The factors affecting outcome were analyzed in 1,064 patients, 621 males and 443 females aged 10 to 104 years (mean 46 ± 23 years), with mild head injury (Glasgow Coma Scale [GCS] score ≥14) but no neurological signs presenting within 6 hours after injury. Intracranial lesion was found in 4.7% (50/1,064), and 0.66% (7/1,064) required surgical treatment. The Japan Coma Scale (JCS) and GCS assessments were well correlated (r = 0.797). Multivariate analysis revealed significant correlations between computed tomography (CT) abnormality and age ≥60 years, male sex, JCS score ≥1, alcohol consumption, headache, nausea/vomiting, and transient loss of consciousness (LOC)/amnesia. Univariate analysis revealed that pedestrian in a motor vehicle accident, falling from height, and mechanisms of injuries except blows were correlated to intracranial injury. No significant correlations were found between craniofacial soft tissue injury and intracranial injury. Patients with occipital impact, nonfrontal impact, or skull fracture were more likely have intracranial lesions. Bleeding tendency was not correlated with CT abnormality. The following indications were proposed for CT: JCS score >0, presence of accessory symptoms (headache, nausea/vomiting, LOC/amnesia), and age ≥60 years. These criteria would reduce the frequency of CT by 29% (309/1,064). Applying these indications to subsequent patients with GCS scores 14-15, 114 of 168 patients required CT, and intracranial lesions were found in 13. Two refused CT. Fifty-four of the 168 patients did not need CT according to the indications, but 38 of the 54 patients actually underwent CT because of social reasons (n = 21) or patient request (n = 17). These indications for CT including JCS may be useful in the management of patients with mild head injury.
This study was conducted to elucidate the pathologic conditions of cerebral circulatory disorders in idiopathic normal pressure hydrocephalus (iNPH). Among 44 possible iNPH patients, 40 patients underwent shunt surgery based on diagnostic flow charts plotted by the Southern Tohoku method and were evaluated to be shunt-effective at the end of the first post-surgical month. The cerebral blood flow (CBF) was measured by N-isopropyl-(123I)-P-iodo-amphetamine single photon emission computed tomography (mean, mCBF; cortical region, cCBF; thalamus-basal ganglia region, tbCBF on autoradiography [ARG] method) and the perfusion patterns of the cerebral cortex were measured based on three-dimensional stereotactic surface projection (3D-SSP) Z-score images, before and 1 month after the surgery in all 40 subjects. The mCBF rose significantly from 32.1 ± 2.74 ml/100 g/min before surgery to 39.8 ± 3.02 ml/100 g/min after surgery (p < 0.03). Investigation of the change of CBF revealed reductions in the cCBF (3 cases), tbCBF (9 cases), and cCBF + tbCBF (28 cases), with the reduced-cCBF group totaling 31 cases and the reduced-tbCBF group totaling 37 cases. Investigation of cerebral cortex hypoperfusion by 3D-SSP Z-score revealed 31 cases with hypoperfusion (frontal lobe type [19 cases], occipitotemporal lobe type [5 cases], mixed type [7 cases]) and nine cases with cortical normoperfusion (N). The pattern of reduction of the cortical blood flow on ARG method was favorably correlated with the pattern of hypoperfusion of the cerebral cortex on 3D-SSP Z-score images before surgery. A reduction of blood flow was found in the thalamus-basal ganglia region of all N type cases. The blood flow improved in 19 of 31 (61.3%) cases of the reduced-cCBF group and in 32 of 37 (86.5%) cases of the reduced-tbCBF group. All of the cases without detectable improvement exhibited increased blood flow in non-reduction areas. Investigation of the hypoperfusion patterns of the cerebral cortex on 3D-SSP Z-score images, revealed a reduction or disappearance of the hypoperfusion site in 19 of 31 (61.3%) cases, either no-change or a shift of the hypoperfusion site in 12 of 31 (38.7%) cases, and a correlation between the pattern of cortical blood flow reduction on ARG method and the pattern of cerebral cortex hypoperfusion on 3D-SSP Z-score images after surgery. Cerebral circulatory disorders in iNPH manifest as either of two pathophysiological conditions: the “circulatory disorder of the cerebral cortical region” and the “circulatory disorder of the thalamus-basal ganglia region.” Various patterns develop according to the disease stage.
