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In some patients with spontaneous subarachnoid hemorrhage(SAH), initial imaging investigations may not be able to detect a bleeding source;repeat imaging may be necessary to reveal these lesions. We reviewed a consecutive series of 45 patients with SAH and negative initial digital subtraction angiograms(DSA)during a 15-year period. The aims were to document the frequency and reason for the negative initial investigations, to determine the appropriate modality and timing of repeat examinations, and to investigate the identified bleeding sources. Twenty-eight(62%)patients underwent repeat DSA, 35(78%)underwent magnetic resonance imaging(MRI), and 33(73%)underwent computed tomography angiography(CTA). Nine lesions(5 small aneurysms, 2 craniocervical junction arteriovenous fistulas, 1 arteriovenous malformation, and 1 internal carotid artery dissection)were identified on subsequent DSA after 2-3 weeks. Most aneurysms were identified on an atypical vascular tree. CTA or MRI alone were unable to disclose the culprit lesions. In retrospect, human errors including oversight were the major reasons for the negative initial investigation results. It is, however, difficult to search for a tiny vascular lesion that might be anywhere in the cranium. Repeat DSA is still the gold standard for the inspection of hidden bleeding sources in patients with SAH of unknown origin.

The outcome of severe acute subdural hematoma is unfavorable. In particular, patients with levels of consciousness of Glasgow Coma Scale(GCS)3 or 4 tend to be refractory to treatment. Decompressive craniotomy should be promptly performed to remove hematoma. However, if an operating room is not immediately available, emergency burr hole surgery is sometimes performed in the emergency room(primary care room)prior to craniotomy. A previous study has reported that the interval from injury to surgery influences the outcome of severe acute subdural hematoma. Therefore, emergency decompression is important to effectively treat patients with severe acute subdural hematoma. We present the cases of two patients with acute subdural hematomas. In both cases, emergency decompressive craniotomy(hematoma removal after craniotomy and external decompression)was performed in the emergency room of the Emergency and Critical Care Center. In both cases, the surgery was followed by favorable outcomes. Case 1 was a 36-year-old female. The patient's level of consciousness upon arrival was GCS 3. The interval from injury to diagnosis on the basis of CT findings was 75 minutes. Surgery began 20 minutes after diagnosis. Case 2 was a 25-year-old male. The second patient's level of consciousness upon arrival was GCS 4. The interval from injury to diagnosis on the basis of CT findings was 60 minutes. Surgery was begun 40 minutes after diagnosis. In both patients, we observed anisocoria and the loss of the light reflex. However, the postoperative course was favorable, and both patients were discharged. In summary, to treat severe acute subdural hematomas, early emergency decompressive craniotomy is optimal. Emergency decompressive surgery in the emergency room is independent of operating room or staff. Therefore, emergency decompressive craniotomy may improve the outcome of patients with severe acute subdural hematomas.

Vertebral artery dissection(VAD)presenting as isolated occipital headache and/or neck pain is being increasingly diagnosed because of the development of magnetic resonance imaging(MRI). While a majority of the patients diagnosed with this condition shows a favorable prognosis, the pain may be a predictor of fatal stroke in some patients. We aimed to find out the features of headache with VAD, identify the clinical manifestations indicative of VAD, and determine the ideal diagnostic approach to this condition to avoid fatal stroke. We reviewed medical records of 41 consecutive patients who showed VAD with isolated headache and were diagnosed between 1995 and 2008. All patients experienced pain in the occipitocervical area ipsilateral to the affected VA. Pain showed a sudden onset in 21(51%)patients, was persistent over several days in 31(76%)patients, and was severe enough to disable daily life activities in 34(83%)patients. Progression of stenosis or aneurysmal dilatation of the vessel was identified on follow-up imaging(angiography, magnetic resonance angiography)in 7 patients(17%), and was found within 14 days after pain onset in 6 of these patients(86%). Patients with persistent, severe, and unilateral pain in the occipitocervical area should undergo MRI examination, including surface anatomy scanning(SAS)imaging, and the possibility of VAD should be considered in their diagnosis. Once VAD is diagnosed, the patient should undergo meticulous blood pressure control, bed rest, and repeated MRI examination for at least 2 weeks after onset.

