Background and Purpose: Burr hole craniostomy for symptomatic chronic subdural hematoma (CSDH) is safe and effective with recurrence rate of up to 33%. The purpose of this study is to analyze the postoperative recurrence risk factors for the CSDH.

Methods: We collected CSDH patient’s clinical data in our institute for the past two years. We divided CSDH patients into recurrence group and no–recurrence group. Mean age, gender, presence of comorbidities, hematoma thickness, presence of midline shift, niveau formation, irrigation and drainage use are compared between the two groups.

Results: In the recurrence group, hematoma thickness was significantly higher than no–recurrence group. Irrigation and drainage was significantly higher in the no–recurrence group.

Conclusions: Irrigation and drainage might reduce recur­rence of CSDH.

Here we investigated the differences in clinical charac­teristics between head injury patients with and without pre­injury antithrombotic therapy to clarify its effect to the clinical course and out­come. A total of 779 patients from January 2015 to December 2018 were included in this study. There were 60 patients with preinjury anti­throm­botic therapy. Patients’ characteristics, symptoms, and clinical findings on hospital arrival, surgically treated or not, and modified Rankin Scale at dis­charge were com­pared. Patients’ age and rate of fall related injury were significantly higher in patients with preinjury anti­throm­botic therapy. They also had significantly more patients who talked and deteriorated (T&D), higher rate of surgical treatment, and worse clinical outcome, although Glasgow Coma Scale on hospital arrival showed no difference. Preinjury antithrombotic therapy significantly increase the rate of T&D and surgical treatment. These findings highlight the effect of preinjury antithrombotic therapy on treating head injury and the importance of close observation and neutralization of antithrombotic drugs.

Mild acute traumatic subdural hematoma is gen­erally treated conservatively. However, some he­ma­toma which have been treated conserva­tively on admission become expanded and need surgery. Contrast–enhanced Computerized Tomo­graphy (CT) is not conventionally used to predict failed conservative treatment in our hospital. In the present study, we report a trauma­tic acute subdural hematoma (ASDH) with a spot sign that required a delayed emer­gency craniotomy. An 80–year–old male, who regularly used anticoagulant agents, took a fall down and was transferred to our emergency department. On admission, we observed a left ASDH in the Head CT scans, and one hour after admission, a high density spot (spot sign) was observed in the hematoma in contrast CT imag­ing. As a result, we opted for the conservative treatment. However, six hours after admission, right hemiparesis appeared and the patient fell into a coma. We performed an emergency cra­nio­tomy and removed the hematoma. He was transferred to a community hospital in about 140 days after admission with neurological im­pairment.

This case demonstrates that the spot sign in ASDH might be useful in the prediction of hematoma expansion.

We report a case of traumatic vertebral arterio­venous fistula (AVF). A 75–year–old man presented with consciousness disturbance and left hemiparesis after falling. Computed tomography (CT) revealed hangman’s fracture, rib fractures and pneumothorax, but there was no intracranial traumatic lesion. Magnetic resonance imaging (MRI) demonstrated central spinal cord injury at the C2 position. External fixation using a halo vest was performed, and his symptoms improved gradually. Three–dimensional CT angiography (3D–CTA) revealed left vertebral artery (VA) injury at the C2 position, change in VA injury from pseudoaneurysm to AVF and reduced anterograde flow in the left VA. Therefore, endovascular trapping was performed for left VA AVF with coil embolization under a fitted halo vest, and shunt flow disappeared. The postoperative course was uneventful and no infarction or recanalization of the embolized area of the left VA was noted on postoperative MRI. Cervical spine fractures rarely cause VA injury, but patients with these or other blunt cerebrovascular injuries should be examined carefully and sufficiently treated in order to improve their outcomes. Furthermore, as it is difficult to gather similar cases at a single institute, joint studies among different institutes are needed to clarify the transition of vessel injury and the timing of treatment intervention.

Objectives: As traumatic basal ganglia hemorrhage (TBGH) is uncom­mon, we retrospectively analyzed our own previous TBGH cases in order to investigate the clinical characteristics of this rare hemorrhagic lesion.

Materials and methods: From January 2012 to June 2018, we treated 6 TBGH cases at our institution. We reviewed the frequency of TBGH cases in acute head trauma, patient’s age, sex, cause of injury, Glasgow coma scale at the time of admission, TBGH site, associated intracranial lesions, treatment method and outcomes in each patient.

Results: During the same period, we treated 214 patients with acute head trauma, and determined the TBGH frequency to be 2.8%. Patients evaluated in the current analysis included 5 males and 1 female, with ages ranging from 17 to 86 years, (mean age of 43.8 years). Cause of injury included traffic accidents in 3, falls in 2, and falling downstairs in 1 patient. Glasgow coma scale at the time of admission was 15 in 1, and less than 8 in the other 5 patients. TBGH sites included the putamen in 3 and the globus pallidus in 3 patients. Computed tomography detected associated intracranial lesions in all cases, with acute subdural hematoma (aSDH) found in 3, traumatic subarachnoid hemorrhage in 2, skull fracture in 2, and corpus callosum injury in 1 patient. With the exception of 1 case, surgical procedures were performed in all patients. Evacuation of TBGH via craniotomy was carried out in 1 patient, and evacuation of aSDH in 3 patients, and placement of external ventricular drainage and intracranial pressure monitoring in 1 patient. At the time of discharge, outcomes based on the Glasgow outcome scale were moderately disabled in 1, and severely disabled in 3, with death occurring in 2 patients.

