Objective: The recurrence of chronic subdural hematoma (CSDH) after burr–hole drainage with irrigation (BHDI) remains a major clinical challenge, particularly during the early postoperative phase when inflammatory neovascularization from the outer membrane is most active. This study aimed to evaluate the efficacy and safety of adjunctive middle meningeal artery embolization (MMAE) for CSDH that recurred within 6 weeks post–initial BHDI.

Methods: We retrospectively analyzed 32 patients (37 hemispheres) who developed recurrence within 6 weeks following initial BHDI between 2016 and 2022. Based on treatment strategy, patients were divided into two groups: BHDI alone (13 sides) and BHDI with adjunctive MMAE (24 sides). The primary outcome was re–recurrence requiring repeat surgery within 90 days. Procedural safety, perioperative complications, and imaging findings were compared between groups.

Results: Baseline demographics and radiological findings were comparable between groups. The postoperative subdural cavity was significantly larger in the BHDI–MMAE group than in the BHDI–alone group (12.7 ± 3.9 mm vs. 8.0 ± 3.2 mm, p < 0.05). Despite this disadvantage, re–recurrence occurred in 3 of 13 sides (23.1%) in the BHDI–alone group but in none of the 24 sides (0%) in the BHDI–MMAE group (p = 0.037). No neurological or visual complications were observed. In cases with ophthalmic collateral flow or limited distal access, proximal coil occlusion using an SL10 microcatheter was performed prior to N–butyl cyanoacrylate injection to prevent reflux, achieving complete occlusion without adverse events.

Conclusions: Adjunctive MMAE effectively prevented re–recurrence in early recurrent CSDH without increasing procedural risk. These findings suggest that embolization during the early postoperative period—when outer membrane vascularity remains active—may represent a pathophysiologically reasonable and safe treatment approach. In cases with limited distal access, proximal coil protection provides a valid alternative to distal microcatheterization.

Objective: We aimed to clarify the relationship between injury mechanisms and care–seeking behavior in infants with accidental domestic head trauma.

Methods: We retrospectively reviewed 60 infants under 2 years of age admitted between 2015 and 2025. Patients were categorized into three groups: Group A (ground–level falls from standing ⁄ walking, n=12), Group B (falls from furniture or strollers, n=25), and Group C (falls from a caregiver’s arms or carrying height, n=23). Abusive head trauma was strictly excluded through a multidisciplinary screening process.

Results: The median time from injury to care–seeking was significantly longer in Group A (60 min) compared to Group B (15 min) and Group C (5 min) (p=0.027). Group A also showed a significant delay compared to the combined higher–altitude fall groups (Group B+C) (p=0.02). Although 37% of patients recognized pre–hospital symptoms such as vomiting or seizures, these cases experienced significantly longer delays in care–seeking compared to asymptomatic cases (p=0.008). The incidence of traumatic brain injury did not differ significantly among the three groups.

Conclusion: Care–seeking behavior for infant head trauma is significantly delayed in ground–level fall cases and cases where symptoms are recognized before arrival. These findings suggest that "normalcy bias" may influence caregivers’ decision–making, highlighting the need for educational interventions regarding the risks of low–energy domestic trauma.

Traumatic chiasmal syndrome is a rare condition characterized by visual field defects due to injury to the optic chiasm and is generally associated with a poor visual prognosis. It often occurs in conjunction with anterior skull base fractures, including those involving the clivus. We report the case of a 30–year–old man who was transported to our hospital by ambulance after a motorcycle accident. On admission, his Glasgow Coma Scale score was E3V5M6. Neurological examination revealed loss of both the direct and consensual light reflexes in the right eye. Computed tomography demonstrated a traumatic subarachnoid hemorrhage and anterior skull base fracture involving the clivus. After regaining consciousness, the patient complained of diplopia and bilateral hemianopsia. He was diagnosed with traumatic chiasmal syndrome complicated by right oculomotor nerve palsy and was treated with steroid pulse therapy. However, his bilateral hemianopsia did not improve. Clinicians should consider the possibility of traumatic chiasmal syndrome in patients with anterior skull base fractures involving the clivus.

