A pilot study of hypofractionated radiation therapy with temozolomide for adults with glioblastoma multiforme.

To evaluate the safety and efficacy of hypofractionated radiotherapy (RT) with a standard temozolomide (TMZ) regimen for adults with newly diagnosed glioblastoma multiforme (GBM), twenty-six consecutive adults (range 39-79 years) who met our enrollment criteria received short courses of hypofractionated RT (45 Gy in 15 fractions over three weeks) with concomitant TMZ at 75 mg/m(2)/d. After 28 days, TMZ was maintained at 150-200 mg/m(2)/d on five days for 12 cycles or until tumor progression or unacceptable toxicity. The primary end point was determined by overall survival (OS) and toxicity. Secondary assessed end points were: progression-free survival (PFS) at six months, health-related quality of life (HRQOL), and pseudo-progression. We assessed HRQOL by use of the Karnofsky performance status (KPS) and the Functional Assessment of Cancer Therapy-Brain (FACT-Br) Subscale. All 26 patients were evaluated for OS, PFS, and HRQOL. At a median follow-up of 20 months, the median OS was 15.6 months (95% confidence interval 9.0-22.2 months) with acceptable toxicity. PFS rate at six months was 65%. KPS and FACT-Br Subscale scores did not decline after this procedure. Pseudo-progression occurred in two (8%) patients. Adult patients with GBM benefitted from favorable OS and PFS rate as a result of the hypofractionated RT with TMZ. An additional advantage is that this procedure may reduce the course of treatment. Further studies using this procedure are warranted.

Epstein-Barr virus-associated primary central nervous system lymphomas in immunocompetent elderly patients: analysis for latent membrane protein-1 oncogene deletion and EBNA-2 strain typing.

Epstein-Barr virus (EBV) has been implicated in the pathogenesis of primary central nervous system lymphomas (PCNLs) in immunocompetent hosts. To investigate the role of EBV in the pathogenesis of PCNLs in immunocompetent hosts, this study assessed six PCNL cases (elderly male immunocompetent patients; age ≥60 years) histologically and immunohistochemically, and an EBV genetic study was performed. Histologically, all cases were diagnosed as diffuse large B-cell lymphoma with extensive necrosis. In all six cases, PCNL cells showed immunohistochemical positivity for latent membrane protein 1 (LMP-1) and Epstein-Barr nuclear 2 (EBNA2). Lymphoma cells also showed positive signals for EBV-encoded small RNAs (EBERs) on in-situ hybridization. EBV subtyping-PCR analysis demonstrated that one case was EBNA 2B type and the other five cases were EBNA 2A type, and two cases were EBV wild-type and four cases showed 30-bp LMP-1 deletion by PCR analysis. It is therefore possible that LMP gene deletion or EBNA-2 strain type are important in the tumorigenesis of EBV-positive PCNLs. In addition, EBV-positive PCNLs in immunocompetent hosts may be related to immunological deterioration derived from the aging process.

Edaravone attenuates cerebral ischemic injury by suppressing aquaporin-4.

Aquaporin-4 (AQP4) plays a role in the generation of post-ischemic edema. Pharmacological modulation of AQP4 function may thus provide a novel therapeutic strategy for the treatment of stroke, tumor-associated edema, epilepsy, traumatic brain injury, and other disorders of the central nervous system (CNS) associated with altered brain water balance. Edaravone, a free radical scavenger, is used for the treatment of acute ischemic stroke (AIS) in Japan. In this study, edaravone significantly reduced the infarct area and improved the neurological deficit scores at 24h after reperfusion in a rat transient focal ischemia model. Furthermore, edaravone markedly reduced AQP4 immunoreactivity and protein levels in the cerebral infarct area. In light of observations that edaravone specifically inhibited AQP4 in a rat transient focal ischemia model, we propose that edaravone might reduce cerebral edema through the inhibition of AQP4 expression following cerebral infarction.

Minocycline attenuates both OGD-induced HMGB1 release and HMGB1-induced cell death in ischemic neuronal injury in PC12 cells.

