Traumatic or non–traumatic intracerebral hemorrhage (ICH) increases the intracranial pressure, leading to disabling hematomas. Iron in the hematoma causes secondary disorders such as inflammation and edema. D–allose, a rare sugar, exerts antioxidant and anti–inflammatory effects. We investigated the effects of D–allose on secondary disorders after ICH. ICH model rats were created by injecting autologous whole blood (100 μL) into the right basal ganglia of adult Sprague–Dawley rats. D–allose (200–400 mg/kg) was admin­istered intraperitoneally immediately after establishing the model. A battery of motor deficit tests was ex­amined 1 day after administration, and brain edema, doses of an oxidative stress marker (8–OHdG, apurinic ⁄ apyrimidinic (AP) site) and inflammatory cytokines (IL–1β, IL–6, TNF–α) in the brain were examined 3 days after administration. All the examined items showed that D–allose significantly suppressed the damage. These results suggested that D–allose suppresses secondary damage following ICH. D–allose is expected to have potential as a therapeutic agent for secondary disorders after ICH.

The outcome of patients with comatose acute sub­dural hematoma (ASDH) with bilateral pupil dila­tion is generally devastating. Here, we report a case of ASDH in which a small craniotomy was suc­cessfully performed at the emergency room. An eighty–six–years–old man was brought to our de­part­ment due to impaired consciousness after a fall. On hospital arrival, Glasgow Coma Scale (GCS) of the patient was 6 (E1V1M4) and bilateral pupils were fully dilated. The head computed tomography (CT) revealed a right acute subdural hematoma with brain herniation. The outcome of this patient was expected to be poor, but we performed a small craniotomy at the emergency room instead of burr–hole craniotomy in order to remove hematoma immediately. The majority of hematoma was suc­cess­fully removed, and the bleeding point was controlled. The time for the surgery was 40 minutes. Postoperative CT showed that the hematoma had been removed with mild brain swelling. The patient’s postoperative course was good, and his conscious level improved to GCS of 14 (E4V4M6). The patient was discharged from hospital on day 49.

Small craniotomy at the emergency room can be an effective life–saving procedure for life–threatening severe ASDH.

Patients with elevated intracranial pressure and bilateral pupil­lary dilatation show poor treatment outcomes. We report a case of severe head injury in a patient with intracranial pres­sure >80 mmHg and bilateral pupillary dilatation, who underwent decompression craniectomy, which resulted in release of superior sagittal sinus stenosis and led to a favorable outcome.

A 52–year–old man presented with severe head trauma sus­tained in a traffic accident. He had a severe consciousness dis­order with bilateral pupillary dilatation. Head computed tomo­graphy (CT) showed fractures of the right frontal and parietal bones with disruption of the sagittal suture and diffuse traumatic subarachnoid hemorrhage without a midline shift. CT venography (CTV) revealed superior sagittal sinus (SSS) stenosis below the fracture and a thin epidural hematoma. Head CT showed no removable hematoma; therefore, an intra­cranial pressure (ICP) sensor was inserted, which revealed ICP of 86 mmHg. The ICP did not respond to medical treatment; therefore, we performed decompression craniectomy. Intraoperatively, a bone fragment at the sagittal suture dis­rup­tion was moved, with removal of the epidural hematoma immediately beneath this site. The ICP normalized postopera­tively, and the SSS showed normal perfusion on CTV the following day. Decompression craniectomy released the SSS stenosis. ICP control was favorable, and the patient’s con­scious­ness level gradually improved. He was transferred to the rehabilitation hospital with a Glasgow Coma Scale of E4V4M6 and modified Rankin Scale score of 4.

Treatment is warranted in patients with severe head trauma without head CT–documented severe brain injury but with high ICP and impaired venous perfusion to ensure favorable outcomes.

Chronic subdural hematomas (CSH) in the posterior fossa are relatively rare. We report a case of bilateral CSH in the posterior fossa developed due to minor trauma under anticoagulation therapy.

A man in his 80s under anticoagulation therapy was admitted to the emergency department with headache and vomiting about a week after a blow the occipital head. CT and MRI showed a bilateral CSH of the posterior fossa. The patient was diagnosed with intracranial hypertension with vomiting symptoms and emergency drainage sur­gery was performed. The hematoma drained through a single burr hole on the cerebellar hemispheric surface. Surgery was completed without continuous drainage, after normalization of intracranial pres­sure was confirmed. The symptoms resolved completely within a few days.

Approximately 70% of patients with CSH of the posterior fossa are reported to be under anticoagulation therapy. Most of these would have a traumatic history as important event. In the present case, his symptoms appeared within a week after injury, which may have been influenced by the anatomical features of the posterior fossa as well as the coagulopathy under anticoagulation therapy. Minimally invasive surgery should be considered for elderly patients and those under anticoagulation therapy.

Diffuse fracture of central skull base is a severe pathology which is hard to be treated because of not only intracranial injury but also cranial nerve injury and rhinorrhea.

