Even people in ancient times were concerned with traumatic brain injury (TBI), as shown by the Edwin Smith Papyrus, an ancient Egyptian medical text depict­ing the diagnosis and treatment of TBI. Although an effective cure for TBI has eluded physicians for several thousands of years, the mortality rate due to TBI decreased after the discovery of antibiotics. The ability to diagnose TBI was dra­sti­cally improved with the advent of head computed tomography, and proper management of intracranial pressure in patients with TBI was eventually found to be important.

After the publication of the Glasgow Coma Scale by Teasdale and Jennett in 1974 and the subsequent Glasgow Outcome Scale by Jennett in 1976, there was a tremendous upsurge in the number of published articles on TBI. Nowadays, more than 4,000 articles on TBI are published annually. Despite the abundance of information on TBI, many of the strategies for treating patients with TBI, such as medication, surgery, and hypothermia for neuroprotection, have failed to be completely effective. Emergency transportation of TBI patients using an ambulance or helicopter and the management of TBI in the intensive care unit have advanced, leading to decreases in the mortality rate, but more needs to be done. In the future, randomized controlled trials need to be conducted to determine effective therapeutic drugs and surgical procedures for TBI patients who are pre–selected using artificial intelligence as likely to benefit from interventions.

Objective: Traumatic brain injury (TBI) resulting from a traffic accident is not so common in young children. We reviewed our experience to clarify the status for further medical care.

Methods: Nineteen patients aged under 7 years with severe TBI caused by traffic accidents underwent inpatient rehabilitation in our hospital between 1993 to 2010, and were followed up until after age 18 years. We retrospectively investigated the causes of injury, treatment during the acute stage, and outcomes including physical disability, intellectual disability, higher brain dysfunction, and epilepsy, and family functioning. The patients were divided into 4 groups by outcome: group I (7 cases) were independent, group II (2 cases) participated in "employment of persons with disabilities", group III (6 cases) had employment that required support, and group IV (4 cases) required full assistance for all activities of daily life. Clinical factors were compared between the 4 groups. The change in severity for each patient at 7, 13, and 18 years of age was assessed.

Results: Average age at injury was 5 years in all 4 groups. Many accidents such as jumping into the road, not wearing seat–belt, and so on seemed to be preventable by adult intervention. The outcome worsened depend­ing on the depth and extent of loss of consciousness. Contusion was most prominent type of brain injury in all groups. Focal damage was prominent and diffuse damage was not seen in group IV. No infarction was found in groups I and II. Neurosurgical treatment was prominent in groups III and IV. Limited help for higher brain dysfunction was required in group I. Some support for higher brain dysfunction and mild mental disability was necessary in group II. Individual support programs for intellectual disability and higher brain dysfunction were necessary in group III. Full support for all daily life was essential in group IV. The severity of disability was gradually im­proved in most patients, but a few in group III showed regression due to intractable epilepsy and bad family functioning.

Conclusion: Nineteen young patients with severe TBI caused by traffic accident were examined. Prevention of traffic accidents is the most im­portant intervention. Moreover, good programs to support higher brain dysfunction and family care are the keys to better outcome.

Objectives: Intracranial pressure (ICP) measurement is recommended when abnormal findings are observed on head CT due to severe traumatic brain injury (sTBI). But ICP sensor place­ment rate in Japan is currently low. In this study we described whether the emergency physicians can play a role as neurotraumatologists who can perform neurosurgical procedure by comparison of ICP sensor placement rate between emergency physician and neurosurgeon in sTBI.

Methods: The subjects were 34 patients with traumatic brain injuries having Glasgow Coma Scale ≦8 at admission and under­going emergency surgical operation. Patients with multiple injuries with an Abbreviated Injury Score (AIS) of 3 or higher at 2 or more sites and patients transferred from another hospital were excluded. We divided cases performed mainly by emer­gency physicians and cases performed mainly by neurosurgeons, and compared the ICP sensor placement rate between the two groups.

