Background: The aim of this study was to determine the risk factors for hematoma progression following conservative treatment of traumatic acute subdural hematoma (ASDH).

Methods: A total of 82 ASDH patients treated conservatively over an 8–year period were retrospectively reviewed. Overall, 14 patients (17%) showed hematoma enlargement in the subacute to chronic period. The remaining 68 patients (83%) demonstrated hematoma resolution. Various factors were compared between the two groups.

Results: There were no significant differences in age, sex, Glasgow Coma Scale on admission, prior use of antithrombotic agents, treatment with tranexamic acid or carbazochrome sodium sulfonate, and the presence of combined cerebral contusion or subarachnoid hemorrhage. The following factors were significantly associated with chronification: initial hematoma thickness (p<0.001) and midline shift (p<0.001). The rate of chronification increased according to initial hematoma thickness, with rates of 0% (0/11 cases, ≤ 3 mm), 11% (5/44 cases, 3.1 – 6 mm), 11% (2/18 cases, 6.1 – 9.9 mm), and 78% (7/9 cases, ≥10 mm). The average interval between injury and surgery was 46 days (≤ 6 mm) and 17 days (≥ 6.1 mm).

Conclusions: Patients with ASDH treated initially by conservative management need to be followed keeping in mind that a thicker hematoma may increase the rate of chronification and shorten the interval of required surgery.

Patients who are taking anticoagulants are known to show poor outcomes for acute subdural hematoma. In cases of non–traumatic cerebral hemorrhage, patients with direct oral anticoagulants(DOAC) bleed less frequently and have less severe outcome than the patients with vitamin K antagonists (VKA). In this study, we reviewed 201 consecutive cases of acute subdural hematoma from April 2012 to March 2020 to demonstrate the difference of the outcome depending on the types of anticoagulants and the effect of neutralization.

Eighty–one cases (40.3%) had taken antithrombotic drugs. There were 37 cases (18.4%) taking anticoagulants, 54 cases (26.9%) taking antiplatelet drugs, and 10 cases taking both. The types of anticoagu­lants were VKA in 30 cases and DOAC in 7 cases. There were 19 patients taking VKA before approval of 4–factor prothrombin complex concentration (4F–PCC), 11 patients after approval and 8 patients of these were neutralized.

The good outcome for the cases without antithrombotic drugs was 59.2%, whereas that of cases without anticoagulants was 35.1%, sig­nificantly lower (chi–square test, p=0.010). It was 51.9% with anti­platelet drug.

Comparing the types of anticoagulant medications, the good out­comes were 26.7% in patients with warfarin and 71.4% with DOAC. There were significantly better with DOAC (Fisher’s exact tests, p=0.021).

Though 21,1% of the cases 4F–PCC approval had shown good out­come, the incidence turned to 36.4% after approval. The median PT–INR before administration of 4F–PCC was 2.49 (2.05 – 4.22), which was 1.09 (0.99 – 1.20) after administration.

DOAC should be selected over VKA to improve the outcome of acute subdural hematomas with anticoagulants. Vitamin K antagonist neu­trali­za­tion with 4F–PCC may improve outcomes. Further studies on the pathological conditions which are to be neutralized are needed.

An 80–year–old man accidentally tripped and fell forward on to a plant support stake, which went up his left nostril and penetrated his head. He was admitted to our hospital as an emergency. On admission, he showed left hemiparesis with Glasgow Coma Scale score of 12 (E4, V2, M6). Skull radiography showed transnasal penetration of the plant support to a depth of 16 cm, and computed tomography (CT) demon­strated contusion of right frontal lobe and acute sub­dural hematoma. CT angiography showed no damage to the intracranial main arteries and cavernous sinus. Emergent craniotomy was performed to remove the stake with difficulty via the nostril because of the ledge formed by a radiolucent cap attached to the tip of the stake. The subdural hematoma was evacuated, the epidural space washed, and the torn dura closed with the galea. After surgery, antibiotics were infused for 2 weeks and spinal drainage was performed for 10 days. No post–treatment complication such as meningitis, brain abscess, and cerebrospinal fluid leakage occurred. He was discharged with Glasgow Outcome Scale score of 3. This case emphasizes the possibility of radiolucent components of any foreign body causing problems with removal after penetrating head injury.

