Chronic subdural hematoma (CSDH) is no longer a benign disease after burr hole irrigation surgery because of the aging of society. We reviewed recent molecular biologic findings and capillary permeability of the hematoma capsule to identify promising therapies other than burr hole irrigation. Delayed magnetic resonance imaging is useful to predict the occurrence of CSDH at the preceding stage of traumatic subdural effusion and indicates the therapeutic window. Molecular biologic studies have demonstrated angiogenesis, inflammation, fibrinolysis, and water channels involved with the formation and enlargement of CSDH. Based on these findings, randomized controlled trials of statin, steroid, and tranexamic acid therapies are continuing. Kinetic dynamic study of the capillaries of the outer membrane of CSDH showed that development depended on the quantity rather than quality of the capillaries. This finding supports the efficacy of middle meningeal artery embolization to prevent or treat CSDH. In the future, pharmacotherapeutic therapies and endovascular treatment may become the first–line treatment in a subgroup of CSDH patients.

Introduction: Stepladders and ladders are widely used not only in labor but also at home, but there are lots of cases of head injuries caused by falls of them. We retrospectively examined cases of head injuries caused by falls from stepladder or ladder at our hospital.

Method: Of the 913 cases of head trauma with intracranial hematoma that were treated in our hospital from January 2010 to December 2020, 30 cases were caused by falling from stepladder or ladder. The analysis focused on clinical findings.

Results: The age ranged from 26 to 87 years (median 68 years), and the gender was 29 males and 1 female. GCS at admission was 3 to 15 points (median value 12), and the main intracranial hematomas on the image were traumatic subarachnoid hemor- rhage in 6 cases, cerebral contusion in 9 cases, acute subdural hematoma in 12 cases, and acute epidural hematoma in 3 cases. A com­parison of the good outcome group (16 cases) and the poor outcome group (14 cases) showed significant differences in age, GCS, ISS, and Ddimer at admission. The causes of poor outcome were 6 deaths due to increased ICP, 2 brain dys­function due to diffuse axonal injury, and 6 residual focal neurological deficit due to cerebral contusions. There was no significant dif­ference in the fall height between the good outcome group (2.6 m) and the poor outcome group (3.3 m).

Discussion: In the cases of head injuries caused by falls from stepladder and ladder at our hospital, poor outcome factors were elderly, low GCS, high ISS, and high Ddimer at the time of visit. In the elderly, not only intracranial hematoma but also diffuse axonal injury was the cause of poor prognosis. Since the height of the fall did not affect the outcome, it is not possible to take a sufficient defensive posture against an unexpected fall, which is one of the causes of the aggravation of the elderly.

We report a case of perilymphatic fistula following blunt traumatic brain injury without temporal bone fracture. A 20–year–old woman presented with tramatic amnesia after head injury sustained in a traffic accident on a bicycle. Computed tomography re­vealed a small contusion in the right frontal lobe but no skull fracture. On admission, she rested for several days in bed because of nausea and was treated conservatively. She had left ear pain and dizziness 2 days after the injury, and left hearing disturbance and tinnitus developed 4 days after the injury. She was discharged from our hospital and consulted an otorhinolaryngologist 13 days after the injury because our hospital does not have an otorhinolaryngology department. She was diagnosed with a perilymphatic fistula and permanent hearing loss. Perilymphatic fistulas are rare following traumatic brain injury, but they often cause severe and/or permanent hearing disturbance. Therefore, patients who have vestibular or cochlear symptoms after head injury should be carefully examined even if brain injury is mild.

The outcome of patients with severe traumatic brain injury presenting with dilated pupils is generally poor, and decompression surgery at the earliest possible is warranted in such cases. Our strategy for managing patients with severe traumatic brain injury comprises completing the series of treatment provided at prehospital, trauma bay, intensive care unit, and rehabilitation center at a single department in a hospital (All–in–One Strategy). Herein, we report the case of a patient with severe traumatic brain injury who was successfully treated using this strategy and who survived to hospital discharge with a good neurological outcome. A 19–year–old male was injured in a traffic accident at midnight, following which a physician–staffed ambulance was dispatched from our hospital. When the physician contacted the patient at the emergency site, the patient was comatose and had developed Cushing reflex. The physician notified the trauma bay for emergency surgery at the emergency site.

Soon after arriving at the trauma bay, the patient underwent head computed tomography, revealing bilateral acute subdural hematoma with multiple contusions. An emergency trepana­tion was performed 58 min after the patient’s arrival at the hospital because his pupils were dilated. Subsequently, the patient was transferred to the operation room and decompressive craniotomy performed 74 min after his arrival. The patient recovered to eat and walk on his own and survived to discharge at day 84 with a Glasgow Outcome Scale category of moderate disability.

