非外傷性

は，様々な原因によって生じ得る．中でも破裂脳動脈瘤によるものは，治療方針に影響を及ぼすため，初期診断が重要である．発症時に意識障害を呈する場合や，くも膜下出血や脳内出血を伴わない場合などに，外傷性と認識し，初期対応する可能性がある．破裂動脈瘤の存在を見落とす危険性があり，再破裂により予後不良となり得る．今回我々は，2例の非外傷性で発症し，病歴や画像所見で初期診断に苦慮したものの，確定診断の後に血管内治療を行い，予後良好であった破裂遠位前大脳動脈瘤の2例を報告する．

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Objective: We retrospectively analyzed our own cases of subacute subdural hematoma (SSH) to investigate the clinical characteristics of SSH.

Materials & Methods: From January 2011 to October 2015 we experienced 5 cases with SSH at our institution. Frequency, age, gender, clinical course, radiological find­ings, operative findings and outcomes were reviewed.

Results: During the same period we treated 85 patients with acute subdural hematoma, thus frequency of SSH accounted for 5.9％. The patient’s ages ranged from 45 to 89 years with a mean age of 72 years. There were 2 men and 3 women. The cause of injury was fall on the same level in 4 patients, fall in 1. Glasgow coma scale score on admission was 15 in 4 patients, 14 in 1. Initial comput­erized tomography (CT) scans revealed mixed density subdural hematoma in 2 patients, homogenously high density in 3. The mean maximal thickness of hematoma was 10 mm. Time intervals to worsening were 5 to 13 post­traumatic days with a mean time interval of 9.6 days. Symptomatologically all patients developed contralateral hemiparesis. CT scans on worsening revealed mixed den­sity in 2 patients, iso in 2, low in 1. The mean maximal thickness of hematoma was 13 mm and revealed mass sign and mild midline shift. Magnetic resonance imaging was obtained only in case 3 and demonstrated high signal intensity on T1 weighted images, low signal intensity on T2 weighted images, high signal intensity with the low intensity rim close to the brain surface on diffusion weighted images. All patients underwent craniotomy to evacuate hematoma. Postoperatively 4 patients recovered fully and 1 patient died of pulmonary failure.

Conclusions: Even though subdural hematoma is treated conservatively at acute stage, it should be kept in mind that it may develop at subacute stage and cause neurological deterioration.

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The patient, a 64–year–old man, was found lying on the bypass road and called emergency medical services. Computed tomography (CT) showed right acute subdural hematoma with midline shift, and we decided to perform craniotomy to remove the hematoma. After removal of the hematoma, micro­scopic examination revealed a small aneurysm in the peripheral portion of the middle cerebral artery running to the cerebral surface of the temporal lobe. The aneurysm was trapped, and the specimen was submitted for pathological examination. Patho­logi­cally, a true aneurysm was suspected. Acute sub­dural hematoma is usually caused by head trauma, but in rare cases, it can be caused by a ruptured aneurysm. In the case of non–traumatic subdural hematoma, not only decompression but also radical treatment is required, which changes the treatment strategy.

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くも膜下出血を伴わず,で発症した末梢性前大脳動脈瘤の2症例を経験した.2症例ともに初期診断時には破裂動脈瘤の診断がつかなかった為,緊急にて減圧開頭硬膜下血腫除去術のみを施行した.1例は術前3DCT angiographyを施行したが,撮像範囲の設定が狭かった為動脈瘤を発見できなかった.2症例ともに術前一時両側の瞳孔が散大したが,1例は意識障害も順調に回復,他の1例も意識障害は遷延化したものの救命することができた.術後血管撮影にて1例はA2～A3部の脳動脈瘤が発見され,後日脳動脈瘤クリッピング術を施行,術後の経過も順調でほぼ全回復の状態で退院した.他の1例はA3末梢部の動脈瘤が発見され,やはり後日開頭術を施行.クリッピングは困難で動脈瘤をトラッピングした.動脈瘤破裂による硬膜下血腫のなかには術前の状態が不良でも救命できる症例があり,積極的に手術に臨むべきと考えられた.

