頭部外傷診療において，当院ではhybrid emergency room system (HERS) を導入し，搬入から画像診断まで時間の短縮，かつその場での

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.

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.

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.

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.

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.

In this study, we reviewed the results of treatment in patients with acute subdural hematoma (ASDH) who underwent emergency burr hole surgery in the emergency center, and investigated factors involved in the outcome. The subjects were 108 patients with ASDH who underwent surgery between January 1996 and October 2004, with a Glasgow coma scale (GCS) score of 8 or lower. They were divided into 2 groups: patients who underwent emergency burr hole surgery in the emergency center, and patients who underwent elective craniotomy. We assigned 17 patients who underwent craniotomy after emergency burr hole surgery (16%) to Group A (burr hole surgery + craniotomy), 47 patients who underwent emergency burr hole surgery alone (43%) to Group B (burr hole surgery alone), and 44 patients who underwent elective craniotomy (41%) to Group C (craniotomy alone). In these patients, we investigated age, GCS score at arrival, interval until surgery, mechanism of injury, CT findings, injury severity score (ISS), presence or absence of reflex to light, presence or absence of shock, and treatment results, and analyzed the correlation between technique and each parameter. Subsequently, patients with a good outcome were compared to those with a poor outcome with respect to each factor. The outcome was evaluated based on Glasgow outcome scale (GOS) scores on discharge; patients with good recovery (GR) or moderate disability (MD) were regarded as achieving a favorable outcome, and those with severe disability (SD), vegetative state (VS), or who were dead (D) were regarded as achieving a poor outcome. Of the patients who underwent emergency burr hole surgery (Group A + Group B), 10 (16%) showed good outcomes. The survival rate was 31%. Good outcomes were achieved in 7 patients (41%) in Group A, in 3 patients (6%) in Group B, and in 14 patients (33%) in Group C. The survival rates were 76%, 15%, and 61% in Groups A, B, and C, respectively. Concerning technique, the proportion of patients aged more than 70 years, the proportion of patients with a GCS score of 4 or lower, the proportion of patients with the disappearance of reflex to light, and the incidence of shock in Group B were significantly higher than the values in Group C. In Group A, the number of patients in whom the interval from arrival until the start of surgery was 30 minutes or less was significantly larger than that in Group B. Five factors influenced the outcome: age (patients aged more than 60 years showed poor outcomes), GCS score at arrival (patients with a GCS score of 6 or lower showed poor outcomes) mechanism of injury (patients who were injured in a traffic accident showed poor outcomes), reflex to light (patients with the disappearance of reflex to light showed poor outcomes), and CT findings (patients with t-SAH showed poor outcomes).

Objective: The Japan Neurotrauma Data Bank (JNTDB) 2004 newest data that registered from the selected hospitals which are distributed all over the country are analyzed from the viewpoint of operative treatment, and it aims at using for the present understanding and a future medical guideline.

Method: Object were brain injury cases who's GCS on admission were 8 or less on admission or within 48 hours after admission and operated cases. The comparative analysis of treatments (550 operated and 497 not-operated cases ) was made for 1047 cases excluding 52 CPA on admission and two undecided　outcome cases from 1101 whole registration data.

Results: In analysis of 550 operated cases, burr hole was performed to 87 cases as the 1st-step operation, and craniotomy for hematoma removal was performed to 392 cases, and there were 37 external decompressions. When 119 operated cases of GCS 3 – 4 of the acute subdural hematoma are compared in terms of the 1st operation, outcome of the craniotomy group was better significantly. About external decompression, 187 cases were analyzed by the age group, and decline in favorable outcome and the upward tendency of mortality rate were accepted by the group aged over 61yr.

Conclusion: It is difficult to decide the indication and operative methods, such as a burr hole operation, craniotomy for hematoma removal, an external decompression, internal decompression, and CSF drainage simultaneously because of many factors. However, the usefulness of the craniotomy was shown as a whole as the 1st operation of an acute subdural hematoma except some cases.

Chronic subdural hematoma is one of the most common diseases encountered in neurosurgical practice. Although its treatment method is well established, the recurrence factor is not clear.

To identify the recurrence factor, we compared the clinical features of recurrence cases and non-recurrence cases of the same patients. The study included 87 cases (96 hematomas) that had undergone burr-hole surgery between January 2000 and December 2013. The study was retrospectively analyzed. Recurrence was defined as the time at which recurrence warranted re-drainage.

The recurrence factors were preoperative consciousness, preoperative paralysis, volume of preoperative hematoma, bilateral operation, and volume of postoperative hematoma and air.

We concluded that operation should be performed, before hematoma increases and symptom progresses, for preven­tion of recurrence.

Objective: Chronic subdural hematoma is one of the most common diseases in neurosurgical practice with a well-established treatment method. Typical treatment includes burr-hole surgery. However, there are some reports of postoperative intracranial hemorrhage.

