Background: While surgical treatment can achieve good outcomes in patients with chronic subdural hematoma (CSDH), recurrence is not rare. Various factors, including patient age, the administration of anticoagulant drugs and the volume of hematoma are associated with the recurrence of CSDH. In the present retrospective study, we analyze predictors of the recurrence of CSDH on pre–operative CT.

Material and Methods: One hundred nine patients with unilateral initial CSDH who were managed between January 2017 and April 2021 were included in the present study. Physical factors including age, sex, diabetes mellitus, anti­platelet or anticoagulant therapy and pre–operative CT findings, including side of hematoma, properties of hematoma (homogeneous, laminar, sepa­rated, trabecular), midline shift value and maximal width of hematoma were analyzed in patients with symptomatic recurrence (recurrent group) and pa­tients without recurrence (non–recurrent group). Symptomatic recurrence was defined as by the presence of neurological deterioration with hematoma re–accumulation on CT.

Results: Twenty–eight of 109 patients (25.7%) had symptomatic recurrence of CSDH. There were no significant differences in the physical factors of the patients in the recurrent and non–recurrent groups. In a multivariate analysis, significant differences were observed in the separated type hema­toma and the midline shift values on pre–operative CT between the recurrent and non–recurrent groups. The receiver operating characteristic curve be­tween symptomatic recurrence and the midline shift value demonstrated a cut–off value of 6.6 mm (AUC, 0.67; sensitivity, 0.71; specificity, 0.58).

Conclusions: The separated type hematoma and the value of midline shift on pre–operative CT were independent predictors of symptomatic recurrence of CSDH. If the midline shift value on pre–operative CT is >6.6 mm, the risk of symptomatic recurrence was high.

Introduction: Intracranial hypotension is a pathology caused by low spinal fluid pressure due to leakage of spinal fluid, and is characterized by orthostatic headache. It is most commonly seen after trauma or lumbar puncture, but minor trauma can be a cause. In this article, we report a case of intracranial hypotension induced by use of a home massage machine in an unusual way.

Case: A 48–year–old–female, who mistakenly used a home–use massage machine for her lower back and lower legs upside–down (from her chest back to her lower back), arrived our hospital with a strong orthostatic headache. Based on the symptoms, intracranial hypotension was considered, and the patient was admitted to the hospital.

Progress: On the day of admission, treatment with bed rest and sup­plemental fluid was started. A full spine MRI revealed an enlarged epidural space and spinal fluid leakage in the backward of 7th cervical vertebra to the 9th thoracic vertebra. A contrast–enhanced brain MRI showed diffuse contrast enhancement of the thickened dura mater, and a diagnosis of intracranial hypotension was made. Since the symptoms did not improve with conservative treatment, blood patch therapy was performed via lumbar puncture on the 15th day of admission. The symptoms disappeared on the day after the surgery, and the patient was able to leave the hospital on the 20th day.

Conclusion: We experienced very rare case of intracranial hypo­tension caused by use of home-use massage machine in an unusual way. Symptoms were dramatically improved by early epidural blood patch.

Kendo is a modern martial art origin from traditional Japanese swords­manship, that is now widely popular over the world. Although Kendo has some opportunities to hitting on the various body parts, including the head with a bamboo sword, traumatic brain injury is uncommon. On the other hand, intra­cranial hematoma is a rare but lethal complication in patients with arachnoid cysts after head trauma. Here we report a 16–year old boy with subdural and intracystic hematoma associated with a known arachnoid cyst. He was diagnosed with an arach­noid cyst (Galassi classification Type Ⅱ) in Lt. middle fossa six months ago. One day after daily Kendo practice, he realized mild headache but never went to the hospital. Twenty hours after the practice, he suddenly became disoriented and was rushed to our emergency room. CT scan revealed a subdural and intracystic hematoma with midline shift, thus urgently we performed trepanation for hematoma aspiration and continued to perform craniotomy for cyst fenestration. He has progressed uneventfully and favorably after the surgery, was discharged from the hospital with independence in Activities of Daily Living (ADL). Because athletes with arachnoid cysts are at risk of intracranial hemorrhage from even minor trauma, symptoms related to increased intracranial pressure must be carefully addressed and the risks must be widely educated.

Introduction: Cerebral venous sinus thrombosis following blunt head trauma in children is extremely rare, but potentially fatal with an acute mortality rate of nearly 10%. Symptoms of cerebral sinus thrombosis are variable, ranging from blurry vision and headaches to complete loss of consciousness, making it is difficult to diagnose at an early stage. We describe a unique case of traumatic blunt head injury, which was imaged using nonenhanced computed tomography (CT), T1 and T2–weighted magnetic resonance imaging (MRI) and MR veno­graphy leading to an early diagnosis and treatment of a cerebral sinus thrombosis in a young child.

Case report: A 6–year–old boy presented to our hospital im­mediately following a traffic accident. A CT scan of the head was emergently ordered and revealed an acute epidural hema­toma, bilateral occipital lesions, an occipital bone fracture. Imaging on the following day, revealed no increases in the size of the epidural hematoma or in the amount of gas seen in the right transverse sinus, but a new increased density area was seen in the lesion of the right transverse–sigmoid junc­tion. T1 and T2–weighted MRI showed a hyperintense area and MRV showed the disappearance of the right sigmoid sinus, leading to the diagnosis of a traumatic venous sinus thrombosis. The patient was treated conservatively with symptomatic relief of nausea and cephalgia and without anti­coagulation. Repeat imaging on day 8 found no increase in the size of the cerebral venous sinus thrombus and the patient was discharged to home on day 17.

Conclusion: We report on a rare pediatric case of atraumatic venous sinus thrombosis successfully diagnosed by non­enhanced CT and MRI imaging at an early stage allowing for a reduction of morbidity and overall survival.

Background: Traumatic carotid–cavernous fistula (tCCF) is rare arteriovenous shunt between carotid artery and cavernous sinus, resulting from head injury. The symptoms in tCCF typically present within several weeks after injury.

We report the rare case of delayed tCCF 4–month after head injury.

Case presentation: A 86–year–old man suffered right–sided head injury due to a fall while walking. He was diagnosed with left–sided subdural hematoma and contusion, but no cranial frac­tures. He had a symptom of headache and nausea, but no cranial nerve palsy. There were no evidence of cerebrovascular disease including tCCF on initial and 15–day follow–up MRI. Four–month after the injury, he suffered from sudden onset of diplopia. MRI revealed the right–sided tCCF draining to the ipsilateral superior ophthalmic vein, inferior petrosal sinus, and inter­cavernous sinus. Two–stage transvenous coil embolization was performed, and the tCCF was eliminated via selective occlusion. His diplopia was completely resolved at 1–month follow–up.

Conclusion: tCCF should be considered even in the chronic stage of head injury. We recommend a longer follow–up period of 6 months after a head injury.

In recent years, traumatic injuries in the elderly have been increasing and have been attracting attention as the population ages. According to the Japan Neurotrauma Data Bank, falls are the most common cause of injury, accounting for more than half of all injuries. Severe head injuries are not infrequently encountered in clinical practice. The occurrence of a single brainstem injury is extremely rare, and the mechanism of its occurrence is still under debate. In this case, the head computed tomography (CT) and magnetic resonance imaging (MRI) showed a brainstem injury that extended vertically around the tentorial incisura, and we diagnosed a single brainstem injury caused by direct injury from the tentorial incisura.