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The new surgical strategy of emergency burr hole (Bh) surgery followed by large decompressive craniectomy (LDC) was pro­posed for the treatment of an acute subdural hematoma (ASDH) of complicated hematoma type in 1994 in Japan. The purpose of this study was to identify patient selection criteria and outcome for adult patients with an ASDH undergoing emergency Bh surgery, and to define the state of the art of this strategy.

We reviewed surgically treated 552 adult patients with an ASDH enrolled in Japan Neurotrauma Data Bank Project 1998 and Project 2004. The mean age of patients was 58 years (range, 16 – 98 years; > 65 years, 41%) and the mean GCS was 6.4 (range, 3 – 15; 3 – 5, 51%). Three surgical procedures were performed: Bh surgery alone (=Bha) in 134 patients, Bh surgery followed by craniotomy or LDC (=Bhc) in 30, and craniotomy or LDC as a primary procedure (=Crt) in 388.

Patients with a GCS score of 3 – 5 and those showing dilated fixed pupil(s) or systemic shock on admission were more frequently underwent emergency Bh surgery than did those not revealing them. The proportion of the Bhc to the Bh (=% Bhc/Bh) was lowest in patients over the age of 65 years com­pared to other younger age groups (p=0.021). The % Bhc/Bh in each GCS group (GCS 3 – 5, 6 – 8, 9 – 15) was 17%, 27%, and 0% respectively (not significant). The mortality and the percent of favorable outcome related to type of operation in subgroups with a GCS score of 3 – 5 were as follows: Bha = 89% / 1% ; Bhc = 45% / 5%; Crt = 54% / 14%. Of 115 cases with favorable outcome 10 cases were underwent Bh surgery (Bha = 8, Bhc = 2). Clinical characteristics of them were a younger age (mean = 33.2 years; unfavorable, 60.0, p<0.001), a higher GCS score (mean = 6.6; unfavorable, 4.6, p=0.002) and low incidence of dilated fixed pupil(s) (40%; unfavorable, 75%, p=0.026).

Emergency Bh surgery is undoubtedly effective for patients with an ASDH of simple hematoma type. The new strategy has provided little improvement in outcome of patients with an ASDH of complicated hematoma type. Nevertheless, with appropriate modifications, this strategy will improve outcome after severe ASDH.

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　【背景】

で保存的加療した症例のなかで亜急性期に血腫が増大する症例が存在する. 当院で経験した亜急性期に血腫が増大した症例の予測因子を検討したので報告する. 【方法】2003年〜2014年に当院脳神経外科で加療したで急性期に手術を行った症例および非積極的治療の症例を除外, 脳挫傷や急性硬膜外血腫を合併していない円蓋部261例を対象とした. 亜急性期に血腫が増大した症例と増大しなかった症例に分けて比較検討した. 【結果】亜急性期に血腫が増大した症例は43例, 血腫が増大しなかった症例は218例であった. 年齢, 糖尿病, Computed Tomographyでの血腫の厚さ・正中線の偏位が予測因子であった. 【結論】高齢者で血腫が厚いが亜急性期まで保存的加療可能であった症例が亜急性期に血種が増大すると考えられた.

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の自然経過で, 急速に血腫が消退した87歳男性, 80歳男性2例と, そうでなかった72歳男性1例を報告した.自然消退の機序は頭蓋内圧亢進による血腫の拡散, MRIによって明らかとなった血腫の再分布, 髄液によるwash outなどが報告されている.本論文では自験例3例と文献例24例より自然吸収のメカニズムを, 若年型と高齢型の2タイプに分類した.前者は薄い血腫で脳腫脹が著明であり, 頭蓋内圧亢進による拡散吸収で血腫が消失し, 後者は血腫は厚いがmidline shiftは軽度で, CT上髄液と血腫が混合したmixed densityを呈し, 血腫消失は髄液によるwash outと考えた.