Case: A 20–year–old man was transported to the emergency room after a collision with a passenger car while riding a motorcycle. His vital signs were stable and disoriented conscious level (GCS E4V4M6) with nasal hemorrhage and bilateral eyelid edema. His visual acuity was bilaterally counting fingers. There were no motor and sensory deficits in the upper and lower extremities. A CT scan of the head revealed bilateral frontal lobe contusions, traumatic subarachnoid hemorrhage, pneumoencephalous, and crushed fracture findings in the central skull base. The patient was firstly treated conservatively, because cerebrospinal fluid (CSF) leakage was not evident at first, and vital signs and level of consciousness were maintained. On the second day from the onset, the left visual acuity became light percep­tion, and the light reflexes became blunted. Steroid pulse therapy was initiated, and an MRI indicated hyperintensity on STIR surrounding left optic nerve suggesting remarkable edema in the intra optic sheath. Since CSF leakage associated with a central crushed skull base fracture was also suspected, we decided to perform an emergent endoscopic surgery so as to decompress the optic nerve by releasing optic canal and repair the central skull base. At the moment of an opening of the anterior wall of the sphenoid sinus, a plenty of CSF flew out after removal of the blood clots. The center of the skull base was fractured in a crushed shape, and a part of the bony fragment was pressing on the left side of the optic chiasm. After removal of that, the left optic canal was opened as far as possible. The dural defect in the anterior cranial floor with CSF leakage was closed with a femoral fascia and a pedicled mucosal flap at the sphenoid sinus. Just after the surgery, left visual acuity was restored to counting fingers and rapid light reflex. Until the 31st day after the surgery, the patient had recovered to an effective visual acuity of 0.4, although incomplete bilateral hemianopia remained.

Endonasal endoscopic decompression of optic canal and repairment of skull base might be effective for diffuse fracture of the central skull base complicated with traumatic optic neuropathy and severe rhinorrhea.

In principle, surgery for acute subdural hematoma (ASDH) involves craniotomy for hematoma removal. Burr hole surgery is not considered a standard procedure due to its limited therapeutic effect; however, it is often performed prior to craniotomy in cases where craniotomy is difficult or in emergency situations. Previous studies reported good out­comes for the use of burr hole surgery alone for removing hema­toma. Although some cases of ASDH can be treated with burr hole surgery alone, prognostic factors and indications for surgery are un­known.

In the present case, the patient was elderly, and her medical history made craniotomy difficult. We treated the patient with burr hole surgery alone and achieved a good outcome. The patient’s age, neurological findings on admission, and the nature of the hematoma may have contributed to the favorable outcome. Burr hole surgery is a minimally invasive procedure and may be an option for ASDH patients who are unable to undergo craniotomy. With the aging population, the number of ASDH patients who face challenges in undergoing craniotomy is expected to rise; therefore, further research on minimally invasive sur­gery for ASDH is necessary.

Although various types of vascular disorders are associated with head trauma, a rare case is a traumatic middle meningeal artery pseudoaneurysm (tMMAP). We report a case of a 70–year–old man with tMMAP presenting with an intracerebral hematoma (ICH). He was rushed to the hospital in a poor state of consciousness after a traumatic fall. A computer tomography (CT) scan taken on ad­mis­sion revealed a traumatic left temporal lobe ICH, subarachnoid hemorrhage, and bilateral acute subdural hematoma. After conservative treatment, his consciousness improved, except for disorientation on day 3 of hospitalization, and a CT scan revealed resolution of ICH. However, on day 10 of hospitalization, he suddenly fell into a coma, and a CT scan revealed that the hematoma in the left temporal lobe had grown and caused a midline shift. We conducted an emergency craniotomy and hematoma removal, during which we encountered an intractable arterial bleeding at the left middle skull base. We could barely stop the bleeding using aneurysmal clips. Suspecting the possibility of a vascular abnormality, we per­formed a postoperative cerebral angiography that revealed a pseudoaneurysm in the left middle meningeal artery. We determined that this pseudoaneurysm was the source of the bleeding and performed an endovascular parent vessel occlusion. After the endovascular surgery, there was no recurrence of hemorrhage. The patient was transferred to a rehabilitation facility because of residual cognitive dysfunction. tMMAP is a rare disorder, and its rupture generally causes an epidural hematoma; however, in some cases, it can cause an ICH. Although it is difficult to predict the rupture in advance, tMMAP must be recognized as a delayed com­plication of traumatic vascular disorders as it can lead to severe conditions.

Collagen matrix is widely used as a dural substitute, but does not effectively prevent adhesions between the dural layer and the scalp flap during cranioplasty. Adhesions may increase risks of periope­ra­tive complication. We report the use of a subgaleal dissection technique for scalp flap reflection during cranioplasty following collagen–matrix duraplasty during decompressive craniectomy, eliminating the need for additional anti–adhesion materials.

An 18–year–old healthy male suffered a severe head injury after a fall, and a computed tomography revealed a massive intra­cerebral hemorrhage in the left temporal lobe with a subdural hemorrhage. Decompressive craniectomy with collagen–matrix duraplasty was initially performed, followed by cranioplasty on day 55 in hospital. During cranioplasty, scalp flap reflection was easily achieved using the subgaleal dissection technique, despite the presence of adhesions formed by the collagen matrix. The bone flap was then placed above the pericranium and temporal fascia. No cerebrospinal fluid leakage occurred during cranioplasty, and the postoperative course was uneventful, with no hematomas, epidural CSF collections, or wound complications.

In our case, subgaleal dissection technique permitted easy and safe reflection of the scalp flap, despite the time that had elapsed since collagen–matrix duraplasty. In addition, preserving the peri­cranium and temporal fascia as a new epidural layer using this technique helped reduce perioperative complications.