Background: Goreisan is commonly used for the conservative treatment of chronic subdural hematoma and for preventing recurrence. However, in some cases, the hematoma does not regress despite the expected therapeutic effect. The aim of this study is to evaluate the efficacy of Saireito in the treatment of chronic subdural hematoma in cases where Goreisan proves ineffective.

Materials and Methods: This study included patients with chronic subdural hematoma who were treated over a 4–year period, from January 2020 to December 2023. Among these, patients who opted for conservative treatment due to factors such as hematoma size were treated with 7.5 g/day of Goreisan. Surgical patients also received Goreisan for recurrence prevention post operatively. In cases where hematoma regression did not occur during treatment with Goreisan, the dosage of Goreisan (7.5 g/day) was replaced with Saireito (9.0 g/day). Of the 30 cases analyzed, 13 were in the conservative treatment group and 17 were in the postoperative recurrence prevention group. Antithrombotic agents were administered prior to treatment in 6 cases, and hemostatic agents were used in 18 cases.

Results: Among the 30 patients who transitioned from Goreisan to Saireito, hematoma resolution was observed in 23 cases, with no change in 5 cases, and deterioration in 2 cases. Surgery was ultimately required in 4 cases, while in 26 cases (86.4%), surgery was avoided.

Conclusions: The results suggest that changing treatment to Saireito may lead to regression of chronic subdural hematoma in many cases, even when Goreisan is ineffective. However, potential side effects of Saireito, including interstitial pneumonia and hepatic dysfunction, have been reported, and these complications should be considered when using Saireito.

Acute injury to the vertebral artery is rare due to its anatomical characteristics, which makes diagnosis and treatment extremely challenging. In this case, we successfully treated a patient with severe bleeding due to an acute penetrating injury to the vertebral artery by performing endovascular embolization using a combination of coils and N–butyl–2–cyanoacrylate (NBCA). A 46–year–old woman was found by her family bleeding and unconscious in her bathroom and was taken to our hospital. On admission, multiple lacerations were observed on the anterior neck, epigastric region, and lower abdomen. Intestinal protrusion was visible through the abdominal wound. Imaging studies were performed immediately; however, by the time they were complete, the patient’s level of consciousness had deteriorated, and she was in shock. Firstly, an emergency laparotomy was performed to stop the bleeding. However, swelling of the neck and continued bleeding from the wound were observed at the end of the procedure. Left vertebral artery angiography revealed extravasation in a wall abnormality at the C4/C5 level, indicating a vertebral artery penetrating injury. Right vertebral artery angiography was then performed to determine the treatment plan, revealing good blood flow in the contralateral vertebral artery. Therefore, it was decided to occlude the left vertebral artery to achieve hemostasis. We were then able to complete the surgical procedure by combining coil embolization and infusion of NBCA. Postoperatively, the patient’s level of consciousness improved, with mild left hemiparesis and ataxia remaining; however, no other neurological symptoms were observed. Two weeks after surgery, the patient was transferred to a psychiatric ward.

Traumatic oculomotor nerve injury; Traumatic brain injury Primary traumatic oculomotor nerve injury is relatively rare, and a few case reports have documented detection of such injuries using magnetic resonance imaging (MRI).

A woman in her 30s was brought to our hospital with impaired consciousness following a severe traffic accident. Her car had been struck from the right side by another vehicle and flipped over. Upon arrival at the hospital, her Glasgow Coma Scale score was 7 (E1V1M5), and her right pupil was dilated. Head computed tomography (CT) revealed a small hemorrhage in the lateral ventricle and around the midbrain. Three hours after admission, her consciousness improved, but there was no change in the right pupil findings.

MRI performed on the third day after admission showed diffuse axonal injury around the corpus callosum and brain contusions in the left midbrain and superior surface of the left cerebellum. We identified a torn right oculomotor nerve at its origin from the mid brain using thin–slice cisternography and fluid–attenuated inversion recovery imaging.

Based on MRI findings, we hypothesized the mechanism of the oculomotor nerve injury.