It may be difficult to perform CT for pediatric head trauma because of body movement and radiation exposure. Imaging application criteria were established, in which patients diagnosed as less likely to have an intracranial lesion meeting the criteria were not indicated for imaging and subjected to course observation at home, and this policy was explained to the parents. When consent was obtained, patients were followed up at home, and we checked on the condition by making a phone call 4-8 hours after injury. The patients were 103 infants aged 15 years or younger brought to the emergency medical care center of our hospital between May and August 2008. Imaging was basically indicated for cases of traffic accidents, falls from a high level, those brought in by ambulance, referred cases, and cases with disturbance of consciousness, neurologically abnormal findings, vomiting on examination, and trauma requiring X-ray examination in addition to that for the head. However, apart from these cases, imaging was not required. Imaging was not necessary for 94% of infant cases. The parents were convinced by the explanation and selected course observation at home in 94% of cases for which imaging was judged as unnecessary. None of the patients required re-examination based on the conditions reported in phone calls to homes. Imaging diagnosis for pediatric head trauma is not always necessary, and its application should be decided on after consultation. When no imaging is performed, this should be fully explained at the initial treatment before selecting course observation at home. Checking on the child's condition by making a phone call several hours after injury is useful for both patients and physicians.

Objective: To evaluate the influence of the primary management on the outcome in severe head-injured-patients, we retrospectively studied the patients transported to our hospital directly and the those referred from other hospitals., Methods: The subjects include 83 patients with severe head injury with a Glasgow coma scale (GCS) score of 8 or lower at the time of arrival at the emergency room during the periods of between January, 2003 to March, 2006. Forty nine patients were transported directly (direct group) and 34 referred from other hospitals (transfer group). The patients in direct group was transported by a helicopter or an ambulance car, and the patients in transfer group were carried by an ambulance car. The variables analyzed in these 2 groups of patients were the initial GCS score, injury severity score (ISS), and the presence or absence of light reflex or shock at the time of transportation, the time periods from the injury and primary management, the time from the injury and operation in surgical patients, the type of primary managements and outcomes., Result: The number of patients with shock was significantly larger in the transfer group than that in the direct group. The shock was considered to be developed during the transportation. The outcomes were then significantly poorer in the transfer group than those in the direct group. There was no significant difference between the time from the injury and primary management in these 2 groups, but the primary management seemed to be more appropriate in the direct group compared to that in the transfer group. These findings suggested that outcomes of severe high-impact head injuries, such as injuries caused by a traffic accident, would be markedly affected by the primary treatment., Conclusion: The doctor-helicopter system, in which emergency physicians arrive at the site shortly after the occurrence of injury, and start primary examination, will influence outcomes of multiple injuries accompanying severe head injury. Severe head-injured patients by high-impact injury should be transported as early as possible to the emergency medical center, and neurosurgeons have an important role in the primary management.

Since low-invasive surgery provides marked symptomatic improvement of patients with chronic subdural hematoma, surgery will be recommended also for the aged. To examine the clinical features and treatment result in the aged patients, we compared the clinical features and surgical results in two groups of patients with 80 or more and less than 80 years. The subjects consisted of 266 adult patients with a total of 333 chronic subdural hematomas who had undergone closed-system drainage between January 1995 and March 2005. The items analyzed were 1) patients background including gender, laterality of hematoma, presence or absence of history of head trauma, history of drinking, and mechanism of injury, 2) clinical symptoms, such as level of consciousness on initial examination, initial symptoms, and the degree of paralysis, 3) those related to surgery, such as time from injury to surgery, length of hospital stay, operation time, and amount of drainage, 4) outcome, such as presence or absence of symptomatic improvement, and recurrence rate. The results of this study showed that chronic subdural hematomas in the extremely aged patients were characterized by 1) infrequent history of head trauma, 2) infrequent headache and frequent dementia, incontinence and deterioration of activity at onset, 3) severe degree of motor paralysis at admission, 4) larger amount of drainage volume, 5) low incidence of outcome improvement. Above these characteristics should be considered at the decision making of surgical treatments for extremely aged patients with chronic subdural hematoma.