A 29-year-old man presented with skull base fractures involving the bilateral petrous bones and clivus to the posterior clinoid process manifesting as bilateral abducens nerves palsy. Conservative treatment resulted in residual bilateral abducens nerves palsy. Posterolateral impact probably resulted in strain-stress in the neighborhood of the foramen lacerum, resulting in a clivus fracture of the posterior clinoid process and bilateral petrous bone fractures. Chalasia of Gruber’s ligament then exerted mechanical pressure on the bilateral abducens nerves.
A 33-year-old man presented with consciousness disturbance (Glasgow Coma Scale score 7) and right hemiplegia after suffering headache persisting for 10 days. Head computed tomography revealed an irregular intracerebral hematoma in the left temporoparietal region, associated with a tubular high density area compatible with a thrombosed transcerebral vein in the left temporal lobe. The patient was free of coagulopathy. Craniectomy was performed to remove the intracerebral hematoma and venous thrombosis was confirmed. Postoperative cerebral angiography demonstrated extensive venous malformation in the left parietal and occipital lobes. Multiple transcerebral draining veins converged in the vein of Galen associated with a varix. Segmental narrowing of the straight sinus was suggestive of congestion in the venous anomaly. The patient showed progressive recovery following surgery, and was discharged with moderate aphasia, mild right hemiparesis, and right homonymous hemianopsia 1 month later. Venous malformations are usually silent, but occasionally become symptomatic due to thrombosis of the draining vein. The presence of stenosis in the draining route may lead to venous congestion, thrombus formation, and catastrophic hemorrhagic venous infarct.
A 29-year-old man developed a delayed postoperative extradural hematoma after the craniotomy to treat recurrent malignant glioma and hydrocephalus. The patient became alert on the day after the operation. Computed tomography (CT) 12 hours after the operation showed no intracranial hematoma and the subgaleal drainage catheter was removed 18 hours after the operation. The patient complained of headache and went into a coma 2 hours after removal of the drain. CT demonstrated massive acute extradural hematoma with marked midline shift. Emergency craniotomy revealed that the source of the hematoma was an injured scalp artery along the route of the drainage catheter. He died of acute brain edema 9 days later. Hemostasis should be confirmed at insertion and removal of the drainage catheter.
A 76-year-old man presented with a cavernous sinus (CS) dural arteriovenous fistula (AVF) associated with the development of a meningioma without venous sinus occlusion. Initial digital subtraction angiography did not reveal the CS dural AVF, which appeared simultaneously with the enlargement of the meningioma and lead to right oculomotor nerve paresis. In this case, the development of meningioma possibly increased the vascular tumor bed and affected the venous hemodynamic return, thus leading to the dural AVF.
Cognitive functions are frequently impaired in patients with normal pressure hydrocephalus (NPH). Two patients with NPH initially had dysfunctional constructional skill but exhibited improvements after shunt surgery. Dysfunction of constructional skill should be added to the important clinical features of NPH. The geometric test can be used as a practical tool for evaluation of parietal lobe function in patients with NPH.
A 68-year-old woman presented to the emergency department for evaluation of bilateral leg weakness. On admission, she had paraparesis with incomplete sensory deficit. Magnetic resonance (MR) imaging of the thoracolumbar spine revealed spontaneous spinal epidural hematoma (SSEH) compressing the spinal cord. The patient was taken to the operating room for urgent surgical decompression and evacuation of the SSEH. After the surgery, she woke up with complete paraplegia. Postoperative MR imaging showed the spinal cord was edematous, with minimal remnant hematoma. MR imaging after 1 month clearly showed anterior spinal artery thrombosis. No significant neurological improvement occurred during the 3-month follow up. Surgeons should consider the possibility of this devastating complication before aggressive and early surgical intervention in a patient with SSEH causing cord compression and neurological deficit.
A 35-year-old man presented with penetrating spinal injury after attempting suicide by stabbing a wooden chopstick into his mouth. The object penetrated the pharynx, and the tip entered the spinal canal of the atlantoaxial vertebrae. Emergent surgery disclosed that the tip of the chopstick had penetrated between the dural sac and the vertebral artery. There was no dural tear or vertebral artery injury. The foreign body was removed successfully from the oral side. He recovered without neurological sequelae.
Codman-Hakim programmable valves allow neurosurgeons to adjust the opening pressure to the patient’s particular clinical needs. However, the pressure control cam is extremely small, so identification of the pressure indicator and its operation is somewhat difficult when initially setting the opening pressure before implantation. We employed a commercial loupe on the program transmitter unit to sufficiently enlarge the view of the cam for clear identification. We recommend that the manufacturer to incorporate a loupe to provide a more sophisticated product.