Results: 20 of the 34 patients (58%) were operated primarily by emergency physicians, and 14 (41%) by neurosurgeons. 19 of 20 cases (95%) in which emergency physicians proactively intervened, ICP sensors were placed, whereas neurosurgeons placed ICP sensors in 8 of 14 cases (57%). The rate of ICP sensor placement was significantly higher in emergency physician–centered cases. In both groups, there were no complications related to ICP sensor placement or sensor malfunction.

Conclusions: The insertion of the ICP sensor, which is necessary for managing ICP, which is one of the important monitoring in neurological intensive care, is a procedure that can be placed relatively easily even by emergency physicians. We believe that it is important for emergency physicians who have neurotraumatologists to actively perform this and to make use of it for the management of intensive neurological care.

Background: The aging of the Japanese population is accompanied by a rapid rise in the number of elderly head trauma patients. The characteristics of elderly patients differ from those of young patients and must be thoroughly understood if appropriate treatment strategies are to be developed. In this study we examined the characteristics of elderly head trauma patients in our institution and clarified the factors that influ­ence their prognosis.

Methods: Nine hundred and eighty–two head trauma patients admitted to Tokyo Medical and Dental University Hospital from 2015 to 2021 were enrolled in the study. The patients were divided into two groups: an elderly group aged 75 years or older (group E) and a non–elderly group aged less than 75 years (group Y). We retrospectively examined the correlations between clinical parameters such as patient background, type of injury, neurological symptoms, head CT findings, post–hospital course, and clinical outcome.

Results: Of the total 982 cases, 200 (20.4%) were in group E. Compared with the younger patients, group E was made up of a higher proportion of males (59.0% vs 80.2%: p<0.01) and a higher proportion of patients taking antithrombotic drugs (28.0% vs 4.3%: p<0.01). Acute subdural hematoma was sig­nificantly more frequent in group E (58.5% vs 30.9%: p<0.01). Talk and Deteriorate and surgical intervention were not sig­nificantly different between the two groups. Group E patients had more infections during hospitalization (29.5% vs 12.5%: p<0.01), more psychiatric symptoms (22.0% vs 9.3%: p< 0.01), a significantly higher rate of poor outcome (44.0% vs 18.9%: p<0.01), and a significantly longer median hospital stay (8 days vs 5 days: p<0.01). The Glasgow Coma Scale at administration and acute subdural hematoma were risk factors for poor outcome, and Talk and Deteriorate, surgical interven­tion, and infection were risk factors for an extended hospital stay.

Conclusion: Acute subdural hematoma was common in the elderly patients and was a significant factor of poor clinical outcome. Infection prevention might be the most important target in elderly patients, as infections are associated with poor clinical outcome and prolonged hospitalization.

Introduction: An organized chronic subdural hematoma (OCSH) is a subtype of chronic subdural hematoma with multiple septa and organi­zation of hematoma components. We report a case with acute subdural hematoma after hematoma removal by craniotomy for OCSH.

Case: A 86–year–old man fell down and hit his head. A primary care doctor performed head computed tomography (CT) and right subdural hematoma was suspected. He was transferred to our hospital. He had no neurological deficits and took direct oral anticoagulant (DOAC) for atrial fibrillation. Brain magnetic resonance imaging revealed high intensity lesion with surrounding low intensity lesion on the surface of right cerebrum with mass effect. He was diagnosed with OCSH. Medical treatment including cessation of DOAC was selected as he had no symptoms. However, he had headache and vomited on the second day and we performed craniotomy for hematoma removal. Although symptoms improved after the operation, they got worsen on the fifth day (3–day after the operation). Head CT revealed high density lesion on the surface of right cerebrum with midline shift and he was diagnosed with right acute subdural hematoma. He underwent hematoma removal by craniotomy. A fresh hematoma and bleeding from hematoma membrane were observed, and we removed them as much as possible. Following that, the patient has had an uneventful course.

Conclusion: Since removal of the hematoma membrane may carry high rates of mortality and morbidity, complete removal of the membrane seems to be difficult. In this regard, meticulous hemostasis of the membrane is quite important to prevent post–operative acute subdural hematoma after craniotomy for OCSH.

