This paper studied the recognition of concussion, which lately has been considered a problem in sports-related head injuries. Participants in a judo leadership training session were surveyed. The result of the survey showed that while most respondents were aware that symptoms such as “impaired consciousness” should be regarded as symptoms of concussion; only half of the respondents knew that symptoms such as “behavioral change” should be regarded as symptoms of concussion. This indicates that it might be possible to overlook concussion or underestimate its symptoms. About half of the respondents said they had experienced the occurrence of concussion on the mat while teaching, and at least 40% of respondents had the judoka resume training without providing sufficient rest. Concussion had long been categorized as a “mild symptom” among head injuries; however, the potential risks associated with concussion have been pointed out in recent years. Therefore, it is important to recognize and understand concussions correctly to ensure the safety of judoka.

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Objective: The number of institutions participating in the Japan Neurotrauma Data Bank was 10 in 1998, but it increased to 19 in 2004. The data of the institutions participating in 1998 and in 2004 were compared.

Methods: The 637 cases in 1998 (1998 group) and the 464 cases in 2004 (2004 group) were reviewed.

Results: There were no significant differences in the distributions of age, gender, and admission Glasgow Coma Scale between the two groups. The most common type of injury was a traffic accident, over 50% in both groups. The most commonly injured was the passenger, while the least commonly injured was the driver. In non-traffic accident cases, the most common injury was a fall in both groups. There were no significant differences in the distributions of the admission injury severity score and the discharge Glasgow Outcome Scale between the two groups. On head CT, more patients had a mass lesion (ML) than diffuse injury. The proportion with ML was higher in the 2004 group than in the 1998 group. Among patients with MLs, there were more evacuated mass lesions (EMLs) than non evacuated mass lesions in both groups. However, the proportion of EMLs and the proportion of skull base fractures were significantly higher in the 2004 group than in the 1998 group.

Conclusion: There were no significant differences in the patients’ background characteristics between the 1998 group and the 2004 group. But, the proportions of patients with mass lesions, evacuated mass lesions, and skull base fractures were higher in the 2004 group than in the 1998 group.

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高血圧性被殻出血36例において, 急性期のCT上の出血の広がりと慢性期 (6ヵ月) に記録したcontingent negative variation (CNV) の振幅低下との関係を検討した.その結果, 出血がpallidumを経て内包に進展して, anterior hypothalamusの外側に接しolfactory tubercleの上方でcorticobulbar tract, ansa lenticularis, inferior thalamic peduncle, anterior commissureを通るfiberなどが収斂する領域を損傷することにより, 著しいCNVの低下が生ずることを知った.また内包まで進展していない症例でも, 優位側では pallidum を含む出血に有意のCNVの低下を認めた.CNVはPhasic attention に関連を持つ機能を反映するとされているが, このような機能の障害はそれ自体が社会復帰の阻害因子となっており, さらに運動麻痺や失語症の機能訓練の効果にも間接的に影響を与えているものと考えられた.