The prognosis for acute epidural hematoma (AEDH) is generally considered good, but outcomes can be extremely poor if craniotomy is not performed in time. Conversely, in cases of severe multiple trauma, choosing treatment priorities can be difficult. We report two cases in which embolization of the middle meningeal artery (MMA) was performed prior to craniotomy. In Case 1, a 48–year–old man was injured in a traffic accident. Computed tomography (CT) showed AEDH and pelvic fracture, and he was in a state of hemorrhagic shock. First, external fixation of the pelvic fracture was performed to control bleeding. In parallel, we decided to place a drain into the epidural space by perforation of the skull for slight cranial decompression. As the patient remained in shock, trans–arterial embolization (TAE) for the pelvic fracture was performed. Following TAE for the pelvic fracture, TAE of the MMA was performed to control bleeding prior to the craniotomy. Hematoma removal was performed safely following the MMA embolization. The patient was transferred to a rehabilitation hospital on hospital day 30 (modified Rankin Scale [mRS] 4, Glasgow Outcome Scale [GOS] 3). Case 2 involved a 64–year–old man who was injured falling from a height of 3 m. CT showed AEDH and multiple rib fractures. Craniotomy was planned, but the operating room was not immediately available. Therefore, we performed coil embolization of the MMA first to buy time before the craniotomy. While TAE for the rib fracture was being performed following the MMA embolization, an operating room became available. Therefore, the TAE procedure was interrupted, and the patient was moved to the operating room. Embolization of the MMA facilitated safe removal of the hematoma. The patient was transferred to a rehabilitation hospital on hospital day 28 (mRS 4, GOS 3). MMA embolization for AEDH is potentially effective as a treatment option. In particular, MMA embolization for AEDH is compatible with treating severe multiple trauma in a hybrid emergency room.

Case: An 81–year–old man with no significant head trauma history presented to our hospital with unconsciousness. Upon arrival, Glasgow coma scale was E2V2M4 and body temperature was 38.1℃. No scalp injury was observed. Head computed tomography (CT) revealed a left acute subdural hematoma (ASDH) with a maximum thickness of 19.8 mm, but no skull fractures were identified. Initially, unconsciousness was attributed to dehydration and urinary tract infection and conservative treatment was initiated. On day 6, CT angiography revealed an aneurysm distal to the left middle cerebral artery. On day 15, craniotomy was performed to prevent re–rupture. Pull–out damage of the arterial twig from the cortical artery was identified and repaired by suturing after ASDH and aneurysm removal. No subarachnoid hemorrhage or cerebral contusion was observed. Based on pathological examination, traumatic intracranial aneurysm (TICA) was diagnosed. Postoperatively, digital subtraction angiography showed disappearance of the aneurysm, and head magnetic resonance imaging revealed no cerebral infarction. No decrease in activities of daily living was observed compared to before hospitalization. The patient was discharged on day 25.

Conclusion: TICA commonly occurs with ASDH involving fractures or in the internal carotid or anterior cerebral artery, but rarely develops in the cortical arteries. TICA rupture is associated with a poor prognosis; however, since preventive surgery is effective, it is important to suspect TICA and perform vascular evaluation.

Carotid stump syndrome is typically associated with internal carotid artery occlusion and may lead to cerebral embolism; however, its occurrence secondary to common carotid artery occlusion is rare. We report a surgically treated case of carotid stump syndrome at the distal stump of the common carotid artery caused by trauma.

