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To determine the association between optic nerve sheath diameter (ONSD) and outcome in patients with traumatic brain injury (TBI) who undergo hematoma removal (HR).This study was a retrospective analysis of data from a single center between 2016 and 2021. Adult patients with TBI who underwent HR within 24 h after admission were included in this study. Preoperative and postoperative ONSD of the surgical side and the mean ONSD of both sides were measured for analysis. The primary outcome was mortality at 30 days. Receiver operating characteristic curve analysis was performed to calculate the area under the curve (AUC) and 95% confidence interval (CI) for 30 days mortality.Sixty-one patients were enrolled in the study. Among them, 48 (78.7%) survived for 30 days after admission. The AUC and 95% CI of the postoperative mean ONSD on both sides and postoperative/preoperative mean of the ONSD ratio on both sides were 0.884 [0.734-0.955] and 0.875 [0.751-0.942], respectively. The postoperative mean of both ONSDs of 6.0 mm had high accuracy as a cut-off value with a sensitivity of 85%, specificity of 83%, positive likelihood ratio (LR) of 5.0, and negative LR- of 0.18.This study demonstrated that postoperative ONSD and the postoperative/preoperative ONSD ratio were associated with postoperative outcome in patients with TBI who underwent HR.

Balloon test occlusion (BTO) can predict the ischemic complication risk associated with arterial occlusion. We present a case of an unruptured, broad-necked internal carotid artery-posterior communicating artery (PcomA) aneurysm that was successfully embolized after super-selective BTO of fetal PcomA with electrophysiological monitoring. The proximal portion of the PcomA was internally occluded without causing major neurological deficits, although we observed a small new infarction in the ipsilateral anterior thalamus postoperatively. We recognized small perforators arising from the proximal PcomA during a previous clipping surgery. Super-selective BTO with electrophysiological monitoring could be useful for functional preservation after infarction from angiographically invisible perforators.

Coagulopathy is often observed in severe traumatic brain injury (sTBI), and hyperfibrinolysis (HF) is associated with a poor prognosis. Although the efficacy of fibrinogen concentrate (FC) in multiple trauma has been reported, its efficacy in sTBI is unclear. Therefore, we delineated severe HF risk factors despite fresh frozen plasma transfusion. Using these risk factors, we defined high-risk patients and determined whether FC administration to this group improved fibrinogen level.In the first part of this study, successive adults with sTBI treated at our hospital between April 2016 and March 2019 were reviewed. Patients underwent transfusion as per our conventional protocol and were divided into two groups based on whether fibrinogen levels of ≥ 150 mg/dL were maintained 3-6 h after arrival to delineate the risk factors of severe HF. In the second part of the study, we conducted a before-and-after study in patients with sTBI who were at a higher risk for severe HF (presence of at least one of the risk factors identified in the first part of the study), comparing those treated with FC between April 2019 and March 2021 (FC group) with those treated with conventional transfusion before FC between April 2016 and March 2019. The primary outcome was maintenance of fibrinogen levels, and the secondary outcome was 30-day mortality.In the first part of the study, 78 patients were included. Twenty-three patients did not maintain fibrinogen levels ≥ 150 mg/dL. A D-dimer level on arrival 50 μg/mL, a fibrinogen level on arrival 200 mg/dL, depressed skull fracture, and multiple trauma were severe HF risk factors. In the second part, compared with 46 patients who were identified as being at high risk for severe HF but were not administered FC (non-FC group), fibrinogen levels ≥ 150 mg/dL 3-6 h after arrival were maintained in 14 of 15 patients in the FC group (odds ratio: 0.07; 95% confidence interval: 0.01-0.59). Although there were significant differences in fibrinogen levels, no significant differences were observed in terms of 30-day mortality between the groups.Coagulation abnormalities on arrival, severe skull fracture, and multiple trauma are severe HF risk factors. FC administration may contribute to rapid correction of developing hypofibrinogenemia.

Background: The pathogenesis and pathophysiology of traumatic coagulopathy during traumatic brain injury is not well understood, and the appropriate treatment strategy for this condition has not been established. This study aimed to evaluate the coagulation phenotypes and their effect on prognosis in patients with isolated traumatic brain injury.Methods: In this multicenter cohort study, we retrospectively analyzed data from the Japan Neurotrauma Data Bank (JNTDB). Adults with isolated traumatic brain injury (head abbreviated injury scale [AIS] >2, any other AIS Results: In total, 556 patients were enrolled, and five coagulation phenotypes were identified. Cluster A (n=129) had the closest to normal coagulation values; cluster B (n=323) had a mild high DD phenotype; cluster C (n=30) had a prolonged PT-INR phenotype with a higher frequency of antithrombotic medication in elderly patients than in younger patients; cluster D (n=45) had a low FBG, high DD, and prolonged APTT phenotype with a high incidence of skull fracture; and cluster E (n=29) had a low FBG and extremely high DD phenotype with high-energy trauma and high incidence of skull fracture. In the multivariable logistic regression analysis, the association of clusters B, C, D, and E with in-hospital mortality yielded the corresponding adjusted ORs of 2.17 (95% CI: 1.22–3.86), 2.61 (95% CI: 1.01–6.72), 10.0 (95% CI: 4.00–25.2), and 24.1 (95% CI: 7.12–81.3), respectively, relative to cluster A.Conclusions: This multicenter observational study identified five different coagulation phenotypes of traumatic brain injury and showed associations of these phenotypes with in-hospital mortality.

