropsychological impairments due to organic brain dam­age and 6 cases were considered as non–organic mental disorders by traffic accident. mTBI was claimed in 25 cases, but none of them were approved as the neuro­psychological impairments. The role of recently developed brain studies including advanced MR images and radio­isotope examinations was not justified in the judgment of organic neuropsychological impairments by traffic accident.

Conclusion: Several important points for neurosurgeons who diagnose and manage the patients with traumatic neuropsycho­logical impairments by traffic accident have clarified in this study. Future registration and prospective studies are necessary to further support the patients with the neuropsychological impairments after head trauma including mTBI by traffic accident.