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Background and purpose: Trend of trepanation as an optional surgical procedure was investigated in cases with severe traumatic brain injury (TBI), by comparing data from Japan Neurotrauma Data Bank (JNTDB) Project 2015 with those from Project 2009.

Materials and Methods: Two–hundred and thirty cases with severe TBI, who were initially treated by trepanation, were involved in this study (M:F = 133:97, Age 67±20 y.o.). In these cases, following parameters were summarized from JNTDB Project 2015 database, to compare with those of 2009; age, gender, cause of trauma, Glasgow Coma Scale (GCS) scores on admission, worst GCS scores, presence of mydriasis, CT findings (intracranial hematoma thickness, width of midline shift, and appearance of ambient cistern), Glasgow Outcome Scale (GOS) scores on discharge. Correlation between preoperative clinical parameters and GOS scores were also examined in cases with acute subdural hematoma (ASDH), in particular.

Results: There was no significant difference in gender, age, cause of TBI, distribution of targeted intracranial hematoma, and GCS scores between Project 2015 and 2009. Mydriasis were presented bilaterally in 66 (29%), unilaterally in 37 (16%), and not in 125 (54%) in Project 2015. Compared to Project 2009, bilateral mydriasis was significantly decreased in Project 2015, as normal pupil reaction was significantly increased. In appearance on CT, ambient cistern appeared normal in 44 (19%), unilaterally compressed in 110 (48%), and disappeared in 76 (33%) in Project 2015. Compared to Project 2009, disappeared ambient cistern was significantly decreased, as normal and unilateral compression was significantly increased in Project 2015. Thickness of midline shift was significantly decreased in Project 2015 than 2009. Intracranial hematoma thickness was significantly larger in Project 2015 than 2009, in contrast. GOS scores were GR in 8 (3%), MD in 31 (14%), SD in 57 (25%), VS in 30 (13%), and D in 103 (45%). Mortality was significantly decreased in Project 2015 than 2009, although favorable outcome (GR+MD) was not significantly different between them. In Project 2015, a combination of GCS score 3 and bilateral mydriasis, or disappearance of ambient cistern on CT could correctly expect mortality in cases with ASDH, as well as Project 2009.

Conclusion: Emergency trepanation is widely used in cases with severe TBI in Japan. Recent decrease in mortality may be brought by avoiding trepanation in cases who presented with a couple or more of brain herniation signs.

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Background and purpose: In this study, both usefulness and limitations of trephination were investigated by analyzing data from Japan Neurotrauma Data Bank (JNTDB) Project 2009.

Materials and Methods: Total 90 cases, treated with trephinations initially for traumatic head injuries, were involved in this study (M : F = 65 : 25, Age 66±22 y.o.). In these cases, following parameters were summarized from JNTDB Project 2009 database; age, gender, cause of trauma, Glasgow Coma Scale (GCS) scores on admission, worst preoperative GCS scores, presence of midriasis, preoperative CT findings (intracranial hematoma thickness, midline shift, and ap­pearance of ambient cistern), Glasgow Outcome Scale (GOS) scores on discharge. Correlation between preoperative clinical parameters and GOS scores were also examined.

Results: GCS scores on admission were 3 – 8 in 70 (78%), 9 – 12 in 8 (9%), and 13 – 15 in 12 (13%) out of 90 cases. Worst preoperative GCS scores were 3 – 8 in 75 (83%), 9 – 12 in 8 (9%), and 13 – 15 in 7 (5%) out of 90 cases. Midriasis were presented bilaterally in 40 (44%), ipsilaterally in 17 (19%), and not in 33 (37%) out of 90 cases. GOS scores were GR in 4 (4%), MD in 12 (13%), SD in 9 (10%), VS in 10 (11%), and D in 55 (61%) out of 90 cases. Among clinical parameters, preoperative worst GCS scores, pupil reaction, appearance of ambient cistern on CT were strongly cor­related with GOS. Although mortality could not be expected by any single parameter, a combination of GCS score 3 and bilateral midriasis, or disappearance of ambient cistern on CT could correctly expect mortality.