Methods: We examined burr-hole surgery performed in the treatment of chronic subdural hematoma at the Department of Neurosurgery at our hospital between January 2000 and December 2014. In total 1,077 patients (1,257 hematomas) were included in the study. We examined the clinical features of 19 patients (21 hematomas) who developed postoperative intracranial hemorrhage. We compared the postoperative intracranial hemorrhage and non-intracranial hemorrhage cases.

Results: Cases with postoperative intracranial hemorrhage could be divided into four main patterns. Pattern A was characterized by intraoperative brain contusion. Pattern B-1 had a relatively good prognosis and was characterized by a subdural hematoma on the operated side. Pattern B-2 had a poor prognosis and was characterized by a subdural hematoma on the operated side caused by blood vessel damage at the time of drainage tube removal. Pattern C had a poor prognosis and was characterized by a subdural hematoma contralateral to the operated side. Pattern D had a poor prognosis and was characterized by an internal hemorrhage of the brain parenchyma. Patients with bleed­ing were more likely to exhibit Pattern C or D. The pro­portion of cases with a history of malignant tumor was significantly greater among the cases with postoperative intracranial hemorrhage than non-intracranial hemorrhage cases.

Conclusion: The tendency for a bleed to occur influenced the region of the bleed, not the operation site, and the prognosis was poor. Attention is necessary during surgery and at the time of drainage tube removal to prevent damage to local structures.

A 61–year–old man suffering from headache and neck pain from past few months and gait disturbance and consciousness disorder from past 1 month presented to our neurosurgery department. Upon arrival at the hospital, the patient had the Japan Coma Scale (JCS) and Glasgow Coma Scale (GCS) scores of 10 and 13, respectively. Magnetic resonance imaging of the head showed bilateral chronic subdural hematoma. Thus, we performed bilateral burr hole hematoma removal and drainage. After the surgery, the symptoms improved. Two days after the surgery, the patient had the JCS and GCS scores of 20 and 8, respectively, and right motor paralysis.

Computed tomography (CT) of the head showed left acute sub­dural hematoma. For early decompression, we performed hematoma removal using the existing burr hole in the emergency room near the CT room. Then, we performed endoscopic–assisted mini–craniotomy for the removal of hematoma. After the surgery, intracranial pressure ⁄ cerebral perfusion pressure was monitored to check for increased intracranial pressure due to rebleeding and cerebral edema. The patient’s JCS scores gradually improved from 20 to 0, and he was discharged from our department on the 34th day of hospitalization.

This case shows the value of craniotomy after the existing burr hole surgery for early decompression in patients with acute epidural hematoma following the burr hole evacuation of chronic subdural hematoma, and this may contribute to improved outcomes. The existing burr hole surgery uses fewer tools and causes less bleeding than the new burr hole surgery, and it should be performed outside the operating room to avoid wasting time.

器質化慢性硬膜下血腫の治療には難渋することが多く，これまでも様々な方法が報告されている。当院で経験した器質化慢性硬膜下血腫で治打撲一方を投与した症例を後方視的に検討し治療方法を考察した。対象症例は9例あり，効果があったと考えられた症例は6例であった。検討の結果，器質化慢性硬膜下血腫に対して

Background: The purpose of this study was to clarify the criteria for initial treatment of chronic subdural hematoma (CSDH) by com­paring the backgrounds and post–treatment courses of patients who underwent drainage or middle meningeal artery (MMA) emboliza­tion for CSDH.

Methods: We performed a retrospective investigation of 23 and 21 patients who underwent drainage and MMA embolization, respec­tive­ly, performed between April 2020 and July 2022 as initial treatment for unilateral CSDH.

Results: There was no significant difference between the drainage and embolization groups in terms of age (78 vs 76 years), gender, lateral­ity of lesion, maximum diameter of hematoma (21 vs 19 mm), pretreatment Markwalder grading system (MGS) score (1 vs 1), or length of hospital stay (5 vs 17 days) between the groups. Pretreatment midline shift was greater in the drainage group than the MMA embolization group (8.8 vs 6.6 mm). Operative time was shorter in the drainage group (32 vs 79 min). Recurrence occurred in 2/23 (8.7%) of the drain­age group, in whom addi­tional MMA embo­lization was per­formed. Additional drainage was required due to exacerbation of symptoms in 4/21 (19%) of the MMA embo­lization group. No perioperative complications occurred in either group. There was no significant difference in median pre­operative MGS score (1 vs 1) or mean maximum hematoma diameter (18 vs 19 mm) in the 17 patients who showed resolution of CSDH by MMA embolization alone or in the 4 patients who required additional drain­age. Mean midline deviation was 6.1 and 8.9 mm in the embo­lization alone and additional drainage groups, respec­tively, and was significantly greater in those who required additional drainage (p=0.002).

Conclusions: The postoperative course between patients who under­went drainage or embolization for CSDH showed no significant difference in the case of very mild preoperative neurological findings (MGS score of about 1). Patient selection for MMA embolization as the initial treatment for CSDH should be clarified based on clinical symptoms and the radiological findings.