The surgical procedures for treating chronic subdural hematoma (CSH) are carried out with a variety of different methods. The generally used operative method is a less invasive burr hole irrigation under local anesthesia. Recently, we have devised a new simple method using an endoscope to treat CSH. We have been using an endoscopically guided method in which a drainage tube is inserted in the hematoma cavity. We also analyzed the endoscopic findings in the hematoma cavities and reported a high recurrence rate in patients with clots in the hematoma cavity, which suggest the importance of clot removal to reduce recurrence. In this study, the advantage of endoscopic surgery for chronic subdural hematoma is demonstrated.

The outcome of multiple injures freqently depends on the priority of treatments, and the decision as to the procedures and timing of primary care is extremely important. We studied the patients with multiple trauma whounderwent emergency endovascular treatment for facial hemorrhage related to external carotid arterial injury. The subjects are 5 patients who underwent embolization of the external carotid artery by an endovascular approach among patients with multiple traumas who were brought to our hospital by ambulance. In these patients, the vital signs on arrival, interval between injury and intravascular surgery, type of brain injury, type and grade of concurrent injury and outcome were studied. Three patients showed hemorrhagic shock on arrival, and 1 patient showed hemorrhagic shock immediately after arrival. The mean interval between injury and endovascular surgery was 3.9 hours. All patients had skull base fracture, and abnormal intracranial lesions on initial CT including 4 focal injuries and 1 diffuse injury. Moderate to severe thoracic/abdominal injuries were noted in 3 patients. In the remaining 2 patients, there was no trauma in the thoracic or abdominal regions. Intraperitoneal hemorrhage with splenic injury was observed in 3 patients. In 3 of 4 patients died by hemorrhagic shock because of the delay of endvascular treatments. In trauma patients with persistent hemorrhage, emergency endovascular treatment should be considered as a primary survey for initial treatment without delay under intensive conservative treatment.

We reviewed the records of 1,335 minor head injury patients with initial Glasgow Coma Scale (GCS) scores of 15 treated by our neurosurgery service between January 1998 and December 2000. Skull X-ray was performed in 945 patients (71%), and Computed tomography (CT) was performed in 590 patients (44%). Skull fracture was shown radiographically in 24 patients (2.5%), and abnormalities on the initial CT were seen in 29 patients (4.9%). The most frequent intracranial lesion on CT was acute epidural hematoma with skull fracture. Significantly more intracranial lesions were found in those with a fracture than in those without by chi2 analysis. Post-traumatic vomiting was significantly associated with radiographical abnormalities, but headache and nausea did not increase the risk of skull fracture and intracranial lesions on the CT. Patients required neurosurgical intervention in 4 cases, and all of those were acute epidural hematoma with skull fracture. In this study, the first thing we should do for asymptomatic minor head injury patients with a GCS score of 15 is to investigate the presence of a skull fracture by skull X-ray. Head trauma patients with a skull fracture and post-traumatic vomiting should undergo CT to facilitate detection of intracranial lesions, even when there are no abnormal neurological signs.

Hypertensive intracerebral hemorrhage (HIH) occurring simultaneously in different locations is rare. We encountered 11 such cases between January 1990 and November 2002. The diagnosis of all 11 cases was established by computed tomography, and the location of the hematomas was: cerebellum and basal ganglia in 5 cases, pons and basal ganglia in 4, and subcortex and basal ganglia in 2. Our patients were analyzed with respect to clinical characteristics, pathogenesis of multiple hematomas, and indication of operation. These patients represented 1% of all 1,069 patients we encountered with HIH. As past history, there were no characteristic disorders except hypertension. There were no characteristic initial symptoms suggesting that hemorrhage had occurred simultaneously. Both supra- and infra-tentorial hematomas were observed in 80% of the patients, and the size of the multiple hematomas was proportional in principle. Cerebellar hematomas were often mild, and pontine hematomas were often severe. The outcome in those patients whose neurological grading was 1 to 3 was good with conservative therapy or surgical treatment. The severity, treatment methods, and outcomes in these patients were similar to those in patients with single HIH, which suggests only a slight influence of multiple lesions on outcome. As for the possible mechanism of simultaneous multiple hemorrhages, we speculated that bleeding occurred simultaneously in the different regions, or that the initial bleeding was followed after a short time by secondary bleeding due to high intracranial pressure and circulatory disturbance. In patients with cerebellar hematoma, initial symptoms suggested the development of secondary hemorrhage after primary hemorrhage. The surgical treatment for multiple hematomas should be determined by the location and maximum axis of the hematoma. We proposed that cerebellar hematomas should be removed if the supra-tentorial hematoma is small.