Conclusion: Emergency trephination is simple and useful technique to achieve quick reduction of intracranial pressure in cases with severe traumatic head injury, however, it may not be indicated in preoperative GCS 3 cases with bilateral midriasis or with disappearance of ambient cistern on CT.

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 A 17-month-old boy was admitted to our hospital in a semicomatose state after a minor head injury. Computed tomography (CT) scans revealed a posterior interhemisphericand athin convexity subdural hematoma. Two and a half hours later, repeated CT scans disclosed a development of the right hemispheric diffuse low density and an enlargement of the interhemispheric subdural hematoma. Decompressive craniectomy and removal of the hematoma was performed immediately. On the second postoperative day, the diffuse low density areas developed in the contralateral frontal and temporal lobes. On the 14th postoperative day, the gyri which had been low in density were markedly enhanced with contrast enhancement. On the 16th postoperative day, CT scans showed a diffuse hemispheric gyral high density with bleeding in the right parieto-occipital lobe. A right occipital lobectomy and removal of the hematoma was performed. Histological examination suggested cerebral infarction probably due to venous congestion. It is also suggested that the diffuse hemispheric gyral high density observed on the 16th postoperative day was the hemorrhagic cerebral infarction.

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円蓋部に著明なをきたした末梢性前大脳動脈瘤の破裂例を報告する.症例は67歳女性で,昏睡にて搬送された.前医のCTで円蓋部に著明なを認め,救急外来での穿頭術に引き続き,緊急で開頭血腫除去術を施行したが,閉頭時に著明な動脈性出血が頭蓋内から起こった.術後の3D-CTA(3D-CT angiography)では,右上方に突出する左末梢性前大脳動脈瘤を認め,開頭脳動脈瘤頚部クリッピング術を施行した.にて発症する末梢性前大脳動脈瘤についての報告は散見されるが,その硬膜下血腫が半球間裂にはほとんどなく,かつ円蓋部に著明な血腫がみられるパターンを取ったという報告は少なく,ピットフォールに陥りやすい所見であり,このパターンでも末梢性前大脳動脈瘤破裂の可能性を考慮に入れ,可能なかぎり3D-CTAなどで術前の血管評価を行うべきである.

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 軽微な外傷で発症した, くも膜囊胞合併の乳児例を経験したので報告する. 症例は10カ月の男児. 高さ50cmから墜落して頭部を打撲し, 第2病日にの診断で入院となった. 第4病日のCT画像で血腫の増大がないことを確認し, 第7病日に退院となった. 退院後, 第65病日に実施したMRIでは血腫の増大を認めたが, 外科的治療を実施せず, 第192病日のMRIでは血腫の縮小が確認された. くも膜囊胞を合併した脳外傷の症例は, ①乳児においても硬膜下血腫の危険因子になること, ②亜急性期から慢性期にかけて再び増大する可能性があることを認識して診療にあたる必要がある.

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In general, subacute subdural hematomas are treated surgically. However, patients who do not show any symptoms are often treated conservatively, despite of the lack of effective medicine. Sairei-tou, a Kampo medicine, promotes endogenous steroid secretion and is considered to have diuretic and anti-inflammatory actions. Recently, the effect of Sairei-tou in reduction of chronic subdural hematomas was reported. Because of similarities in the growing mechanisms of chronic subdural hematomas and subacute subdural hematomas, we considered the effect of Sairei-tou in reducing subacute sub­dural hematomas.

We observed reduction in hematomas in 3 patients with asymptomatic or symptomatic subacute subdural hematomas who were administered Sairei-tou. Therefore, Sairei-tou could be considered as a medication for reducing subacute subdural hematomas.

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Diffuse hemispheric ischemic changes are often confirmed in cases of infantile acute subdural hematoma in acute phase, and diffuse brain atrophy was also confirmed in chronic phase. This atrophy is often confirmed in cases where abnormal findings were not confirmed on brain CT or MRI in acute phase. ¹²³I-iomazenil SPECT findings in two cases of acute subdural hematoma were compared with CT findings in these cases in chronic phase.

