【解説】

「スポーツにおける脳振盪に関する国際会議」は2001年にウィーンで第１回会議が開かれたのち，近年は夏季オリンピックの年の秋に開催されており，第2回 （プラハ, 2004年），第3回 （チューリッヒ, 2008年），第4回 （チューリッヒ, 2012年） を経て，2016年にベルリンにて 「第5回国際スポーツ脳振盪会議」 が開催された。この国際会議の目的は選手の安全を確保することと，選手のコンディションを改善することであり，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，最終的に以下の共同声明 （consensus statement） を公開するとともに，声明の根拠となった系統的なレビュー12編^{24,25,i–x）}を発表した。

脳振盪を負った選手を評価する標準的ツールSport Concussion Assessment Tool （SCAT），5歳から12歳までの小児に用いるchild SCAT，非医療従事者が脳振盪を疑う際に用いるConcussion Recognition Tool （CRT） はそれぞれ，SCAT5，child SCAT5，CRT5へと改訂された。

この共同声明 （McCrory P, Meeuwisse W, Dvoraket J, et al. Consensus statement on concussion in sport —the 5th inter­national conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 51: 838–847, 2017） や上記のツールはすべてWeb上で自由に閲覧でき，ダウンロードも可能である。関係者は原文にあたり，その内容に精通していることが求められるが，一部から公式な日本語訳を強く望む声があり，本学会のスポーツ脳神経外傷検討委員会の有志が，前版^xi）の訳者らとともにこれにあたった。

次回の改訂は2020年の秋以降に予定されているので，本稿が来る東京オリンピックならびにパラリンピックにおけるこの領域の基本的な指針となる。しかし本文中にもある通り，この共同声明は臨床的なガイドラインを目指すものでも，法的に正しい対処を示すものでもない。現時点における総論的な指針と考えるべきであって，個々のケースへの対応には，現場の裁量が認められていることを強調したい。

Introduction: To ascertain recent trends in pediatric head trauma, we analyzed patients who visited the emergency room–type critical care center and neurosurgery department at our hospital.

Subject and Methods: We retrospectively analyzed 149 pedi­atric patients (≤15 years old) with head trauma hospitalized between January 2009 and September 2017.

Results: Patients included 3 neonates, 34 infants, 44 pre­school children, 49 school children, and 19 adolescents (12–15 years old). Male–to–female ratio was 2:1. Most patients (118 patients, 79%) resided in Kawasaki City in northeastern Kanagawa Prefecture, where our hospital is located, while some (31 patients, 21%) visited or were transferred from outside the region serviced by our hospital. The most common mechanism of injury was a fall (91 patients, 61%), followed by traffic accident trauma (34 patients, 23%) and child abuse (9 patients, 6%). The most common route for hospitalization was ambulance (77 patients, 52%), followed by self–presentation to the night–time emergency center (57 patients, 38%) and general outpatient visit (15 patients, 10%). Fourteen patients (9%) underwent surgery, while the remaining 135 patients (91%) did not. Of the non–surgical cases, 76 patients (56%) presented with hemorrhagic lesions and 59 patients (44%) were hospitalized for observation of injuries such as cerebral concussion or skull fracture not in­volving intracranial hemorrhage. Surgical cases included acute–phase surgery in 11 patients (79%) and chronic–phase surgery in 3 patients (21%). Outcomes were satisfactory for all non–surgical cases. In surgical cases, outcomes were satisfactory in 9 patients (64%; good recovery, n=7 patients; moderate dis­ability, n=2 patients), and poor in 5 patients (36%; severely disabled, n=3 patients; persistent vegetative state, n=1 patient; dead, n=1 patient) including 3 patients with multiple traumas.

Conclusion: The prognosis for pediatric head trauma is considered relatively good. In our investigation, non–surgical cases accounted for most cases and showed satisfactory prog­nosis. However, the outcomes of severe cases requiring surgery were not always good. In our department, we plan to be pro­actively involved in severe cases in the nearby area as the last stronghold against severe pediatric head trauma.

Background: Although various precautions against fall accidents during hospitalization are taken in every medical facility, some accidents are fatal to the patients.