We report a case of severe acute subdural hematoma (ASDH) with cerebral contusion that had a good out­come after small craniotomy and intracranial pressure (ICP) management. A 78–year–old man presented to our hospital with trauma and consciousness disturbance (GCS E1V1M5) after a traffic accident. His vital signs were normal, but head CT showed right ASDH and cerebral contusion in the right front­oparietal lobe. After securing the airway, hematoma removal with small craniotomy and ICP sensor im­plantation were performed, and intensive neurological management was started. During the hospital stay, normal ICP was maintained and no additional large craniotomy or decompression craniectomy was re­quired. The postoperative course was uneventful and the patient was transferred to a rehabilitation hospital on the 24th day after the injury. At 1–year follow–up, he had resumed normal daily activities (GOS good recovery) with GCS E4V4M6. This case suggests that hematoma removal with small craniotomy can be effective treatment for an elderly patient with ASDH accompanied by cerebral contusion, with avoidance of additional large craniotomy and decompression craniectomy.

A 65–year–old man who had a history of hypertension and diabetes presented with a left oculomotor nerve palsy. A close examination revealed a left internal carotid artery aneurysm, and an aneurysmal clipping was performed. Using a Mayfield three–point head clamp, a pin was inserted into the right frontal region to avoid the frontal sinus and fixed at 60 lb. After the operation, the patient was discharged without any wound problems. At the outpatient department, a chronic subdural hematoma was pointed out, and medication was given. However, the fever continued for 1 month after the operation. A full–body search found no cause of fever. There was an enlargement of the right subdural space, and MRI showed a high signal in the diffusion–weighted image of the same site. The patient was diagnosed with a subdural empyema due to pin fixation. The craniotomy was performed, and the bone perforation was shown at the pin fixation site. The granulation was found in the dura just below. Operative findings revealed dark red purulent fluid within the hematoma cavity. No causative bacteria were detected in the culture, and the fever disappeared immediately after the operation. The patient was discharged to home on postoperative day 14 and diagnosed with osteoporosis.

The Mayfield three–point head clamp is widely used in neurosurgery. Although there have been reports of skull fractures or epidural hema­tomas, the subdural empyema is rare. In this case, it was considered that the source of infection broke into the skull due to bone perfora­tion associated with osteoporosis during clipping surgery, and then the infection spread to subdural hematoma late. Infection may occur even in the chronic phase with compromised patients such as diabetes. An early improvement was observed by removing the empyema, but caution is required especially in patients with osteoporosis and dia­betes.

Introduction: Traumatic carotid–cavernous sinus fistula (CCF) is difficult to cure by transvenous and/or transarterial embolization be­cause of the large fistula site, and parent artery occlusion is some­times required. We report a case of traumatic CCF treated by extracranial to intracranial bypass followed by endovascular treatment.

Case: A 34–year–old man was taken to the emergency room after falling from the fourth floor. His Glasgow Coma Scale score was E1V2M3. On the 40th day after admission, he began to complain of headache. Digital subtraction angiography showed traumatic CCF and reflux into the superior ophthalmic vein. The balloon occlusion test (BTO) was performed to evaluate ischemic tolerance in case of permanent occlusion of the right internal carotid artery (ICA). BTO of the right ICA for 20 minutes provoked tonic movement of left upper extremity. Aortography during BTO showed good crossflow through the anterior and posterior communicating arteries, but the crossflow was stolen by the CCF, and the venous phase in the right hemisphere was delayed by 2 seconds. Considering the possibility that the patient could not tolerate the parent artery occlusion well, a right superficial temporal artery–middle cerebral artery bypass was performed, followed by transvenous embolization. However, transvenous embolization did not provide sufficient obliteration of the CCF, so parent artery occlusion of the right ICA using coils was performed. The patient had an uneventful postoperative course and was transferred to convalescent rehabilitation with modified Rankin scale 2 on the 67th day after admission without any new neurological complications. The necessity of bypass was difficult to evaluate using BTO in our case of traumatic CCF because of the extent of shunt volume, so we performed low–flow bypass before parent artery occlusion to anticipate any intolerance.

An arachnoid cyst is sometimes found in chronic subdural hematoma patients, and the two lesions usually reside ipsilaterally. However, although it is rare, there are cases where the lesions occur contralaterally. Here we report a case of a chronic subdural hematoma that occurred at the contralateral side of a middle fossa large arachnoid cyst. Although the hema­toma was successfully surgically evacuated by drainage, a space–occupying hematoma formed within the arachnoid cyst post–surgery. No surgical intervention was required, but it took seven months for the hematoma to resolve. This case highlights a possibility that achieving complete hemostasis of chronic subdural hematoma could be more difficult in cases complicated by a large arachnoid cyst than typical cases.