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内頸静脈血酸素飽和度(internal jugular venous oxygen saturation; SjvO₂)の測定は,脳循環・代謝の総和を反映する持続モニターであり,(1)動脈血酸素飽和度(SaO₂), (2)脳酸素消費量(cerebral metabolic rate for oxygen; CMRO₂), (3)脳血流量(cerebral blood flow; CBF), (4)ヘモグロビン(Hb)により変化する。SjvO₂の持続モニタリングにはオキシメトリーシステム,すなわち光ファイバーを利用した分光光度法を用いる。超音波ドプラー法や胸鎖乳突筋三角部アプローチにより,血液酸素飽和度の連続測定が可能なカテーテルの先端を内頸静脈球部に留置して測定する。正確な連続測定のためには6～8時間毎に採血してCO-oxymeterで酸素飽和度を測定し,オキシメトリーの測定値を修正するin vivo較正を行う。カテーテルは,一般に優位灌流側とされる右内頸静脈に留置するが,優位灌流側は個体差や病態により変わり得る。SjvO₂の正常値は55～75%(成人)で脳低酸素の閾値は50%とされるが,過換気によるCBF低下,内頸静脈球部血と脳静脈洞血との較差,SjvO₂低下の持続時間などを考慮する必要がある。SjvO₂の有用性を検討するため,脳循環・代謝に関係する指標や因子であるcerebral circulatory index (CCI), CMRO₂, CBF, PaCO₂,動脈血pH (pHa), cerebral perfusion pressure (CPP),およびcerebral vascular resistance (CVR)との相関を正常人において検討した。その結果,SjvO₂はCCIとよく相関(r=0.95)し,CMRO₂ (r=0.68), CBF (r=0.56), PaCO₂ (r=0.51)ともある程度の相関関係がみられた。一方,pHa, CVRとの相関はよくなく,CPPとの相関(r=0.26)が最も低く,これは脳血流に自己調節能が存在するためである。また,SjvO₂と近赤外分光法による脳組織ヘモグロビン量との比較では脳循環のCO₂反応性でよい相関を示した。種々の病態におけるSjvO₂の変化は貧血,低体温,麻酔薬,人工心肺時,頭部外傷,その他の頭蓋内病変,蘇生後脳症などで検討されている。SjvO₂は重症頭部外傷患者で最もよく研究され,血圧上昇に応じてSjvO₂が上昇する症例では脳循環の自己調節能が消失している。また,び漫性脳損傷後6時間以内にSjvO₂が50%以下を示した症例は予後不良であり,SjvO₂によりある程度の予後予測が可能である。以上の知見から,脳指向型患者管理における治療方針をSjvO₂と頭蓋内圧で分類した。SjvO₂は全脳におけるCMRO₂とCBFのバランスの指標であり,その変化の原因となる脳循環・脳代謝の生理学的背景や病態生理を把握できれば,持続SjvO₂測定は脳指向型集中治療において有用なベッドサイドモニターとなる。

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視床下核の脳深部刺激療法(STN-DBS)は,現在,パーキンソン病に対する外科治療の中心的役割を担っている.手術のよい適応としては,(1)運動症状の変動が激しい症例で,特にon-periodではADLが自立している症例,(2)副作用のためドパが十分に内服できない症例,(3)ドパ誘発性ジスキネジア(DID)が激しい症例,などが挙げられる.運動症状の変動が激しい症例では,off-periodを改善し「底上げ」することにより病態を改善する.ドパが副作用のため十分に内服できない症例に対しては,ドパの効果をSTN-DBSが「肩代わり」する.DIDに関しては,ドパを減量することによる二次的な効果だけでなく,直接作用も有すると考えられる.また,情動に関する検討では,運動症状の改善には依存しないで,うつが改善することがしばしば観察された.精神症状や認知機能障害の多くはコントロール可能で,出現しても一過性であった.5年以上のfollow-upが可能であった自験例のほとんどで,こうした効果は維持されていた.

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We have been employing preoperative embolization prior to microsurgical removal of cerebral arteriovenous malformations (AVMs) since 1988. In the present study, we analyzed the effects of preoperative embolization in a consecutive series of 24 cases of high-flow, large AVMs (>4cm in maximum diameter) treated between 1985 and 1991. We have chosen to use polyflilament polyester threads as an embolization material, because they cause minimal inflammatory reactions and no risks of venous occlusion. The threads were 200 micron in diameter and 5-10mm in length. We embolized 1 or 2 feeders each time until the mean feeder pressure rose to 70-90mmHg. This was repeated several times with an interval of 1-2 weeks. Microsurgical removal was performed within 1-2 weeks after the final embolization. In five cases, we encountered headache, deterioration of impaired consciousness or hemiparesis after embolization. However, all of these were transient. There was no major difference in location, age or initial symptoms between the group treated by microsurgical removal alone, and the group treated by combination of microsurgery and embolization. However, the AVMs operated after embolization were larger in volume than those treated by microsurgery alone. A classification of Spetzler and Martin also indicated that more difficult AVMs were treated by microsurgery with preoperative embolization. The total amount of blood loss was significantly small in cases operated after embolization in the group of very large AVMs (>20ml). Consequently, the operation time tended to be shorter in cases operated with embolization. Hyperemic complications were significantly less frequent in cases operated after embolization. Although there was no significant difference in overall outcome between these 2 groups, new deficits produced by microsurgical removal were significantly less frequent in cases operated after embolization. Earlier surgery after embolization appeared to be important to avoid recruitment and enlargement of small deep penetrating feeders. Polyfilament polyester threads are useful as an embolization material to make earlier surgery easier because of minimal inflammatory reactions and no risks of venous occlusion.