To identify the association between skull fracture (SF) and in-hospital mortality in patients with severe traumatic brain injury (TBI).This multicenter cohort study included a retrospective analysis of data from the Japan Trauma Data Bank (JTDB). JTDB is a nationwide, prospective, observational trauma registry with data from 235 hospitals. Adult patients with severe TBI (Glasgow Coma Scale9, head Abbreviated Injury Scale (AIS) ≥ 3, and any other AIS 3) who were registered in the JTDB between January 2004 and December 2017 were included in the study. Patients who (a) were 16 years old, (b) developed cardiac arrest before or at hospital arrival, and (c) had burns and penetrating injuries were excluded from the study. In-hospital mortality was the primary outcome assessed. Multivariable logistic regression analyses were performed to calculate the adjusted odds ratios (ORs) of SF and their 95% confidence intervals (CIs) for in-hospital mortality.A total of 9607 patients were enrolled [median age: 67 (interquartile range: 50-78) years] in the study. Among those patients, 3574 (37.2%) and 6033 (62.8%) were included in the SF and non-SF groups, respectively. The overall in-hospital mortality rate was 44.1% (4238/9607). A multivariate analysis of the association between SF and in-hospital mortality yielded a crude OR of 1.63 (95% CI: 1.47-1.80). A subgroup analysis of the association of skull vault fractures, skull base fractures, and both fractures together with in-hospital mortality yielded adjusted ORs of 1.60 (95% CI: 1.42-1.98), 1.40 (95% CI: 1.16-1.70), and 2.14 (95% CI: 1.74-2.64), respectively, relative to the non-SF group.This observational study showed that SF is associated with in-hospital mortality among patients with severe TBI. Furthermore, patients with both skull base and skull vault fractures were associated with higher in-hospital mortality than those with only one of these injuries.

Background: The Spetzler–Martin Grade (SMG) is widely used to evaluate the risk of resection of cerebral arteriovenous malformation (AVM), and direct surgery is strongly recommended for low SMG lesions. Micro-AVMs are defined as AVMs with a nidus Case Description: (Patient 1) A 30-year-old man was brought to our hospital and diagnosed with a micro-AVM, which was classified as SMG II AVM. He underwent evacuation of the intracerebral hematoma and subsequently underwent AVM resection. However, the lesion was not identified because it was not exposed in the cerebral cortex although we searched for the lesion. Therefore, endovascular embolization was performed before subsequent surgical resection. During AVM resection following embolization with Onyx, the IUS clearly demonstrated the Onyx-embolized lesion, and it was resected uneventfully. (Patient 2) A 46-year-old man with a ruptured SMG II AVM underwent AVM resection using a microsurgical technique with IUS after embolization for AVM preoperatively. IUS clearly showed abnormal vessels embolized with Onyx and indicated the correct location of the nidus, although the lesion was not observed directly from the brain surface. After identifying some embolized AVM constructions, we excised the entire AVM with ease and safety. Conclusion: The combined use of presurgical embolization, which focuses on marking the lesions and IUS, may contribute to improving surgical outcomes of low SMG micro-AVMs, which are not exposed on the brain surface.

Background: Fibromuscular dysplasia (FMD) can cause cerebral aneurysms and dissection, which can lead to stroke. Angiographic findings are important in the diagnosis. We report a case of FMD in which the cause of hemorrhage could not be determined by angiography. Case Description: A 73-year-old woman suffered from intracerebral hemorrhage (ICH) associated with FMD without abnormal angiography cerebral vessels. She presented with headache and nausea. Subsequent head-computed tomography-revealed ICH in the left frontal lobe, and contrast-enhanced magnetic resonance imaging revealed a gadolinium-enhancing lesion in the perihematoma area and in the genu of the corpus callosum. Although cerebral angiography revealed a string of beads appearance in the bilateral extracranial internal carotid arteries, no abnormality explaining the hemorrhage was identified. The hematoma was removed and the pathological diagnosis was FMD. In the pathological specimen, various patterns of vulnerable vessels, such as aneurysmal dilatation and obstruction, were observed, which could easily collapse and result in hemorrhage. In the case of ICH of unknown origin, microscopic vessel disruption due to FMD should also be considered. Conclusion: FMD can cause ICH in microscopic vascular lesions that are undetectable on angiography.