High mobility group box-1 (HMGB1), a non-histone DNA-binding protein, is massively released into the extracellular space from neuronal cells after ischemic insult and exacerbates brain tissue damage in rats. Minocycline is a semisynthetic second-generation tetracycline antibiotic which has recently been shown to be a promising neuroprotective agent. In this study, we found that minocycline inhibited HMGB1 release in oxygen-glucose deprivation (OGD)-treated PC12 cells and triggered the activation of p38mitogen-activated protein kinase (MAPK) and extracellular signal-regulated kinases (ERK1/2). The ERK kinase (MEK)1/2 inhibitor U-0126 and p38MAPK inhibitor SB203580 blocked HMGB1 release in response to OGD. Furthermore, HMGB1 triggered cell death in a dose-dependent fashion. Minocycline significantly rescued HMGB1-induced cell death in a dose-dependent manner. In light of recent observations as well as the good safety profile of minocycline in humans, we propose that minocycline might play a potent neuroprotective role through the inhibition of HMGB1-induced neuronal cell death in cerebral infarction.

The free radical scavenger edaravone rescues rats from cerebral infarction by attenuating the release of high-mobility group box-1 in neuronal cells.

Edaravone, a potent free radical scavenger, is clinically used for the treatment of cerebral infarction in Japan. Here, we examined the effects of edaravone on the dynamics of high-mobility group box-1 (HMGB1), which is a key mediator of ischemic-induced brain damage, during a 48-h postischemia/reperfusion period in rats and in oxygen-glucose-deprived (OGD) PC12 cells. HMGB1 immunoreactivity was observed in both the cytoplasm and the periphery of cells in the cerebral infarction area 2 h after reperfusion. Intravenous administration of 3 and 6 mg/kg edaravone significantly inhibited nuclear translocation and HMGB1 release in the penumbra area and caused a 26.5 +/- 10.4 and 43.8 +/- 0.5% reduction, respectively, of the total infarct area at 24 h after reperfusion. Moreover, edaravone also decreased plasma HMGB1 levels. In vitro, edaravone dose-dependently (1-10 microM) suppressed OGD- and H(2)O(2)-induced HMGB1 release in PC12 cells. Furthermore, edaravone (3-30 microM) blocked HMGB1-triggered apoptosis in PC12 cells. Our findings suggest a novel neuroprotective mechanism for edaravone that abrogates the release of HMGB1.

Expression of CXCL12 on pseudopalisading cells and proliferating microvessels in glioblastomas: an accelerated growth factor in glioblastomas.

CXCL12, an alpha-chemokine that binds to G-protein-coupled CXCR4, plays an important and unique role in the regulation of stem/progenitor cell trafficking. To elucidate the correlation between the CXCR4/CXCL12 axis and glioblastomas (GBs), the present study assessed CXCR4/CXCL12 expression in 44 astrocytic tumor tissues using immunohistochemical analyses. Several cell lines of brain tumors were also analyzed by RT-PCR analyses. Although low-grade, astrocytic tumors were rarely positive for CXCL12 immunohistochemically, all GBs showed moderate to intense immunostaining with CXCL12, with particularly intense immunostaining being observed in the pseudopalisading cells and the proliferating microvessels. Regarding CXCR4, widespread positive immunoreactivity was noted in the tumor cells in almost all cases of GBs. In contrast, RT-PCR analysis showed low expression of CXCR4/CXCL12 in the aerophilic condition of GB cells and high expression of CXCR4/CXCL12 in the hypoxic condition of GB cells. Taken together, these results suggest that secretion of CXCR4/CXCL12 by hypoxic pseudopalisading and proliferating microvascular cells contributes to an outward migration of tumor cells away from hypoxia, creating a peripherally moving wave and subsequent microvascular proliferation. Pseudopalisades and proliferating microvessels are also considered to be associated with accelerated growth in GBs. These results indicate that expression of CXCL12 is an accelerated growth factor in GBs.

Effect of 35 degrees C hypothermia on intracranial pressure and clinical outcome in patients with severe traumatic brain injury.