Case 1 (9-month-old boy) required craniotomy for left acute subdural hematoma, showed left hemispheric diffuse low density on CT on the 4th hospital day, and showed left hemispheric high signal and no abnormal findings in the right hemisphere on diffusion-weighted MRI on the 6th hospital day. ¹²³I-iomazenil SPECT on day 31 showed reduced uptake in the whole left hemisphere and right frontal lobe, which was matched to brain atrophy on CT in chronic phase. Case 2 (8-month-old boy) required craniotomy for left acute subdural hematoma, showed left hemispheric diffuse low density on CT on the 4th hospital day, and showed left hemispheric high signal and slightly elevated signal in the right hemisphere on diffusion-weighted MRI on the 3rd hospital day. ¹²³I-iomazenil SPECT on the 4th day showed uptake reduction in the whole left hemisphere and right frontal lobe, which were matched to brain atrophy on CT in chronic phase.

In conclusion, reduction of ¹²³I-iomazenil uptake with SPECT in two cases of infantile acute subdural hematoma was matched to brain atrophy in these cases in chronic phase. ¹²³I-iomazenil SPECT may predict prospective brain atrophy more accurately than conventional CT and MRI.

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Purpose: We examined the usefulness and limitations of burr-hole surgery in the emergency room by retrospectively investigating the characteristics and outcomes of patients who underwent the burr hole surgery for traumatic severe brain injury.

Methods: A total of 53 patients underwent burr-hole surgery in the emergency room. We analyzed a preoperative factors such as GCS score on admission; systolic blood pressure; pupil findings; blood tests (fibrin degradation product (FDP), D-dimer); morphology of hematoma; ICP immediately after burr-hole surgery; and the mean interval from contact to emergency service to burr-hole surgery. Patients were devided into groups on the basis of diffuse injury (DI) groups and evacuated mass lesion (EM) groups in accordance with National Traumatic Coma Data Bank (TCDB) classification. Student's t-test and Fisher's exact probability test as statistical analysis were conducted with a significance level of p<0.05.

Results: 1) FDP and D-dimer were significant prognostic factors in all patients; 2) survival following burr-hole surgery alone was common among DI group with mild impairment of the coagulopathy and no extensive brain swelling, and in whom ICP could be controlled with subdural drainage; 3) survival following additional craniotomy following burr-hole surgery alone was common among EM group with mild impairment of the coagulopathy and mild brain parenchymal injury; 4) in patients with a GCS score of 3, FDP and D-dimer were significant prognostic factors; and 5) patients with shock, such as complication by pelvic fracture, experienced particularly poor outcomes.

Conclusion: Burr-hole surgery in the emergency room was considered useful for the following purposes: 1) quick reduction of intracranial pressure at an early stage prior to craniotomy in the EM group; and 2) managing hematomas and controlling ICP with cerebrospinal fluid drainage in the DI group. 3) Survival was possible under certain conditions, even in the most severe cases such as GCS score of 3.

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Three patients with acute subdural hematoma (SDH) caused by a ruptured intracranial aneurysm were admitted in a comatose state with signs of cerebral herniation. In one patient, while the SDH was evacuated by an emergency craniotomy, cerebral angiography was performed. Aneurysmal neck clipping was performed during the same operation. The man made a good recovery. In the other patients, while the SDH was irrigated by emergency trepanation, cerebral angiography was performed. These hepatomas were inoperable and the 2 patients died the day after admission. Several recent reports have suggested that SDH evacuation with craniotomy and aneurysmal neck clipping should be conducted simultaneously. However, the start of a one-stage operation for SDH and ruptured aneurysm is usually delayed several hours due to the need for preoperative examinations including angiography. A portable digital imaging system (PDIS) showing real time subtraction images is useful for finding critical vascular anomalies. The authors emphasize that a one-stage operation can be started within 50 minutes after admission by using a PDIS.