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For the treatment of intractable neuropathic pain, drug challenge test is necessary and useful to examine the pharmacological background of the pain in each case. Based on the results of drug challenge test, we can select the candidates for low-dose ketamine drip infusion (LDKDI) therapy and cerebrospinal stimulation therapy. In cerebrospinal stimulation therapy, dual-lead spinal cord stimulation should be selected at first, since we can insert electrodes percutaneously and this is suitable for both the test stimulation and chronic implantation. For the treatment of peripheral deafferentation pain, which includes phantom limb pain and peripheral nerve injury pain, deep brain stimulation therapy of the thalamic relay nucleus is suitable. Motor cortex stimulation therapy is suitable for the treatment of central deafferentation pain, which includes post-stroke pain. LDKDI therapy combined with cerebrospinal stimulation therapy achieves remarkable pain reduction in the treatment of neuropathic pain.

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 ガイドラインの理念は, 医療の質を一定の水準に保ち診療に資すことであり, そのためには, 診療・治療・管理のminimal essentialが求められ, 新たなエビデンスに対応して常に改訂することが不可欠である. 本ガイドラインは2000年に初版が発刊され, 2006年の第2版に続く改訂であり, 常に変化する日本の医療環境と神経外傷学の発展に対応してきた. 本項では第3版においてアップデートされた項を解説するとともに, 日本脳神経外傷学会の日本頭部外傷データバンクの結果から, 本ガイドラインが重症頭部外傷の治療に及ぼした影響と重症頭部外傷の治療・管理の現状を解説する. 急激な病態の変化に対応しなければならない重症頭部外傷では, 治療の選択が脳神経外科医の裁量に委ねられることが多い. 高度な裁量を遂行するためには判断能力を高めることが必要であり, その1つの方法として本ガイドラインを活用していただければ幸いである.

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Introduction: Using the near-infrared spectroscopy (NIRS), we evaluated the central circulation of patients with either dizziness and orthostatic dysfunction or dizziness alone.
Methods: We used the NIRO-200 NIRS instrument to monitor bilateral oxygenation changes in cerebellar hemoglobin levels in 57 subjects during an orthostatic exam. Of the 46 patients with dizziness, 8 had orthostatic dysfunction. To determine whether NIRS is useful for evaluating patients with dizziness, we compared blood pressure changes with orthostatic dysfunction test scores. Diagnostic criteria for orthostatic dysfunction were as follows: (1) a greater than 21 mmHg reduction in systemic blood pressure, (2) a greater than 16 mmHg reduction in pulse pressure, and (3) a greater than 21 beats per minute increase in pulse rate.
Results: We observed four different types of changes in oxy-hemoglobin during the orthostatic test. In type I, a rapid temporal decline of oxy-hemoglobin was followed by rapid recovery. In type II, the decline of oxy-hemoglobin was followed by recovery of oxy-hemoglobin levels above the initial levels. In type III, the decline of oxy-hemoglobin was followed by recovery of oxy-hemoglobin levels below the initial levels. In type IV, the decline of oxy-hemoglobin persisted without recovery. Most of the control patients displayed type I changes. Patients with orthostatic hypertension more frequently displayed type II and IV changes. Nine of the dizzy patients had a positive orthostatic test. Of these patients, 3 displayed type II changes and 6 displayed type IV changes.
Conclusions: In normal subjects, cerebellar circulation remains stable, at least if orthostatically induced changes in blood pressure remain within normal ranges due to autoregulation. We suspect that dysfunctional autoregulation was responsible for the reduced cerebellar circulation in patients with orthostatic dysfunction. We propose that NIRS is an excellent, non-invasive tool for evaluating patients with dizziness that present with orthostatic dysfunction.

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