Introduction: Diffuse idiopathic skeletal hyperostosis (DISH) is a con­di­tion in which minor trauma can cause unstable vertebral fractures. Because conservative treatment, such as bed rest and bracing, may cause nonunion and delayed paralysis, surgical treatment, such as long posterior fixation using instrumentation between at least the three–above and three–below vertebral levels, is recommended. However, long posterior fixation is unsuitable in patients with high operative risks due to serious medical comorbidities or an advanced age. We herein report a case of lumbar reverse chance fracture treated with vertebral body stenting (VBS) and short posterior fixation.

Case report: A 96–year–old woman was admitted to our hospital for cerebral infarction presenting with severe left hemiparesis. On ad­mis­sion, radiological examinations revealed no fresh vertebral fracture but did note an old vertebral fracture at the Th12 and L5 levels with DISH and severe kyphosis. However, she complained of back pain seven days after admission without any obvious history of trauma. Radiological examinations revealed fresh reverse chance fracture at the L2 level. Although conservative treatment was administrated, there was no marked improvement in the symptom. She continued to suffer from severe back pain. We performed VBS and posterior fixation using instrumentation between the one–above and one–below vertebral levels because of the patient’s advanced age and severe kyphosis. Her severe back pain improved immediately after the procedure. Follow–up computed tomography at six months post­operatively revealed bony fusion between the fractured ends.

Conclusion: Vertebral fractures with DISH are often challenging for spinal surgeons and patients. It is important that the treatment strat­egy be considered on a case–by–case bias, especially in patients with advanced age. Less invasive surgery as was performed in this case may be a viable option in similar patients.

Traumatic microbleeds (TMBs) has been recognized as a sur­rogate marker for evaluating severity and predicting outcome in patients with diffuse axonal injury (DAI). Herein, we present 2 patients suf­fered from DAI by traffic accident, in which mag­net­ic resonance imaging (MRI) with susceptibility weighted imaging (SWI) showed multiple TMBs in the corpus callosum and subcortical white matter at acute ⁄ subacute time after the injury. The patients were treated conservatively and gradually regained consciousness. Thereafter, they recovered well with almost normalization on examination by neurorehabilitation, and returned to their previous social life within a short period. Although we do not deny the usefulness of TMBs in the diagnosis of DAI, we should aware that TMBs detected with SWI represents microvascular injury, which is not always the same pathology with axonal injury.

Traumatic optic neuropathy (TON) is caused by injury or compression to the optic nerve due to trauma, but treatment methods remain controversial. We report six cases of optic nerve decompression surgery for TON using the extradural optic canal approach to examine the efficacy of surgical treatment. Visual acuity, flicker value, relative afferent pupillary defect (RAPD), and other factors were evaluated before and after the operation. Surgical procedures included removing parts of the optic canal to reduce pressure on the nerve. The average age of patients was 65.7 years, and injuries were caused by falls, accidents, or tumbling. Preoperative com­puted tomography revealed optic nerve canal fractures in four patients, and facial or cerebral injuries in the others. Steroids were administered to all patients, and surgery was performed within one day in three cases, and up to 18 days post–injury in the others. Four patients experienced im­proved visual acuity after surgery, with no complications. This study shows the benefit of early treatment and that optic nerve decompression can improve visual acuity in TON patients, and further implies that surgical treatment may be implemented more aggressively. Individualized treat­ment strategies are recommended.