Methods: We retrospectively analyzed 11 patients with acute subdural hematoma caused by fall accidents during hospitalization who were treated at National Hospital Organization Tokyo Medical Center from April 2014 to December 2018. They were divided into two groups: the poor prognosis group comprised six patients with GOS (Glasgow Outcome Scale) score 1 or 2 (dead or vegetative state, respectively); and the good prognosis group included five patients otherwise. Between these groups we compared age, Glasgow Coma Scale (GCS), computed tomography (CT) findings, primary disease and its treatment, antiplatelet agents or anticoagulants, systolic blood pressure at admission, medical history of diabetes mellitus, hemoglobin count, platelet count, prothrombin time–international normalized ratio (PT–INR), and hypnotics before sleep.

Results: All patients were over 65 years old. In the poor prognosis group, platelet count was significantly lower than that in the good prognosis group (p=0.02), and every patient had been taking antiplatelet agents or had platelet count lower than 50,000/µl. Also, both the maximum width of subdural hematoma and distance of midline shift measured on CT scans significantly exceeded those in the mild cases group (p=0.01, 0.03, respectively). Importantly, of the six patients in the poor prognosis group, four had malignant neoplasm and three had been undergoing chemotherapy, whereas only one patient had cancer and no patient was under anticancer drugs in the good prognosis group.

Conclusions: In general, acute subdural hematoma is frequently caused by accidents such as traffic accidents or fall after consuming alcohol. However, the current study may suggest that in hospital we should be careful of elderly patients falling whose primary hemostatic mechanism might be impaired by tumor–bearing, chemotherapy, and antiplatelet agents or anticoagulants.

Brain tissue is atrophied by slow compression. This change is, different from that by rapid compression which often develops various complications such as brain edema and hemorrhage, a silent change neurologically difficult to detect. Little is investi­gated about this slow compression injury, and unknown impor­tant mechanism of neuronal death might be involved in this. In order to elucidate the pathophysiology of slow compression injury, it would be necessary firstly to clarify the morphological features of the injured brain tissue in clinical case, then to make an animal experiment model which reproduces similar patho­logical tissue changes. Clinical case: We examined an autopsied brain with frontal meningioma of a 75–year–old male. Thinning of the cortex adjacent to the tumor, atrophy of the ipsilateral cerebral hemisphere and flatten­ing of neuronal cell body and nucleus was observed in the cortex adjacent to the tumor. Animal model: A device for slow compression was installed on the parietal cortex of Japanese white rabbits (n=9) and gradually compressed (100 µm/day) the brain for 56.0 ± 1.3 days. Cortical thick­ness decreased to 0.19 ± 0.07 of the control, cross sectional area of lesion side decreased to 0.63 ± 0.10 of the control, Nuclear height ⁄ width ratio of the neuron decreased to 0.43 ± 0.10 from the control. Neurite density was de­creased in Golgi staining specimens. Coil like change of perforating artery was observed in the soft X–ray micro­angiography. Regional cerebral blood flow of the com­pressed brain tissue measured by the hydrogen clearance method was kept at 0.95 ± 0.17 of the control. In conclusion, slow brain compression causes tissue atrophy, neuronal deformation and reduction of neurite density. This change is not associated with significant decrease of regional cerebral blood flow.

Psuedoaneurysm of common carotid artery (CCA) is rare complication of cervical surgery, radiation and infection but is life–threatening by its rupture. Although surgical treatment has been the first–line treatment for such hemorrhage, in some cases, transarterial embolization or bare stent placement is performed. If the hemostasis is insufficient by these treatment, placement of covered stent is an option. However, stiffness of the covered stent and sharp angle of the aorta and the left CCA often make it difficult to deliver the covered stent. We report a case of hemorrhage from pseudoaneurysm of CCA successfully treated with covered stent placement using pull through technique between the femoral artery (FA) and the superficial temporal artery (STA).