The strong impact from the right side likely displaced the brainstem to the left, causing it to contact the tentorium. This displacement result in injury to the left midbrain and cerebellum, and tearing of the right oculomotor nerve. Therefore, we suggest that brainstem mobility plays a key role in the mechanism of traumatic oculomotor nerve injury. Her oculomotor nerve palsy showed no significant improvement, and memory dysfunction persisted. She was transferred to a rehabilitation hospital.

Objective: Most pseudoaneurysms of the superficial temporal artery are of traumatic origin; however, they can also have iatrogenic, idiopathic, or other causes. These pseudoaneurysms typically present as a painless, pulsatile swelling subcutaneous mass following head trauma. The standard treatment is surgical resection, but certain cases may require conservative management, thrombin injection, or endovascular intervention. Even though endovascular intervention has been reported only in some cases, it may be the most appropriate treatment in certain scenarios. We herein report the efficacy of endo vascular intervention for the treatment of a superficial temporal artery pseudoaneurysm; we also provide a review of other treatment modalities and present previous reports on endovascular treatments.

Case Report: A 43–year–old woman presented with a progressively enlarging, painless subcutaneous mass in her right frontal region. She had a head injury in a traffic accident two weeks prior. Head CT angiography revealed an 8–mm pseudoaneurysm in the anterior branch of the right superficial temporal artery. In view of her cosmetic concerns, we performed endovascular intervention 21 days post–injury. Because of difficulty in crossing the lesion, we performed proximal occlusion. We confirmed complete loss of contrast enhancement via angiography and loss of blood flow via intraoperative Doppler ultrasound. We found that the pseudoaneurysm had regressed significantly a month after embolization.

Conclusion: Coil embolization of a superficial temporal artery pseudoaneurysm yielded excellent cosmetic results without leaving a surgical scar. Various treatment strategies are available for these pseudoaneurysms, each with its own advantages and disadvantages. The optimal therapeutic approach is that which is tailored to an individual patient’s condition and preferences.

Although a traumatic orbital hematoma is rare, it can cause severe visual impairment. We report two cases of traumatic orbital hematoma causing visual impairment and undergoing craniotomy to remove the hematoma.

Case 1: A 54–year–old man suffered visual impairment due to head trauma caused by a fall, and his visual acuity was counting fingers. CT image showed an extraconal hematoma in the upper part of the right orbit and a fracture of the superior wall of orbit. Craniotomy and hematoma evacuation were performed. The hematoma was located between the orbital wall and the periosteum. After the surgery, his visual acuity improved to 0.9.

Case 2: A 71–year–old man lost his balance and a chopstick pierced his right upper eyelid, causing visual impairment. CT image showed an intraconal hematoma in the upper and outer parts of the right orbit, which remarkably compressed the eyeball forward. After CT scan, his visual acuity worsened to no light perception and his right intraocular pressure was at 57 mmHg. Craniotomy to remove the hematoma was performed, but his visual acuity did not improve.

Traumatic orbital hematoma increases intraocular pressure and causes orbital compartment syndrome, resulting in severe visual impairment. For traumatic orbital hematoma presenting visual impairment, prompt decompression by craniotomy to remove the hematoma may be effective for improving visual impairment.

Paroxysmal sympathetic hyperactivity (PSH) is a clinical syndrome characterized by transient, simultaneous surges in sympathetic nervous system activity. It typically presents with episodic tachycardia, hypertension, hyperthermia, tachypnea, diaphoresis, and posturing. Approximately 80% of PSH cases occur following traumatic brain injury (TBI), though it may also develop after hypoxic encephalopathy or stroke. Despite its relatively high incidence in severe TBI, PSH remains underrecognized in clinical settings, partly due to a lack of standardized diagnostic criteria and inconsistent terminology. Symptoms often resemble those of epileptic seizures or sepsis, which increases the risk of misdiagnosis. Importantly, PSH episodes are unresponsive to antiepileptic drugs and can significantly hinder rehabilitation and prolong hospitalization, ultimately worsening functional outcomes and increasing healthcare costs.