The favorable effect of burr hole irrigation and closed drainage system has been reported in the treatment of chronic subdural hematoma (CSH). After analyzing the relationship of the direction of the drainage tube and recurrence, we have suggested that the residual air after surgery night be important as one of the factors causing recurrence. The present study included 128 chronic subdural hematomas in 102 patients who had been treated in our institute between January, 1996 and October, 2000. We attempted to place the tip of the external drain at the occipital side within the hematoma cavity between January, 1996 and December, 1998 (occipital drainage group), while we tried to insert the tip of the external drain at the frontal side using an endoscope between January, 1999 and October, 2000 (frontal drainage group). We focused on the residual air on CT, the direction of the drainage, recurrence of the hematoma and the size of the hematoma. Some statistical analyses were conducted using these factors. The recurrence rate was slightly lower in the frontal drainage group than that in occipital drainage group. There was no difference in the residual rate of air immediately after the surgery on CT and the recurrence rate between the 2 groups. However, the interval preceding the recurrence was statistically significantly longer in the frontal drainage group. A higher rate of recurrence was noted for cases in which the volume of hematoma was more than 70 ml. The residual rate of air 1 week after surgery was significantly higher in the recurrent group than in non-recurrent group. In this study, it is demonstrated that a long-standing residual of air after surgery is one of the causes of the recurrence of CSH. We must contrive to reduce the residual air after surgery for the treatment of CSH.

On the genesis of chronic subdural hematoma (CSH), it is one of the possible explanations that a head injury triggers uncertain cause off for the formation of the hematoma membrane, where the bleeding occurs to form and enlarge the hematoma. Although some reports on the staging classification based on computed tomography (CT) findings are available the natural course or history of the hematoma formation is not yet known. As previously reported, we have been using an endoscopically guided method in which a drainage tube is placed in the most frontal area of the cavity so as to evacuate the residual air efficiently. In this study, we analyzed the endoscopic findings in hematoma cavities and compared them with the clinical data, focusing on the post-trauma interval and recurrence of the hematoma. Between January 1999 and October 2000, we had an opportunity to observe the inner aspect of 60 hematomas in 48 patients. A trabecular structure was found in 39 hematoma cavities (65%), whereas apparent clot formation was observed in 18 cavities (30%). Septum formation leading to a multi-loculated hematoma was observed in 10 cavities (17%). Twenty-six patients with 32 hematomas with the obvious history of head injury were classified into 4 groups according to the post-traumatic interval to the surgery, which are stage I; less than 30 days, stage II; 31 to 60 days, stage III; 61 to 90 days and stage IV; more than 91 days. Clot formation and a trabecular structure were frequently seen in stages II and III. Clot formation was statistically and significantly seen in the recurrent group. The results suggest that CSHs increase in size in stages II and III, when clot formation and a trabecular structure are frequently observed. Endoscopic observation of hematomas may assist to know hematomas, and clot formation may be a warning of hematoma recurrence.

The possibility exists that residual air after surgery is one cause of recurrence of chronic subdural hematoma. We have devised a new simple method which decreases postoperative residual air, using external drainage and an endoscope. First, we make endoscopic observations of the inner aspect of the hematoma cavity. Then, we insert external drainage apparatus into the most frontal area of the hematoma cavity, we regard this location as the most appropriate place to ensure most effective drainage. The present study included 37 chronic subdural hematomas in 32 patients who had been treated between January and December, 1999. Their ages ranged from 48 to 86 years old, with an average of 72 years. Insertion of external drainage in the most frontal area of the hematoma cavity was successfully achieved in 27 (73%, Group I) out of 37 cases and resulted in no recurrence. In the remaining 10 hematomas (27%, Group II), external drainage was not able to be inserted in the most frontal area, and four hematomas (40%) had recurrence (p < 0.01 vs Group I). Insertion in the most frontal area of the hematoma cavity decreases residual air after surgery, and may be effective for the prevention of recurrence of chronic subdural hematoma.