Background: Elderly patients with traumatic brain injury (TBI) are increasingly common in Japan. The number of patients taking anti­thrombotics is also increasing due to the aging population. Generally, the clinical outcomes of TBI patients with antithrombotic therapy are poor. Thus, revealing the clinical characteristics of TBI with anti­thrombotic therapy is required. This study investigated clinical characteristics and prognostic factors of acute subdural hematoma (ASDH) with antithrombotic therapy.

Methods: The clinical data of 88 consecutive ASDH patients were retrospectively reviewed. Patients were divided into two groups, anti­thrombotics (–) group and antithrombotics (+) group. Age, sex, mechanisms of injury, Glasgow coma scale score (GCS score) on admission, types of hematoma, surgery, Glasgow outcome scale (GOS) at discharge and time from onset to admission were analyzed by univariate and multivariate analysis.

Results: Twenty–five patients (28.4%) took antithrombotics. Fall injuries were most common mechanism of injury (61 of 88 cases, 69.3%). 23 patients (26.1%) were severe brain injury (GCS score ≦ 8 on admission), 16 patients (18.2%) developed talk and deteriorate and 27 patients (30.7%) underwent surgeries. Only GCS score ≦ 8 on admis­sion was associated with poor outcome defined by vegetative state or dead at discharge.

Compared with antithrombotics (–) group, antithrombotics (+) group was significantly older (82 years versus 73 years, p<0.05) and fall related injuries were more common. In antithrombotics (+) group, 52.0% of patients (13 of 25 cases) admitted hospital over 6 hours from onset. Among patients admitted hospital within 3 hours from onset, poor clinical outcome was comparable between antithrombotics (+) and (–) group (41.7% [5 of 12 cases] versus 40.4% [18 of 45 cases]). Although, among patients admitted hospital over 3 hours from onset, poor clinical outcome was more common in anti­thrombotics (+) group (38.5% [5 of 13 cases] versus 20.0% [4 of 20 cases]).

Conclusion: Only GCS score on admission was significantly associated with poor outcome of ASDH. ASDH patients with antithrombotic therapy are characterized by fall related injury of elderly people, tend to get severe due to delay in admission. Early diagnosis and adequate intervention are required.

Angiosarcoma is a disease with poor prognosis and frequently occurs on the head and face of older adults. Although it is a disease unfamili­ar to neurosurgeons, it is considered necessary to have knowl­edge of this disease. Herein, we report the case of an 84–year–old woman who was diagnosed with an angiosarcoma post–mortem. She initially presented with facial swelling, which had continued for 1 week after she had suffered several falls. Head computed tomography (CT) showed no obvious traumatic changes in the skull, and she was followed–up in the outpatient department. However, one month later, she was transported with anorexia. A wide range of subcutaneous hematomas and contusions in the right facial region and oozing from the wound site were observed. Head CT showed no obvious traumatic changes, and blood tests showed anemia, undernutrition, and dehydration. The patient was then admitted to the hospital because of poor general condition. Subcutaneous swelling and anemia progressed even after hospi­talization, and trans arterial embolization of the right superficial temporal artery was performed on the third day of hospitalization. However, her anemia did not improve postoperatively and transi­tioned to disseminated intravascular coagulation (DIC) tendency. On the 6th day, a sudden drop in blood pressure and heart rate resulted in cardiac arrest. Resuscitation was unsuccessful, and she died. The diagnosis of angiosarcoma was made from the pathological autopsy. This case elucidates the importance of a quick diagnosis when swelling of the head and face is observed without any improvement.

Traumatic acute subdural hematoma (ASDH) is generally occurs as a result of bleeding from cortical arterial and venous injuries and brain contusion. We report a case of ASDH due to middle meningeal artery (MMA) injury with skull base fracture involving the foramen spinosum. An 86–year–old man suffered traffic accident. When he was transferred to our hospital, he had mild disorientation. Computed tomography (CT) scans showed right ASDH and skull base fracture involving the foramen spinosum. Ten minutes later, he fell in severe consciousness disturbance associated with expansion of ASDH, which was emergently removed. During the operation, active bleeding of MMA was found at the level of foramen spinosum. This rare case was considered as ASDH due to both MMA injury and dural tear due to skull base fracture involving the foramen spino­sum.

A 61–year–old man suffering from headache and neck pain from past few months and gait disturbance and consciousness disorder from past 1 month presented to our neurosurgery department. Upon arrival at the hospital, the patient had the Japan Coma Scale (JCS) and Glasgow Coma Scale (GCS) scores of 10 and 13, respectively. Magnetic resonance imaging of the head showed bilateral chronic subdural hematoma. Thus, we performed bilateral burr hole hematoma removal and drainage. After the surgery, the symptoms improved. Two days after the surgery, the patient had the JCS and GCS scores of 20 and 8, respectively, and right motor paralysis.