BACKGROUND: From 1994, we have used therapeutic hypothermia in patients with severe traumatic brain injury (Glasgow Coma Scale scores of 5 or less). In 2000, we altered the target temperature to 35 degrees C from the former 33 degrees C, as our findings suggested that cooling to 35 degrees C is sufficient to control intracranial hypertension, and that hypothermia below 35 degrees C may predispose patients to persistent cumulative oxygen debt. We attempted to clarify whether 35 degrees C hypothermia has the same effect as 33 degrees C hypothermia in reducing intracranial hypertension and whether it is associated with fewer complications and improved outcomes. METHODS: We compared intracranial pressure (ICP) and biochemical parameters in the 30 patients treated with 35 degrees C hypothermia (January 2000 to June 2005) with those in the 31 patients treated with 33 degrees C hypothermia (July 1994 to December 1999). RESULTS: Patient characteristics were similar in the two groups. The mean temperature during hypothermia was 35.1 +/- 0.7 degrees C in the 35 degrees C hypothermia group and 33.4 +/- 0.8 degrees C in the 33 degrees C hypothermia group. Mean ICP was controlled under 20 mm Hg during hypothermia in both the 35 degrees C hypothermia and 33 degrees C hypothermia groups. The incidence of intracranial hypertension and low cerebral perfusion pressure did not differ between the two groups. The 35 degrees C hypothermic patients exhibited a significant improvement in the decline of serum potassium concentrations during hypothermia and in the increment of C-reactive protein after rewarming. The mortality rate and the incidence of systemic complications tended to be lower in the 35 degrees C group. CONCLUSIONS: Cooling patients to 35 degrees C is safe and the ICP reduction effects of 35 degrees C hypothermia are similar to those of 33 degrees C hypothermia.

Caspase-9 pathway activation by inhibiting endogenous fibroblast growth factor signaling in human glioma cells.

The cell survival activity of human glioma cells is largely dependent on autocrine fibroblast growth factor (FGF) signaling. Caspases, a family of cysteine proteases, play an integral part in the execution phase of apoptosis. To better understand the mechanism of resistance to apoptosis in human glioma cells, we investigated the effect of a blockade of endogenous FGF signaling through the expression of the dominant negative type I FGF receptor (DNFGFR) in U251MG cells. The cells were infected with adenovirus vector expressing DNFGFR (AdDNFGFR) and apoptosis was semi-quantified by the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling (TUNEL) method and flow cytometric annexin V assay. The activation of caspase-3, -8, and -9, the activation of Akt, a serine/threonine protein kinase, and the cleavage of poly(ADP-ribose) polymerase (PARP) were analyzed by immunoblotting. The infection with AdDNFGFR (multiplicity of infection of 200) induced marked apoptosis, along with a down-regulation of akt phosphorylation, and activation of caspase-9 and -3, but not -8. By contrast, LacZ virus (a control) had minimal effects. The level of the cleaved form of PARP was increased in a time-dependent fashion, and this increase was inhibited by adding Z-DEVD-FMK, a caspase-3 inhibitor, and Z-LEHD-FMK, a caspase-9 inhibitor. Moreover, ultraviolet exposure (100 J/m(2)) induced apoptosis and caspase-8, but not caspase-9, activation. Our data suggested that the induction of apoptosis through the inhibition of endogenous FGF signaling is caspase-9 pathway- dependent. The suppression of this or other specific anti-apoptotic pathways may lead to genetic or pharmacological manipulations that favorably modulate the malignant behavior of human gliomas.

Age-associated increases in poor outcomes after traumatic brain injury: a report from the Japan Neurotrauma Data Bank.

Age is an important factor influencing outcome after severe traumatic brain injury (TBI). In general, the older the victim, the higher the probability of a poor outcome. To investigate the mechanism underlying the link between age and outcome, the data for 797 patients enrolled in the Japan Neurotrauma Data Bank (JNTDB), aged 6 years or older, with Glasgow Coma Scale (GCS) scores of 8 or less on admission or deterioration to that level within 48 h of impact were analyzed. Thirty-eight percent of the patients were between the ages of 40 and 69 years, and 24% of the patients were older than 69 years. Older patients had higher rates of mortality and lower rates of favorable outcome. The frequency of mass lesions which were associated with poorer outcomes significantly increased with age, but regardless of the intracranial lesion type, older patients had poorer outcomes. The GCS score and the occurrence of systemic complications did not differ significantly according to age. Multiple systemic injury was less frequent in older patients. The varied occurrence of intracranial lesion types according to age is likely caused by the disparity between the young and aged brain in the progression of secondary brain injury. Alteration in the pathophysiological response, which is related to the development of secondary brain injury in the aging brain, probably contributes to more severe and irreversible brain damage in older patients, and is thus associated with poor outcomes.

