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Our surgical procedure is safe and effective when performed with strict operative indications. Endoscopic surgery for ASDH in elderly adults may be an alternative to a large craniotomy in simple-type hematomas.

Background and purpose It is sometimes difficult to diagnose intracranial vertebral artery dissection in patients with headache as the only symptom. Knowledge of the characteristics of the headache would facilitate the diagnosis. In this study, we aimed to clarify the characteristics of intracranial vertebral artery dissection-related headache using our original self-administered questionnaire. Methods Via the questionnaire, we ascertained headache characteristics and investigated whether they differed between two types of unruptured intracranial vertebral artery dissection, headache type and ischemic type, based on analysis of the responses. Then, we tried to validate the consistency of commonly used criteria for intracranial artery dissection by comparing them with our results. Results Thirty-seven patients were analyzed. Our results identified the following seven headache characteristics in patients with intracranial vertebral artery dissection: (i) occurring in the occipitonuchal region (89%); (ii) unilateral (81%); (iii) pulsatile (70%); (iv) of acute onset (70%); (v) severe (73%); (vi) without nausea or vomiting (73%); and (vii) with concomitant clinical symptoms unrelated to ischemia (81%). Comparison of headache characteristics between the two types of intracranial vertebral artery dissection headache showed that the pain was significantly more severe in headache type than ischemic type intracranial vertebral artery dissection ( p = 0.01). Concomitant clinical symptoms occurred significantly more often in ischemic type than headache type intracranial vertebral artery dissection ( p = 0.03). Our results generally satisfied the established headache diagnostic criteria. Conclusion The pain characteristics of headache type and ischemic type intracranial vertebral artery dissection shown in our study may facilitate its diagnosis.

Chronic subdural hematoma (CSDH) with brain herniation signs is rarely seen in the emergent department. As such, there are few cumulative data to analyze such cases. In this study, we evaluated the clinical features, risk factors, and rates of completion with impending brain herniation on arrival in a cohort study. We analyzed 492 consecutive patients with CSDH between January 2010 and October 2015. First, we analyzed the clinical factors and compared them between patients with or without brain herniation signs on admission. Second, we compared clinical factors between patients with or without completion of brain herniation after operation among patients who had brain herniation signs on arrival. Eleven (2.2%) patients showed brain herniation signs on arrival, and six patients (1.2%) progressed to complete brain herniation. Patients with brain herniation signs on arrival were significantly older (P = 0.03) and more frequently hospitalized with a concomitant illness (P < 0.0001). Niveau formation (P = 0.0005) and acute-on CSDH (P = 0.0001) on computed tomography were also more frequently seen in patients with brain herniation signs. Multivariate logistic regression analysis showed that age older than 75 years (OR 2.16, P < 0.0001), niveau formation (OR 3.09, P < 0.0001), acute-on CSDH (OR 14, P < 0.0001), and admitted to another hospital (OR 52.6, P < 0.0001) were independent risk factors for having had brain herniation signs on arrival. On the other hand, having a history of head injury (P = 0.02) and disappearance of the ambient cistern (P = 0.0009) were significantly associated with completion of brain herniation. The prognosis was generally poor if the patient had presented with brain herniation signs on admission. Our results demonstrate that the diagnosis is often made late, despite hospitalization for a concomitant illness. When the elderly show mild disturbance of consciousness, physicians except neurosurgeons need to consider the possibility of CSDH regardless of a recent history of head injury.