A 69–year–old man with esophageal carcinoma who had undergone chemotherapy and 60 Gy radiotherapy (2 Gy × 30 times) 2 years before, salvage surgery 32 days before, and drainage for the mediastinal abscess 9 days before had an episode of sudden hemorrhage via the drain and cervical swelling. Angiography showed aneurysm–like finding at left CCA, 7 cm distal from the origin, but not whole aneurysm was visible. So, it seemed to be a dissecting psuedoaneurysm. Because the surgery treatment was very difficult due to high adhesion and invisible whole aneurysm, we planned covered stent placement. But it was difficult to deliver the covered stent due to stiffness of covered stent and the sharp angle of aorta and left CCA. Finally, we could deliver the covered stent with pull through technique between the FA and the STA and completed the procedure to get hemostasis.

Pull through technique may facilitate safe and stable covered stent delivery to stop hemorrhage from iatrogenic pseudo­aneurysm of common carotid artery.

Penetrating head injury is rare. It is reported due to damage by bullets in Europe and the United States, however, in Japan most of such cases are reported owing to damage caused by everyday items, such as chopsticks. Penetration pathway may include the orbit, nasal cavities, oral cavity, skull base, etc. The extent of brain damage depends on the penetration route. Here, we report a case of a 1–year–old boy with an intra­cranial injury that penetrated the skull base caused by a chopstick. The child fell down and got injured while holding chopsticks. The chopstick penetrated the sphenoid between the cheekbones and the maxillary bones reaching the middle cranial fossa and the frontal lobe through the temporal lobe. Head computed tomo­graphy (CT) and CT angiography were performed to evaluate penetration route, presence of chopstick pieces, and presence of vascular injury. In an emergency operation, we removed the chopstick, washed, and closed the dura. After operation, antibiotics were infused. Post–treatment complications such as obvious infection and stroke were not observed, and he was dis­charged with good progress.

We presented a patient with acute bilateral epidural hematomas, which were operated simultaneously. A 56–year–old male accidentally fell down and hit his head against the floor. He was observed because he had no symptom, but his consciousness deteriorated 6 hours later. Immediate Computed Tomography (CT) revealed symmetrical bilateral epidural hematomas in each pari­eto­temporal regions. Then he was transferred to our hospital. On admission, his consciousness level was 200 in Japan Coma Scale (JCS). We called for an emergency operation for rapid decompression of the brain. After we estimated the area of hematomas by CT scan, we realized that we couldn’t make bilateral craniotomies and remove the hematomas at the same time in supine position. So we decided to operate in prone position. Bilateral craniotomies were carried out at the same time, and the epidural hematomas were also simultaneously removed successfully by the two groups of neurosurgeons. Clinical course after operation was uneventful and the patient was discharged post operative day 10. Simultaneous bilateral craniotomies and removal of the epidural hematomas would have contributed to obtaining the good result in this patient.

We present two cases who were able to achieve independent ambula­tion with early gait training after traumatic brain injury (TBI). The first patient was a 10–year–old female who was injured by a traffic accident. On the day of admission, her Glasgow Coma Scale (GCS) was E1V2M5. On the 3rd hospital day, rehabilitation was started, and on the 7th hospital day, gait training was started (GCS: E3V2M5). She gained conscious­ness on the 21st hospital day, and independent ambulation was obtained on the 23rd hospital day. She was transferred to another hospital on the 33rd hospital day.

The second patient was an 18–year–old female who was injured by a traffic accident. On the day of admission, GCS was E2V2M4. On the 3rd hospital day, rehabilitation was started, and on the 5th hospital day, gait training was started (GCS: E3V4M5). She gained conscious­ness on the 13th hospital day, and independent ambulation was ob­tained on the 28th hospital day. She was discharged from the hospital on the 39th hospital day.

The occurrence rate and severity of gait disturbance are low and mild in patients with TBI, and there are many reports showing a relatively good prognosis. However, there are few reports of rehabilitation and gait training in the acute phase. In the present cases, gait training was started early. The two patients had disturbance of consciousness at hospitalization with a GCS of 8 or less, and disturbance of consciousness continued until 21th and 13th hospital day. In both patients, indepent walking was obtained within 1 month after injury. In conclusion, we reported two rare cases who were able to achieve early independent ambulation with early gait training after TBI.