Chordoid meningioma arising in the pineal region: a case report.

We report a rare case of chordoid meningioma arising in the pineal region, which presented in a 22-year-old woman. Her only complaint was headache, and neurological examination revealed no deficits. She had suffered from prolonged fever a few weeks earlier, and her hematological findings included hypochromic microcytic anemia and a high serum level of C-reactive protein (CRP). Cranial magnetic resonance (MR) images demonstrated a 25 x 30 mm mass in the pineal region, which showed iso-to low intensity on T1-weighted images (T1WI), high to low intensity on T2-weighted images (T2WI), and homogeneous enhancement with gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA). We performed subtotal removal of the tumor with an occipital transtentorial approach (OTA), and all her preoperative symptoms completely abated. Histological examination of this tumor specimen showed the typical pattern of chordoid meningioma. Chordoid meningioma has been known to correspond with Castleman's disease, and pineal meningiomas are extremely rare among intracranial meningiomas. The details of this case are presented with a review of the literature.

Pilot trial of the rate of response, safety, and tolerability of temozolomide and oral VP-16 in patients with recurrent or treatment-induced malignant central nervous system tumors.

BACKGROUND: The aim of this study was to determine the response and toxicity of patients with recurrent or treatment-induced brain tumors to TMZ and oral VP-16. METHODS: Eleven patients with recurrent or treatment-induced malignant CNS tumors, including treatment-induced PNET (in 1 patient), brainstem glioma (in 3 patients; 1 with treatment-induced, 2 with recurrence), recurrent anaplastic astrocytoma (in 3 patients), and recurrent glioblastoma (in 4 patients) were evaluated in a pilot study of TMZ and oral VP-16 chemotherapy. All patients received TMZ at 150 mg/m2 per day on days 1 to 5 and oral VP-16 at 50 mg/m2 per day on days 1 to 12. Cycles were repeated every 28 days. RESULTS: None experienced major acute toxicity related to TMZ and oral VP-16 during a total of 52 treatment courses. Five (45%) of 11 patients showed a PR to treatment. Among the 11 patients enrolled, 7 patients are alive with disease at a median of 9 months from time of study entry. The 6-month PFS is 45% (95% CI, 40%-74%). The histologic subtype of the tumor, its location, and its maximum response to chemotherapy did not have an impact on the duration of disease control. CONCLUSION: This limited pilot study confirms the innocuousness and the activity of the combination of TMZ and oral VP-16 in recurrent malignant brain tumors. This promising activity warrants further investigation of this combination in larger phase II or III studies.

Expression of cyclooxygenase-2 and vascular endothelial growth factor in primary central nervous system lymphomas.

Cyclooxygenase (COX) is the rate-limiting enzyme that catalyzes the initial step in biosynthesis of prostaglandins (PGs) from arachidonic acid. COX-2 has been associated with inflammatory processes and tumorigenesis. In order to investigate the correlation between VEGF, COX-2 expression, and tumorigenesis in primary central nervous system lymphomas (PCNSLs), the present study assessed 26 cases of PCNSL by immunostaining for VEGF and COX-2. Immunohistochemical studies were evaluated as follows: (-), no staining; (1+), 0-30% positive cells; (2+), 30-60% positive cells; (3+), >60% positive cells. VEGF expression was detected in 21 of 26 cases; of these, 14, 1 and 6 were scored as 3+, 2+ and 1+, respectively. COX-2 expression was detected in 22 of 26 cases; of these, 14, 4 and 4 were scored as 3+, 2+ and 1+, respectively. For double immunofluorescence, 20 of 26 cases that were detected with both VEGF and COX-2 were examined and almost all tumor cells coexpressed both VEGF and COX-2 in the examined cases. However, COX-2 and VEGF expression in PCNSLs did not correlate with neoangiogenesis and patient survival in the present study, in contrast to previous findings in systemic lymphomas. It is suggested that the high frequency of COX-2 and VEGF coexpression in PCNSLs may be associated with tumorigenesis of PCNSLs and could possibly lead to a future therapeutic trial of PCNSLs with selective COX-2 inhibitor therapy.