Penetrating intraorbital injuries of foreign bodies cause various symptoms and complications, and it might be difficult to diagnose especially small foreign body depending on its characteristics. We report a case of intraorbital abscess due to an inserted bamboo fragment via a small wound. An 82–year–old man felt a sharp right supraorbital pain during handling with bamboo. As the pain was transient, he did not consult to any medical doctors. Ten days after the injury, he visited our hospital complaining with progressing redness of the right conjunctiva. Plain computed tomography (CT) showed a hyperdense lesion in the right retroocular space and some air–like spots. However, we could not identify this lesion. We per­form magnetic resonance imaging (MRI) examinations. T1–weighted imaging (T1WI) showed the low intensity tissue surround­ing the linear foreign body showing lower intensity. The foreign body was a well delineated stick–shape object. Considering the image findings and his medical history, we made a diagnosis as intraorbital abscess due to an inserted bamboo fragment. After performing pterional craniotomy, orbital rim was removed. We opened periorbita and approached retroocular space. We found abscess, in which we re­moved a small fragment of bamboo. His postoperative course was uneventful. Postoperative CT scan and MRI showed the abscess dis­appeared and the impairment of the right eye movement gradually alleviated. According to this case experience, we examined MRI findings of wet and dry bamboo pieces, which found that wet bamboo showed high intensity but dry one showed very low intensity. When a small foreign body penetrates the orbit without passing through conjunctiva, patients are sometimes asymptomatic and unable to notice it at the acute phase. In this case, we could make a diagnosis based on the detailed medical history, the presence of abscess and characteristic imaging findings. We must notice of difficulty of imag­ing diagnosis of penetrated bamboo pieces.

A head injury resulting in a scalp laceration directly over the ventriculoperitoneal shunt with exposure and fracture of the shunt valve system, and active leakage of cerebro­spinal fluid, is an emergency situation. An 80–year–old woman presented to our hospital with a head injury. She underwent ventriculoperitoneal shunt surgery 21 years ago after subarachnoid hemorrhage. The injury occurred just above the ventriculoperitoneal shunt system. There was remarkable bleeding and cerebrospinal fluid leakage from the wound. The valve was broken at the distal end of the prechamber and separated into two parts. We made a skin incision just above the reservoir. The ventricular catheter could not be removed because of its high resistance. The catheter was cut at the distal side of the reservoir, and the contaminated valve and prechamber were removed. A new drainage tube was connected to the am­putated catheter near the reservoir. The placement of long–tunneled external ventricular drain was performed. The drainage tube was cut 22 days after the injury and the remaining tube was implanted subcutaneously. In our patient, the prevention of infection and appropriate man­agement of the cerebrospinal fluid drainage were required as soon as possible. Flexible treatment is desired depend­ing on the adhesion of the ventricular catheter and the wound situation.

We report a case of acute subdural hematoma (ASHD) that oc­curred due to damage to the pial artery pseudoaneurysm during burr hole drainage surgery for chronic subdural hematoma (CSDH). The patient was an 84–year–old male with recurrent bilateral CSDH, exhibiting a unique CT finding of adhesion between the outer and inner membranes of the hematoma on the left side. Burr hole drain­age surgery was performed for the CSDH, and acute bleeding occurred during drainage on the left side. A head CT scan revealed ASDH, and emergency craniotomy was performed for hematoma evacuation. Upon opening the dura mater, active bleed­ing was observed from a pial artery. Microscopic observation showed that the bleeding point was like a pseudoaneurysm, and hemostasis was achieved by clipping the bleeding point. Histopathological examination of the bleeding site tissue confirmed the possibility of a pseudoaneurysm. The cause of acute bleeding in this case was due to damage caused by the insertion of the drainage tube. The finding of adhesion between the outer and inner membranes of the hematoma may suggest adhesion of the arachnoid and pial arteries. Furthermore, the possibility of a pseudoaneurysm being formed cannot be ruled out in this case. We must take care of insert­ing a drainage tube, as it may damage blood vessels or pseudo­aneurysms and cause acute bleeding. Although a rare com­plication, awareness of its occurrence is clinically significant.