We report on a rare case of isolated oculomotor nerve palsy in association with an epidural hematoma. A 67–year–old female was involved in a bicycle accident and hit the temporal side of her head. She experienced loss of consciousness for several minutes but was awake and oriented on admission. Computed tomography (CT) showed a left temporal bone fracture and a 4 × 3 × 3 cm acute epidural hematoma in the middle fossa. Left intra– and extraocular muscle impairment appeared several hours later. The epidural hematoma did not progress on CT and was managed conservatively. After 8 days, her left pupil shrunk slightly and response to light began to appear. Eighteen days later, the pupillary light reflex recovered and visual acuity and ocular fundus were normal. However, anisocoria of about 1 mm and ptosis remained. Restriction of eye movement was not evident on manual inspection, but the Hess screen test revealed an adduction disturbance of the left eye. Thirty days later, computed tomography revealed that the hematoma had resolved. Magnetic resonance imaging performed 2 months later demonstrated no new lesion. The ptosis had improved but diplopia subjectively remained.

The cause of her symptoms in this case was considered to be compression of the oculomotor nerve near the superior orbital fissure by the temporal lobe, secondary to an expanded epidural hematoma. The oculomotor nerve palsy had improved 2 months later with conservative treatment alone. A comparison of the recovery process between surgical treatment and conservative management need further study.

We report a case of internal carotid artery dissection caused by seat belt injury, successfully treated with endovascular surgery. A man in his 50s was involved in accidents when he was driving his car. His right mandible, neck and shoulder were compressed by the seatbelt at that time. He felt continuous pain in his mandible, neck and shoulder, then consulted an orthopedic surgeon but no abnormal finding was pointed out. Four days later, in the morning he transferred to our hospital due to headache. Head computed tomography (CT) showed no intracranial traumatic lesion, then he returned to home. However, in the evening he was again transferred to our hospital due to left hemiparesis. Magnetic resonance imaging (MRI) demonstrated acute ischemic lesion on right cerebral hemisphere, and MR angio­graphy (MRA) revealed right internal carotid artery occlusion. Emergent cerebral angiography showed right internal carotid artery dissection and right middle cerebral artery occlusion. Endovascular thrombectomy and carotid artery stenting was performed. Postoperative course was uneventful. He discharged with no abnormal neurological deficit. Delayed presentation of seat belt injury is rare, but we should keep in mind that serial follow–up by MRI or CTA would reveal eventual change of carotid artery even if it is asymptomatic.

Objectives: As the incidence of stepladder related fall injury (sLRFI) is increasing in Japan, we retrospectively analyzed our own previous sLRFI cases to investigate the clinical characteristics of sLRFI and to give information about the awareness of stepladder safety and pre­cautions.

Materials and Methods: From April 2009 to March 2019, we treated 8 sLRFI cases at our institution. The frequency of sLRFI cases in acute head trauma, patient’s age, sex, cause of injury, Glasgow Coma Scale (GCS) on admission, type of head injury, extracranial lesions, neurosurgical treatment method and outcomes in each patient were retrospectively reviewed.