N-butyl cyanoacrylate (NBCA) has been used to embolise brain arteriovenous malformations (AVMs) for over 30 years. It is a mixed with lipiodol in varying proportions. We report a 22-year-old male with intraventricular hemorrhage from a ruptured intranidal AVM aneurysm in the left temporal lobe. The intranidal aneurysm and the nidus were successfully embolized using a 20% NBCA and lipiodol mixture without any complications according to computed tomography (CT) immediately after treatment. Scattered high-density spots were observed in both lateral ventricles on CT 5 days after embolization, suggesting migration of lipiodol. We speculated that the aneurysm was a pseudoaneurysm whose wall protruded into the inferior horn of the left lateral ventricle, and the lipiodol in the NBCA migrated into the ventricles after the thin part of the wall ruptured. The patient developed pyrexia due to chemical meningitis, which responded to steroid treatment for one month.

[Background] We evaluated the association between D-dimer (DD) levels and long-term neurological prognoses among patients with isolated traumatic brain injury. [Methods] Using data from multiple centers in the Japanese Neurotrauma Data Bank, we conducted an observational retrospective cohort study. Patients with isolated traumatic brain injury (head Abbreviated Injury Scale score > 2; any other Abbreviated Injury Scale score

Background: Most meningiomas related to head trauma have been reported to show intradural lesions; however, they can also occur as primary extradural meningiomas (PEMs) and have often been reported to histologically demonstrate atypical or malignant subtypes. Therefore, early detection and complete resection of related tissues are required; however, to date, only a few PEM cases related to trauma or injury have been reported. Herein, we present a patient with a rapidly growing posttraumatic PEM, in which echosonography is efficient not only for early diagnosis but also for intraoperative strategies. Case Description: A 62-year-old male presented to a nearby clinic with a complaint of a painless head bump that gradually grew larger in relation to trauma 6 weeks earlier. He underwent echosonography and pointed out the possibility of a cranial tumor and consulted our hospital. Although preoperative imaging studies, such as computed tomography or magnetic resonance imaging, did not provide reliable information on dura mater invasion, echosonography demonstrated dural invasion and intradural lesions in which large vessels passed the surface of the lesion. Based on these findings, we could safely resect the lesion within a sufficient range. Conclusion: Echosonography may not only be a cue for an early diagnosis but also provide important information for the treatment strategy of PEM that is related to head trauma.

Background Penetrating injury of the vertebral artery (VA) is uncommon because it lies deep in the neck and is surrounded by a bony foramen. Vertebral–venous fistula is a rare vascular condition in which there is direct aberrant communication among the extracranial vertebral artery, its radicular or muscular branches, and adjacent venous structures. Case Presentation We report an asymptomatic patient of fistula from the vertebral artery to the paravertebral veins secondary to a cervical stab wound that increased in size and flow, as observed on the angiogram 10 days later, which was successfully treated by endovascular surgery. The postoperative angiogram showed improved visualization of the bilateral posterior cerebral arteries. Conclusion Endovascular embolization at the early phase should be undertaken for traumatic high‐flow vertebral–venous fistula, even if the patient is asymptomatic, to prevent progressive posterior circulation insufficiency due to the rapid growth of the fistula, which can ultimately lead to the steal phenomenon., We report an asymptomatic patient of fistula from the vertebral artery to the paravertebral veins secondary to a cervical stab wound that increased in size, as observed on the angiogram 10 days later, which was successfully treated by endovascular surgery.

Purpose Fluid-attenuated inversion recovery (FLAIR) vascular hyperintensity (FVH) extent or FVH-DWI mismatch as a primary influencing factor of clinical outcome in acute ischemic stroke is controversial. This study elucidated the regional pathophysiology and tissue fate in four types of cortical territories classified by the initial FVH and DWI findings in patients with acute proximal middle cerebral artery (M1) occlusion successfully recanalized using mechanical thrombectomy. Methods We retrospectively evaluated 35 patients successfully recanalized within 24 h of acute M1 occlusion onset between 2016 and 2019. Each Alberta stroke program early CT score area of M1–M6 were categorized as group A (DWI-, FVH-), B (DWI-, FVH+), C (DWI+, FVH+), or D (DWI+, FVH-). Territorial collateral status was graded on a 4-point scale by initial angiogram. Follow-up head computed tomography (CT) findings on days 2–9 were assessed for the territorial outcome. Results Overall, 210 cortical territories were identified; of these, 88 (41.9 %) were categorized into group A; 72 (34.3 %), group B; 37 (17.6 %), group C; and 13 (6.2 %), group D. The rate of territories with good collaterals (grade 2 or 3) significantly decreased in the order of groups as 78.3 %, 62.7 %, 27.6 %, and 0%, respectively (Ptrend Conclusion Categorization of cortical areas based on the FVH and DWI findings can stratify territorial collateral status and tissue fate.