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Introduction: We report a case of craniotomy performed in the emergency department (ED) for a non-traumatic acute subdural hematoma.

Case: An 84-year-old man with long-term psychiatric hospitalization independently performed activities of daily living.

History: While watching TV, he vomited and started losing consciousness. Head computed tomography (CT) revealed a left-sided acute subdural hematoma, and he was transferred to our hospital via ambulance. On admission, his Glasgow Coma Scale (GCS) (E1, V1, and M4) showed pupils 2.0 mm/3.0 mm, sluggish light reflexes bilaterally, and right hemiplegia. Following head CT, his consciousness level deteriorated to GCS (E1, V1, M2), pupils 2.0 mm/5.0 mm, and bilateral loss of the light reflex. He developed a non-traumatic acute subdural hematoma without cerebral contusion. The ED performed a craniotomy for hematoma removal. On postoperative day 27, he was transferred to psychiatric care.

Conclusion: Since non-traumatic acute subdural hematoma does not cause brain contusion, an early craniotomy may improve its prognosis. Prompt interprofessional coordination between a neurosurgeon, anesthesiologist, and operating theater nurse for emergency craniotomies and hematoma removal in the ED may be a useful therapeutic strategy in such cases.

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The case of 82-year-old female who presented with acute subdural hematoma (ASDH) secondary to ruptured intracranial aneurysm is reported. According to the history of the present illness, the patient had suddenly lost consciousness and was immediately brought to our hospital. There was no definite evidence of head trauma, and other etiologies, such as a cerebrovascular accident in her recent past history that might have caused ASDH, were also ruled out. Computed tomography (CT) on admission showed a right-sided ASDH with extension of the hematoma along the tentorium, but none of the characterstic features of subarachnoid hemorrhage (SAH) were observed. However, angiography with magnetic resonance imaging performed after the initial CT revealed a saccular aneurysm of the right internal carotid artery projecting posterolaterally. Emergency surgery was performed to remove the ASDH and clip the aneurysm neck in the acute stage. At surgery, marked adhesion of the arachnoid membrane and absence of cerebrospinal fluid flow were noted in the right sylvian and basal cisterns. Importantly, no clear evidence of SAH was observed during surgery. After removing the ASDH, the right internal carotid-posterior communicating (IC-PC) saccular aneurysm was successfully treated with a Yasagyl titanium clip. There are almost over 20 reports in the literature on ASDH caused by a ruptured aneurysm without evidence of SAH on a CT scan. Based on those reports and our own, ruptured aneurysm should be considered one of the causes of non-traumatic ASDH. In conclusion, the main cause of the occurrence of the phenomenon mentioned in our patient was probably related to the combined presence of the arachnoid adhesion in the sylvian cistern, the special shape of the aneurysm, and the direction in which the aneurysm projected.

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We have performed burr hole surgery in the emergency room for severe acute subdural hematoma from April 2007 in twenty five patients. All patients were deep comatose and showed cerebral herniation sign with bilateral pupillary ab­normalities. Burr hole surgeries were performed as soon as possible after CT evaluation. Continually decomporresive craiectomies were followed if clinical improvements were achieved and mild baribiturate-moderate hypothermia combined (MB-MH) therapy was induced postoperatively in some cases. The mean average was 65.6 years (range 16 – 93). The causes of head injuries were traffic accident in 9, fall down in 13 and unknown in 3. The mean GCS on admission was 4.4 (range 3 – 9). The mean time interval from arrival to burr hole surgery was 33.5 minutes (range 21 – 50 minutes). Decompressive craniectomy was indicated in 14 cases and MB-MH therapy was induced in 13 cases. The overall clinical outcome consisted of good recovery in 3, moderate disability in 2, severe disability in 3, persistent vegetative state in 3 and death in 14. Favorable results can be expected even in patients with serious acute subdural hematoma. Emergent burr hole surgery was effective to decrease intracranial pressure rapidly and to save time. So active burr hole surgery in the emergency room is strongly recommended to all cases of severe acute subdural hematoma.

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