The brain of a child is highly plastic and may often recover more markedly than an adult brain if treated promptly and properly after sustaining traumatic brain injury. A 4–year–old boy fell off a bicycle and his helmet–protected head was run over by a large truck. At presentation, he had a Japan Coma Scale of III–300 and Glasgow Coma Scale of 3; he had equal pupils without dilation, positive bilateral pupillary light reflexes, and a subcutaneous hematoma on the right side of the head. The helmet he was wearing was intensely damaged. Head computed tomography revealed bilateral open indented fractures of the forehead, bilateral frontal lobe contusions, acute subdural hematoma, and diffuse brain swelling. Under the administration of a hypertonic decompression agent, the patient received emergency bilateral decompressive craniectomy and durotomy. After the surgery, both the intensivist and the pediatrician managed the patient’s intracranial pressure and general condition. Due to post­opera­tive brain swelling, unequal pupils were observed intermittently in accord­ance with postural changes of the body and aspiratory stimulation. The patient re­ceived barbiturate therapy and body temperature management. Although difficulties were encountered in controlling complications, the patient gradu­ally regained consciousness. A cranioplasty was performed, and the patient was discharged from the hospital to his home and was able to return to his kindergarten a little less than 2 months after sustaining the traumatic brain injury. Approximately 8 years later, his full–scale IQ was found to be 87 using the Wechsler Intelligence Scale for Children, Fourth Edition. He is currently in his sixth year of elementary school and is attend­ing a normal class. This case shows that even after brain trauma caused by an enormous impact, some children may be able to make a remarkable recovery if they receive prompt intervention in the form of multidisciplinary intensive care. We herein report the detailed findings of this case.

Two approaches can be employed for the treatment of traumatic optic neuropathy. Conservative therapy primarily uses steroids and surgical intervention that involves optic nerve canal de­compression. However, no standard guidelines have been established for this method. Herein, we report the improvement of visual function in three patients after surgical intervention and steroid administration during the acute phase.

Case 1: A 42–year–old man sustained a traffic accident injury; his left visual acuity had deteriorated to light perception upon arrival at the hospital. Emergency surgery involving optic nerve canal decompression was performed; thereafter, his visual acuity improved up to counting fingers in the upper half but remained partially blind in the lower half.

Case 2: A 54–year–old man fell from a bicycle; his left visual acuity had deteriorated to no light perception upon arrival at the hospital. Emergency surgery involving optic nerve canal de­compression was performed; following the surgery, his visual acuity improved up to counting fingers.

Case 3: A 46–year–old man who fell from a ladder had his right visual acuity deteriorated to light perception upon arrival at the hospital. Emergency surgery involving optic nerve canal decompression was performed; his right visual acuity improved up to counting fingers postoperatively.

The fundamental principle in the treatment of traumatic optic neuropathy is early decompression of the optic nerve. Therefore, performing optic nerve canal decompression and steroid administration as early as possible is advisable.

Introduction: Acute brain swelling after head trauma is generally believed to be caused by impaired cerebrovascular autoregulation (vaso–paralysis), cellular edema, and vasogenic edema. Brain swelling caused by vaso–paralysis after repeated head trauma has gained attention as "second impact syndrome" and is frequently reported. However, reports of cer­ebral edema following concussion are rare.

Case: A 24–year–old male soccer player with no history of concussion experienced facial head trauma by impact with an opponent player’s knee during a match. Immediately after the injury, the patient presented with disorientation, amnesia, and headache, and a concussion was sus­pected, and the patient was admitted to our hospital. At examination 3 h post–injury, the patient’s orientation improved, but the headache persisted, along with mild antegrade amnesia, sluggish thinking, impaired memory, and concentration. Magnetic resonance imaging (MRI) of the head ruled out intracranial hemorrhage. However, fluid–attenuated in­ver­sion recovery, diffusion–weighted imaging, and ADC revealed a high–intensity area in the right temporo–occipital cortex. Arterial spin label­ing ruled out increased blood flow to this site. With rest and treatment, MRI signal changes disappeared the next day, and subjective symptoms improved 3 days after presenting to our hospital. Following a graduated return to play protocol, the patient returned to play within 1 week and did not experience any recurrence of symptoms.

Discussion: This case was diagnosed clinically as a concussion as head MRI revealed vasogenic edema localized to the right temporo–occipital cortex. Since no increase in cerebral blood flow was observed, the cause was determined to be transient hyperpermeability rather than vaso–paralysis. The MRI signal resolved one day post–injury, and the patient returned to sports smoothly. Based on these results, the concus­sion diagnosis may not have been clinically severe.

Conclusion: Concussions may result from vasogenic edema due to in­creased vascular permeability.