Survey of Current Neurotrauma Treatment Practice in Japan

PEER-REVIEW REPORTS

Survey of Current Neurotrauma Treatment Practice in JapanEiichi Suehiro, Hirosuke Fujisawa, Hiroyasu Koizumi, Hiroshi Yoneda, Hideyuki Ishihara, Sadahiro Nomura,

Koji Kajiwara, Masami Fujii, Michiyasu Suzuki

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INTRODUCTION

The purpose of neurotrauma treatment is toprevent secondary brain damage after theinitial head injury. Neurosurgeons have todetermine their treatment strategy thinkingbroadly within the context of the complexityof the various conditions associated withbrain damage. Factors, such as initial braindamage, cerebral blood flow, brain metab-olism, brain edema, and various other gen-eral conditions, must be considered. There-fore, neurotrauma treatment is a suitableclinical training topic for young neurosur-geons. In recent years, however, establish-ment of emergency centers on a nationwidescale means that the neurotrauma patient istaken to and treated in emergency centers.Furthermore, in present day Japan, treat-ment is concluded in the emergency center.This has caused misgivings to arise as neu-rotrauma treatment has moved from theprovince of the neurosurgeon to the emer-gency doctor. In this situation, standard

Key words� Guidelines� Neurosurgeon� Survey� Traumatic brain injury

Abbreviations and AcronymsEM: Emergency departmentICP: Intracranial pressureMRI: Magnetic resonance imagingNS: Department of neurosurgerySjO2: Jugular venous oxygen saturationTBI: Traumatic brain injury

Department of Neurosurgery, YamaguchiUniversity School of Medicine,

Ube, Yamaguchi, Japan

To whom correspondence should be addressed:Eiichi Suehiro, M.D. [E-mail: [email protected]]

Citation: World Neurosurg. (2011) 75, 3/4:563-568.DOI: 10.1016/j.wneu.2010.09.013

Journal homepage: www.WORLDNEUROSURGERY.org

Available online: www.sciencedirect.com

1878-8750/$ - see front matter © 2011 Elsevier Inc.All rights reserved.

guidelines for management of severe trau- s

WORLD NEUROSURGERY 75 [3/4]: 563-5

atic brain injury (TBI) were announced in000 by the Japanese Society of Neurotrau-atology. Because large amounts of money

nd large numbers of staff are necessary foreurotrauma treatment, the quality of treat-ent greatly varies among facilities in Ja-

an. In this study, we investigated how neu-otrauma patients are treated and who arereating these patients in the medical cen-ers of Japan.

ATERIALS AND METHODS

questionnaire regarding management ofevere TBI was sent to each specialist train-ng medical center of the Japanese Neuro-

� BACKGROUND: The Japanese Soguidelines for management of severeevaluate subsequent implementation osevere TBI practices in Japan.

� METHODS: A questionnaire regardieach of the 384 Japanese Neurosurgcenters and answers were received b

� RESULTS: Of the medical centers, 29department. Initial TBI treatment respNeurosurgery in 34% of the medical29%, and in 36% responsibility is assperformed by neurosurgeons in 90% oment was assigned to neurosurgeonsimaging was done in 52% of the centinserted in 55%, and jugular venousHypothermia therapy was performed inadministered in 76%, and barbituratecenters, 94% acknowledged the guidemented protocols that conformed to th

� CONCLUSIONS: Neurosurgeons inment of severe TBI, but few medical cecenters find it difficult to conform to thand equipment. These problems can bgeons into centralized centers andsystem.

urgical Society (384 facilities) in October i

68, MARCH/APRIL 2011 ww

008. The selection type questionnaire wasesigned to be easily answered and con-isted of 21 questions (Figure 1). Answersere received by the respondent returning

he answered form in the enclosed self-ad-ressed envelope. The collected answersere totaled, and conformity to the guide-

ines in management of TBI patients setorth by the Society were assessed with re-pect to the department charged with thenitial treatment of TBI patients, surgeryerformance, and postoperative manage-ent. These results were classified as per

acility scale (i.e., secondary or tertiaryedical service centers). The problems as-

ociated with a facility’s scale were exam-

y of Neurotraumatology announcedumatic brain injury (TBI) in 2000. Tose guidelines, we investigated current

anagement of severe TBI was sent toSociety specialist training medicalil from 233 centers (60.7%).