Impact of combination therapy with repeat surgery and temozolomide for recurrent or progressive glioblastoma multiforme: a prospective trial.

BACKGROUND: The purpose of this study is to evaluate the feasibility of repeat surgery combination with postoperative TMZ for adults with recurrent or progressive GBMs. METHODS: Of 35 patients who had diagnoses of GBM between 2002 and 2005, 7 (20%) underwent second surgeries and TMZ for recurrent or progressive disease. We examined the case histories of these 7 patients and determined the location of tumor and extent of their surgical procedures. Using the KPS, we assessed each patient's neurologic state before and after initial and repeat surgery. We calculated survival times from time of initial surgery and compared actual survival with statistically predicted survival times for each patient. RESULTS: Median survival rates were higher than predicted: The statistical risk estimate for median survival time after repeat surgery for these patients was 9 months; the actual survival time from initial operation until time of death averaged 15.1 months. The neurologic status before and after second surgery also averaged 76 points on KPS. Survival time did not depend on removing the entire tumor at initial and second surgery. CONCLUSION: Combination with repeat surgery and TMZ improved overall survival of these GBM patients.

[The influence of the primary management on the outcome of severe traumatic brain injury: role of neurosurgeons].

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.

[A rare case of intracranial meningioma with intratumoral metastatic breast cancers].

We report an uncommon case of breast cancer metastasis to an intracranial meningioma. A 47-year-old female was admitted to our hospital due to general convulsion. She had undergone a radical operation for left breast cancer 4 years refore, and received postoperative adjuvant therapies. MRI revealed a solid well-circumscribed tumor in the right frontal convexity. The patient underwent tumor resection successfully. The pathological examination revealed ductal carcinoma in the tissue of a transitional meningioma. Tumor-to tumor metastasis is a rare event. Literature review and discussion of such an uncommon occurrence was presented.

Granulocytic sarcoma: an unusual complication of acute promyelocytic leukemia causing cerebellar hemorrhage. Case report.

Granulocytic sarcomas are rare tumors that occur primarily in patients with acute myelogenous leukemia or other myeloproliferative disorders, are seldom seen in patients with acute promyelocytic leukemia (APL), and have never been reported to occur in the cerebellum. The authors describe the case of a patient with APL who harbored a hemorrhagic granulocytic sarcoma in the cerebellum. This 39-year-old woman presented with cerebellar ataxia. Magnetic resonance images revealed an intraaxial tumor in the cerebellum. Bone marrow samples showing infiltration by leukemic blast cells and data from hematological tests led to a diagnosis of APL. The patient was treated with chemotherapy and surgery. She had no response to chemotherapy and died of progressive intratumoral hemorrhage. Results of histopathological studies and immunohistochemical staining of the cerebellar tumor confirmed a granulocytic sarcoma. Flow cytometry showed that the blast cells were positive for leukocyte common antigen, CD13, and CD33 markers. Bone marrow cytogenetics revealed that the patient had a 46,XX karyotype. Although no cytogenetic abnormality was present, fluorescence in situ hybridization detected a chimeric fusion of PML and RARA. This is the first report to document a granulocytic sarcoma in the cerebellum as the primary presentation in a patient with APL and abnormal coagulation. As predicted by the unusual clinical manifestations and radiological findings, the patient's survival was short. Although central nervous system complications in patients with APL are rare, the data in this case highlight the need for individualized treatment when such conditions occur.

Regulation of vascular smooth muscle proliferation and migration by beta2-chimaerin, a non-protein kinase C phorbol ester receptor.