The patient was a man in his 40s who had sustained an occupational injury one month earlier in which his right upper arm was caught in a conveyor belt. He underwent surgical repair for a scapular fracture, a right humeral fracture, and associated injuries, and was discharged on hospital day 23. Two days later, he developed right hemiparesis and aphasia at home and was brought back to our hospital. On arrival, his NIHSS score was 10. MRI revealed an acute infarction in the left frontal lobe and a subacute hemorrhagic infarction in the left parietal lobe. MRA showed absence of visualization of the left common carotid artery, while the intracranial left internal carotid artery remained patent. Four–dimensional CT angiography revealed retrograde flow from the left vertebral artery to the left external carotid artery through the occipital artery, with subsequent antegrade flow into the left internal carotid artery. Stagnation of contrast material was observed at the distal stump of the left common carotid artery. Surgery was performed to restore antegrade flow in the occluded common carotid artery. Intraoperatively, a thrombus extending from the common carotid artery into the internal carotid artery was identified. Flow restoration was not feasible, and the procedure was completed with ligation of the distal common carotid artery stump. The postoperative course was uneventful, without recurrent cerebral infarction.

This case highlights the effectiveness of surgical intervention in preventing recurrent cerebral embolism in carotid stump syndrome secondary to traumatic common carotid artery occlusion

A female elementary school student died after a sudden deterioration following a blow to the right parietal region. A head CT revealed subcortical hemorrhage in the left cerebellar hemisphere, prompting an administrative autopsy to determine the cause of the cerebellar hemorrhage. Autopsy findings revealed no skull fractures or dura mater injuries. Slightly dilated veins were observed on the surface of the cerebellar hemisphere. Histological examination of the hematoma and surrounding brain tissue showed scattered dilated vessels lacking elastic laminae around the hemorrhage. Adjacent to a small artery in this area, a 5 mm aneurysm was found, covered by fibroblasts and containing an organized thrombus. Based on the autopsy findings, the diagnosis was hemorrhage from an aneurysm arising from a cerebral arteriovenous malformation. In cases of intracranial hemorrhage preceded by head contusion where the injury appears inconsistent with the reported external force, it is considered necessary to actively perform an autopsy.

We report a case of 33–year–old male sustained a high–speed motorcycle crash and was found in cardiopulmonary arrest at the scene. On arrival at our hospital, spontaneous circulation had returned, but he remained comatose with bilateral fixed dilated pupils. Cervical computed tomography (CT) revealed a horizontal fracture of the C1 anterior arch and a vertical atlanto–axial dislocation (AAD). Head CT showed diffuse subarachnoid hemorrhage. CT angiography revealed a dissecting aneurysm in the basilar artery (BA) with extravasation and distal BA occlusion. Given the absence of brainstem reflexes and the severity of the vascular injury, invasive treatment was not pursued. The patient was declared brain–dead and became an organ donor. Horizontal C1 fracture of and vertical AAD are both extremely rare cervical spine injuries, typically caused by high–energy trauma with severe hyperextension. Traumatic dissection of the BA is also uncommon. The coexistence of these injuries is exceedingly rare and often fatal. Early emergency response enabled imaging–based diagnosis, though active treatment was not possible. This case emphasizes the lethality of complex cervical spine and vascular injuries following high–energy trauma, and the importance of rapid assessment even in non–survivable cases.

Background: Traumatic isolated interhemispheric subdural hematoma (IHSDH) is uncommon and typically follows a benign course with conservative management. However, cases presenting with falx syndrome may require individualized treatment, and the optimal timing of surgical intervention remains uncertain.

Case Description: An 89–year–old man receiving anticoagulation therapy developed progressive left lower–extremity weakness two days after a minor head injury. Neurological examination revealed monoparesis consistent with falx syndrome. Computed tomography demonstrated a right isolated IHSDH with a maximal thickness of 14 mm. Despite conservative management, including discontinuation of anticoagulation and osmotic therapy, foot drop persisted. Follow–up imaging showed a cast–like organized hematoma with surrounding fluid components. Surgical evacuation was performed on day 16. The hematoma was firm and required piecemeal removal. Postoperatively, the patient experienced rapid improvement of foot drop; however, disuse syndrome had progressed during the preoperative waiting period, necessitating approximately one month of rehabilitation before independent ambulation was regained.

Conclusion: This case illustrates that isolated IHSDH presenting with falx syndrome may not always improve sufficiently with conservative therapy. When neurological deficits persist, earlier surgical intervention—even in the absence of acute deterioration—may be beneficial, particularly in elderly patients at risk of functional decline due to disuse.