Computed tomography (CT) of the head showed left acute sub­dural hematoma. For early decompression, we performed hematoma removal using the existing burr hole in the emergency room near the CT room. Then, we performed endoscopic–assisted mini–craniotomy for the removal of hematoma. After the surgery, intracranial pressure ⁄ cerebral perfusion pressure was monitored to check for increased intracranial pressure due to rebleeding and cerebral edema. The patient’s JCS scores gradually improved from 20 to 0, and he was discharged from our department on the 34th day of hospitalization.

This case shows the value of craniotomy after the existing burr hole surgery for early decompression in patients with acute epidural hematoma following the burr hole evacuation of chronic subdural hematoma, and this may contribute to improved outcomes. The existing burr hole surgery uses fewer tools and causes less bleeding than the new burr hole surgery, and it should be performed outside the operating room to avoid wasting time.

It is reported that 2.3% to 20.4% of patients who have a chronic subdural hematoma (CSDH) develop seizures as a complication. The relationship between the epileptic focus and sulcal hyper­intensity on fluid–attenuated inversion recovery (FLAIR) images has been confirmed radiologically.

We recently encountered a patient with CSDH presenting with seizures, with a small hematoma displaying sulcal hyperintensity on FLAIR images.

Case: An 88 year–old man was hospitalized for chronic heart failure at another hospital and he developed transient left hemi­plegia. Magnetic resonance imaging (MRI) demonstrated bilateral CSDH and right sulcal hyperintensity on FLAIR images although the right hematoma was thin. Two days later, the patient developed transient left hemiplegia and was referred to our hospital with consciousness disorder. He developed general­ized seizures post–admission. We administered antiepileptic drugs and per­formed middle meningeal artery (MMA) embolization on day 2 of admission. The sulcal hyperintenisty disappeared after 32 days post–operation.

The effectiveness of MMA embolization for CSDH with sulcal hyper­intensity on FLAIR images has not been reported previously. We show that middle meningeal artery embolization is effective for CSDH with sulcal hyperintensity on FLAIR.

Since 2000, sports–related concussions have been attracting at­ten­tion. We report on the response to two players who suffered sports–related head trauma during the National Sports Festival rugby competition. In the first case, a 25– year–old man suffered head trauma playing rugby. He lost consciousness for several tens of seconds immediately after the trauma occurred. Computed tomography (CT) revealed acute subdural hematoma along the cerebellar tentorium and slight subarachnoid hemorrhage in bilateral cerebral hemispheres. Three days later, he was discharged with no disturbance of consciousness or neurological defi­cits. The “World Rugby” guidelines did not mention the reinstate­ment of athletes with intracranial lesions. According to the “Interim consensus statement for guideline development” from The Japan Society of Neurotraumatology, we recommended that the patient discontinue play. He com­plied with our recommendations and retired from rugby. The second case involves an 18–year–old man. He also participated in the National Sports Festival rugby competition. He collided with an opponent when a scram col­lapsed and was injured. When he arose, he became unsteady and was discharged from the game per the judgment of the Medical Director. Following an initial examination, the patient was taken to the hospital with a suspected concussion. Although head CT showed no obvious traumatic injury, concussion was diagnosed due to a mild headache and the opinion of the Medical Director. The patient complied with the diagnosis, however, the coach did not, so we recon­firmed the situation surrounding the incident, consulted with the patient again, and reconfirmed the concussion diagnosis. These cases could not be dealt with by comply­ing with the current guidelines. Doctors who treat sports–related head trauma must make medical decisions with athletes’ safety as the top priority.

The outcome of penetrating head trauma is relatively poor, because some nerves, vascular structures and eloquent brain areas are directly injured and infection rate is very high. There are various penetrating substances, which must be dealt with flexibly. In penetrating head trauma, penetration of the calvaria is rare, because of the existence of hard skull bone. We report a case of transcranial head trauma caused by a nail–gun.

A 53–year–old man attempted suicide using a nail–gun, shooting nails into the temporal and frontal lobes. On admission examina­tion, the patient was found to have impaired consciousness with Japan Coma Scale (JCS) 3 and incomplete right hemiparesis. Computed tomography showed nails in the right frontal, left frontal, and left temporal lobes. The nail in the left temporal lobe penetrated from the forehead to the temporal lobe of the left basal ganglia and was accompanied by intracerebral hemorrhage along the passway. Cerebral angiography confirmed that these nails did not injure any artery nor vein. The right temporal nail was manually removed under local anesthesia. The next day, the nails in the left frontal and left temporal lobes were removed by craniotomy, and the damaged frontal sinus was repaired using a pericranial flap. The left temporal nail had a deep head and was pulled out retrogradely from the tip. We could be safely removed by peeling off the surrounding brain matter. Postoperative bleeding and cerebro­spinal fluid leakage did not occur. Administration of antibacterial agents was started earlier from admission, and a follow–up cranial Magnetic Resonance Imaging confirmed no complications such as abscess formation. In this case, the three nails were surgically re­moved within 48 hours. For penetrating head injuries, removing the foreign body as soon as possible is recommended to avoid infec­tion, but there are no established removal methods. A tailored operation for each case is required considering the foreign body’s position, penetration route, and the damaged part’s location. Although careful follow–up will be required, we examined the acute treatment strat­egy for penetrating head trauma, including a review of literature.