Results: During the same period, we treated 989 patients with acute head trauma, and determined the sLRFI frequency to be 0.8%. Patients evaluated in the current analysis included 7 males and 1 female, with ages ranging from 52 to 86 years (mean age of 76 years). Mean GCS on admission was 12 points. Cause of injury were non–occupational falls in 7 patients and occupational in 1. Seven out of 8 patients fell from the top of the stepladders or during straddling the stepladders. Type of head injury included acute epidural hema­toma in 3, acute subdural hematoma in 3, cerebral contusion in 3, traumatic intracerebral hematoma in 1, traumatic subarachnoid hemor­rhage in 5, chronic subdural hematoma in 2, pneumocephalus in 1 and skull fracture in 3. Extracranial lesions included clavicular fracture in 1 patient, rib fracture in 2, hemopneumothorax in 2. Neurosurgical procedures were performed in 6 patients. Evacuation of hematoma via craniotomy was carried out in 4 patient, irrigation of hematoma through a burr hole in 2. At the time of discharge, outcomes based on the Glasgow outcome scale were good recovery in 3, moderately disabled in 3, severely disabled in 1, with death occurring in 1.

Conclusions: Clinical characteristics of sLRFI were evaluated based on our previous cases. The typical patients of sLRFI were male, elderly and non–occupational users. As the trend of stepladder falls has been increasing, preventative strategies should be established to support stepladder safety usage.

Pseudoaneurysm of the middle meningeal artery (MMA) is a rare entity and is generally associated with traumatic brain injury. We reported a case of pseudoaneurysm of the MMA after frontotemporal craniotomy. A 71–year–old female presented with headache and dizziness, and was diagnosed as having subarachnoid hemorrhage due to ruptured aneurysm of the anterior communicating artery. Clipping of the aneurysm was performed by frontotemporal craniotomy via a trans sylvian approach. At 25 days after the surgical procedure, 3D CT angiography (3D–CTA) revealed aneurysm of the MMA. Cerebral angiography was performed at 29 days after surgery, and a 4–mm aneurysm with pooling of contrast agent was observed in the posterior branch of the MMA. Rapid aneurysmal growth was observed when com­pared to the cerebral angiography performed on the 8th post­operative day for the purpose of evaluating cerebral vasospasm. The aneurysm was located within the craniotomy, and trapping was performed on the aneurysm at 33 days after surgery. The aneurysm was excised and submitted for examination as a patho­logy specimen. The defect in the arterial wall and spilled blood were lined by surrounding connective tissue, and a diagnosis of pseudoaneurysm was made. This case was considered as pseudo­aneurysm due to iatrogenic injury triggered by craniotomy. A few cases of pseudoaneurysm of the MMA have been described in the literature and are mostly associated with head injury, not iatrogenic. Since pseudoaneurysm has a high mortality rate after rupture, sufficient hemostasis of the MMA during surgery is required. Furthermore, it is important to perform imaging examinations due to the possibility of pseudoaneurysm.

An 85–year–old woman who had suffered a fall in a care facility had sustained a head injury that resulted in a consciousness disorder. The patient was transported to our hospital by an ambulance. Ventricular abdominal shunting was performed for normal pressure hydrocephalus. Upon arrival at the hospital, the patient had Japan Coma Scale (JCS) and Glasgow Coma Scale (GCS) scores of 20 and 8, respectively. Computed tomography (CT) of the head showed a 22–mm–thick subdural hematoma and midline deviation on the side of the shunt tube. To preserve the shunt tube, we performed endoscopy–assisted craniotomy for the removal of a small hematoma. After surgery, intracranial pressure ⁄ cerebral perfusion pressure was monitored to prepare for increased intracranial pressure due to rebleeding and cerebral edema. No shunt tube ligation was per­formed, and the shunt valve pressure was set to the maximum value of 200 mmH2O; postoperative rebleeding and cerebral edema were not observed. The patient’s JCS score gradually improved from 20 to 2, and she was transferred to a rehabilitation hospital on the 38th day of hospitalization.

Endoscopy–assisted minicraniotomy for the removal of an acute subdural hematoma on the ipsilateral side of the ventriculo­peritoneal shunt tube was performed in a small craniotomy area, and no shunt tube damage or infection was observed.

If bleeding can be reliably stopped under the endoscope, rebleeding can be prevented by changing the shunt valve set pressure to high pressure without shunt tube ligation.