β–adrenergic blockers (BBs), such as propranolol, have been reported as potentially effective treatments for PSH by inhibiting sympathetic hyperactivity. While some studies suggest that BBs may reduce the duration of hospitalization and mortality in severe TBI patients, robust clinical evidence remains limited.

Here, we report two adolescent cases of PSH that occurred during the acute phase of severe TBI. In both cases, propranolol administration resulted in a marked reduction in PSH episodes. In particular, Case 1 demonstrated prolonged PSH symptoms unresponsive to conventional therapies, including sedatives and muscle relaxants, until propranolol was introduced. Case 2, treated with propranolol at an earlier stage, showed more favorable neurological outcomes. These cases suggest that propranolol may be an effective therapeutic option for PSH and that early intervention could contribute to improved functional recovery.

We report a case of penetrating head trauma by three nails. A 57–year–old man attempted suicide by firing three nails from a nail gun into the cranium through the left temporal region. On arrival, he had impaired consciousness, which gradually improved spontaneously. No neurological deficits were observed. Computed tomography (CT) confirmed penetration of the three nails into the left temporal lobe. Although CT angiography could not clearly define the relationship between the nails and nearby vessels, cerebral angiography suggested possible contact with the M2 segment of the middle cerebral artery. Considering the risk of infection and bleeding, we opted for foreign body removal by craniotomy. Since the three nails were inserted at slightly different angles, removing them simultaneously was expected to have a high risk of bleeding, so bone removal and dura mater incision were performed separately for each nail. Since the dura mater around the nail was embedded, a radial incision was made, and the nail was carefully detached and removed. No new hemorrhage was observed during or after nail extraction. The bone flap was not replaced, and the surgery was completed. No signs of infection were observed postoperatively, and antibiotics were administered for 8 days postoperatively. No neurological abnormalities were observed, and the patient was discharged from the psychiatric ward on the 18th day after surgery.

This case highlights the importance of preoperative evaluation using angiography to understand the trajectory of foreign bodies and their relationship with cerebral vessels for safe surgical planning. In cases involving multiple foreign bodies, careful planning for each object and perioperative management are crucial. Additionally, when penetrating head trauma is associated with attempted suicide, comprehensive management, including infection prevention and mental health care, is essential.

Penetrating head injury; Nail–gun; Angiography Penetrating cranial injuries caused by nail guns are rare in Japan, and their management poses unique challenges due to the risk of vascular injury and difficulties in imaging metallic foreign objects. We report the case of a 63–year–old male who accidentally shot himself in the right frontal region with an automatic nail–gun while performing a painting task. Upon arrival at the emergency department via ambulance, his neurological status was intact, and there was no active bleeding from the wound. Computed tomography (CT) demonstrated a nail penetrating the cranial bone with minor intracerebral hemorrhage along the wound tract in the frontal lobe. Conventional CT evaluation was limited due to the metallic artifact, so cerebral angiography was performed to assess vascular injury. The angiography revealed that the nail had barbs but did not contact the major arteries or veins. Rotational and multi–angle short–axis imaging centered on the nail enabled detailed visualization of its spatial relationship to the surrounding vessels, facilitating safe surgical planning. Craniotomy was performed under general anesthesia, and the nail was carefully extracted along with a small portion of adherent dura mater and bone flap, minimizing tissue injury. Intraoperative inspection confirmed preservation of the cortical veins and limited contusion of the brain. Postoperatively, the patient had no neurological deficits, infection, or other complications, and he was discharged home after 3 weeks. This case underscores the critical role of preoperative imaging in treating penetrating cranial injuries, particularly if metallic foreign objects with barbs are involved. Acquisition of multi–angle images allows precise evaluation of the relationship between the foreign object and adjacent vessels, thus informing the surgical strategy and minimizing the risk of vascular injury. Such detailed preoperative assessment, time permitting, will contribute significantly to favorable outcomes and safer management of these rare but potentially severe injuries.