The proliferation and migration of vascular smooth muscle cells (SMC) are important aspects of atherogenesis. Activated growth factor signaling in injured vessels subsequently promotes a number of intracellular events resulting in the phenotypic modulation of SMC. Here, we investigated the role of beta2-chimaerin, a non-protein kinase C phorbol ester receptor with Rac-GTPase-activating protein activity, in growth factor-stimulated SMC. The endogenous expression of beta2-chimaerin was detected in cultured human SMC by reverse transcription-polymerase chain reaction and immunohistochemistry. Next, the overexpression of HA-tagged wild-type human beta2-chimaerin was attempted using cultured rat SMC with a recombinant adenovirus (Adv-beta2-Chim). Adv-LZ encoding beta-galactosidase (LacZ) was used as the control. The proliferation of SMC stimulated by platelet-derived growth factor (PDGF-BB, 10 ng/ml), as measured by cell-counting and 5-bromo-2'deoxyuridine incorporation assay, was suppressed by infection with Adv-beta2-Chim (50-200 MOI), but not with control viruses. PDGF-induced SMC migration was inhibited by approximately 25% after infection with Adv-beta2-Chim (200 MOI) using a modified Boyden's chamber assay with a fibronectin-coated membrane. Confocal microscopy revealed that PDGF stimulation altered the sub-cellular localization of beta2-chimaerin. The administration of 12-O-tetradecanoyl phorbol 13-acetate also induced changes in the sub-cellular localization of beta2-chimaerin, which was not affected by a presence of the PKC inhibitor (GF109203X). Finally, PDGF-induced Rac1 activation was found to be inhibited in the Adv-beta2-Chim-infected cells. Thus, we demonstrated that beta2-chimaerin regulates the proliferation and migration of SMC downstream of growth factor signaling pathway via the regulation of Rac1 activity. The signaling mediated by beta2-chimaerin may play a role in the regulation of SMC phenotypes, thereby implicating human atherogenesis.

Immunologic evaluation of personalized peptide vaccination for patients with advanced malignant glioma.

PURPOSE: The primary goal of this phase I study was to assess the safety and immunologic responses of personalized peptide vaccination for patients with advanced malignant glioma. EXPERIMENTAL DESIGN: Twenty-five patients with advanced malignant glioma (8 grade 3 and 17 grade 4 gliomas) were evaluated in a phase I clinical study of a personalized peptide vaccination. For personalized peptide vaccination, prevaccination peripheral blood mononuclear cells and plasma were provided to examine cellular and humoral responses to 25 or 23 peptides in HLA-A24+ or HLA-A2+ patients, respectively; then, only the reactive peptides (maximum of four) were used for in vivo administration. RESULTS: The protocols were well tolerated with local redness and swelling at the injection site in most cases. Twenty-one patients received more than six vaccinations and were evaluated for both immunologic and clinical responses. Increases in cellular or humoral responses specific to at least one of the vaccinated peptides were observed in the postvaccination (sixth) samples from 14 or 11 of 21 patients, respectively. More importantly, significant levels of peptide-specific IgG were detected in the postvaccination tumor cavity or spinal fluid of all of the tested patients who showed favorable clinical responses. Clinical responses were 5 partial responses, 8 cases of stable disease, and 8 cases of progressive disease. The median overall survival for patients with recurrent glioblastoma multiforme in this study (n = 17) was 622 days. CONCLUSIONS: Personalized peptide vaccinations were recommended for the further clinical study to malignant glioma patients.

Final report of the Japan Neurotrauma Data Bank project 1998-2001: 1,002 cases of traumatic brain injury.

A 4-year study (Japan Neurotrauma Data Bank) of the medical treatment of 1002 cases of traumatic brain injuries in Japan was conducted from 1998 to 2001 at 10 emergency medical centers. Patients with severe head injury were eligible for entry with a Glasgow Coma Scale score of 8 or less at admission. Patients who underwent craniotomy were also included. Children under 5 years old were excluded. An original data sheet with 392 items from multi-focal viewpoints, such as etiology of injury, pre-hospital care, initial treatment including neuro-intensive care unit, and surgical treatment, was created. The results show that the patient's age and mechanism of injury are the most important factors in the outcome.

[Clinical features and surgical results of chronic subdural hematoma in the extremely aged patients].

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.