Conclusions: Clinical characteristics of TBGH were evaluated based on our previous cases. Although TBGH is uncommon, medical staff need to have a basic knowledge of this traumatic injury.

The case was a 65–year–old male. The patient fell from a stepladder and was injured. Computed tomo­graphy revealed a fracture extending to the left lateral foramen in the 6th cervical spine, and 3DCTA re­vealed occlusion of the left cervical ver­tebral artery, basilar artery, and posterior cerebral artery. Revascularization therapy was performed with a diagnosis of cerebral infarction due to cerebral main artery occlusion of unknown onset time. A 6Fr guiding catheter was placed in the left vertebral artery, and thrombus crushing and throm­bus collection were performed using a stent–type thrombectomy device. After the operation, the dis­turbance of consciousness improved.

The vertebral artery dissection associated with trauma often accompanies cerebral infarction, and a lucid interval of several hours to several weeks is observed before the onset of symptoms. Neck pain after trauma requires careful observation considering the possibility of vascular dissection. When neurological symptoms appear, vascular assessment should be performed promptly, and revascularization therapy should be considered if indicated.

We report a case of coil embolization for a patient who showed progressive growth of a traumatic middle meningeal artery aneurysm (TMMA) and dural arteriovenous fistula (dAVF).

A 56–year–old woman was transported to our hospital with, suspected high–energy trauma. Acute epidural hematoma and multiple bone fractures were seen on head CT, but CT angio­graphy (3DCTA) showed no obvious traumatic vascular injury. On the day after the injury, no obvious neurological deteriora­tion was observed. MRI was performed on the 7th day for head­ache and cerebral contusion, and a right pseudoaneurysm of the middle meningeal artery was found suspected to be TMMA. Cerebral angiography performed on the 10th disease day revealed a right dAVF in addition to the right TMMA. Coil embolization was performed on the lesion, after which the headache disappeared and the lesions disappeared on 3DCTA.

In cases where a skull fracture is observed due to high–energy trauma, TMMA should be considered, with screening for traumat­ic vascular lesions using noninvasive MRA or 3DCTA. In addition, traumatic vascular injury may progress and needs to be evaluated over time.

Retroclival epidural hematoma, which usually occurs secondary to head trauma caused by a high–velocity force in pediatric patients, is a relatively rare entity. We report here the case of a 9–year–old boy who was involved in a motor vehicle accident. His level of consciousness on admission was 15 on the Glasgow Coma Scale, although with palsy of bilateral hypoglossal nerves. Initial computed tomography (CT) scan revealed retroclival epidural hematoma and traumatic subarachnoid hemorrhage (tSAH) in the basal cistern and other cisterns around the brainstem. Two hours of observation in the intensive care unit revealed progressive deterioration of his level of consciousness combined with left abducens palsy. Follow–up CT scan at the time demonstrated a significant increase in the hematoma and tSAH, along with ventricular enlargement, suggestive of obstructed hydrocephalus, which required emergency surgery for placement of an external ventricular drain (EVD). After removal of the EVD on the fourth postoperative day, he showed good recovery from the acute obstructed hydrocephalus, and the head trauma was further treated conservatively by cervical fixation using a neck collar. This case suggests that we should be aware of the possibility of acute obstructed hydrocephalus in cases with a considerable volume of retroclival epidural hematoma, and should perform intensive monitor­ing of neurological status in the first several hours.

Introduction: In Japan, the number of the severe head traumatic injury especially among young people has been decreasing because of toughening the road traffic law, decrease of the number of car owners among young people, and improvement of vehicle technologies for safety drive especially notable for evolution of automatic driving these days. It is of course favorable situation for us Japanese, but it has been worrisome problem for the neuro­surgical trainee to experience the brain injury operations for the young patients. Miura peninsula, where our hospital is located in, is one of the most aging society in Japan. 61 traumatic brain injuries were operated in our hospital from 2016–2018, and average age is 67.9, and the number of the cases whose age was under 30 was only 3. The brain of the elderlies is atrophic and fragile and has low metabolic rate and hardens arteries, so the brain injury operations for the young patients is different from that for the elderlies.

Method: We have cooperated with the hospitals in Viet Nam since 2014, and some doctors in each country go and participate in medical practice especially in operation. In Viet Nam where there are some traffic problems such as so many owners of motor bicycle and too lenient traffic rules, there are much more traffic accidents than in Japan. Young neurosurgeons from our hospital experience the general operations like traumatic brain injury cases. On the other hand, the doctors from Viet Nam learn especially about microsurgical technique and monitoring system.

Result: Doctors from our hospital operated from 8–12 cases of traumatic brain injury cases during their stay. Every case was under 30 years old.

Conclusion: In Japan, as an aging society, it is getting to be difficult to experience the operations for traumatic brain injury in youth. In order to take over the experiences and techniques of traumatic brain injury operations, the international medical exchange could be one considerable option.