ave neurosurgeons in their emergencyibility resided in the Departments ofers, in the emergency department ind to both departments. Surgery was

centers and postoperative manage-6%. Acute stage magnetic resonanceAn intracranial pressure sensor wasen saturation was measured in 21%., positive normothermia therapy was

apy was administered in 70%. Of thes but only 72% of the centers imple-idelines.

n are positively involved in manage-s monitor TBI patients. Many medicalidelines due to lack of neurosurgeonsdressed by consolidation of neurosur-rovement of the medical insurance

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PEER-REVIEW REPORTS

EIICHI SUEHIRO ET AL. NEUROTRAUMA TREATMENT IN JAPAN

RESULTS

Questionnaire RecoveryAnswers were obtained from 233 specialisttraining medical centers of the Japanese Neu-rosurgical Society after sending out the ques-tionnaire to 384 centers. Recovery percentageof the questionnaire was thus 60.7%.

The largest respondent group was ter-tiary medical service centers (135 centers),

Please answer the following question.

1. Is your hospital a secondary or tertiary medical serv

2. Does your facility have an emergency center?: Yes

a. Does your emergency center have neurosurgeo

3. Does your facility have an ICU?: Yes / No

4. Initial treatment of TBI patients : Emergency docto

5. Surgery for TBI patients: Emergency doctors / Neu

6. Postoperative management: Emergency doctors / N

7. MRI in the acute stage for TBI patients: Yes / No /

8. An intracranial pressure monitor: Yes / No (Reason

9. Jugular venous oxygen saturation monitor: Yes /

doctors)

10. Hypothermia therapy: Yes / No (Reason: no signifi

11. Positive normothermia therapy: Yes / No (Reason:

12. Barbiturate therapy: Yes / No (Reason: no significa

13. Emphasis on guideline for TBI management: Yes /

14. Conformance to guideline: Yes / No (Reason: no

15. Your facility’s name

Please send the answered form back with the enclos

Figure 1. The questionna

Table 1. Emergency Centers

Emergency center content Ye

No

Bl

Neurosurgeons in the emergency center Ye

No

Blank

564 www.SCIENCEDIRECT.com

ollowed by secondary medical centers (91enters). Answers were obtained from 71niversity hospitals.

mergency Centersf all facilities, 51% have an emergency

enter (Table 1). Specifically, the percent-ge having an emergency center in tertiaryedical service centers was 80% (Table 1).

nter? : Secondary / Tertiary

belong exclusively to the center?: Yes / No

urosurgeons / Combination

eons / Combination

rgeons / Combination

ssible

gnificance / equipment shortage / lack of doctors)

eason: no significance /equipment shortage / lack of

equipment shortage / lack of doctors)

ificance / equipment shortage / lack of doctors)

quipment shortage / lack of doctors)

cance / equipment shortage / lack of doctors)

-addressed envelope.

sisted of 21 questions.

All CentersSecondary Medical

Service Centers

120 (51%) 10 (11%)

111 (48%) 80 (88%)

2 (1%) 1 (1%)

67 (29%) 6 (7%)

118 (50%) 46 (50%)

48 (21%) 39 (43%)

WORLD NEUROSURGE

f the emergency centers, 29% have neuro-urgeons belonging exclusively to the cen-er (Table 1). In tertiary medical service cen-ers, 44% of the emergency centers haveeurosurgeons (Table 1).

epartments Responsible for TBIreatmentnitial treatment of TBI patients was the re-ponsibility of the department of neurosur-ery (NS) in 34% of the medical centers, themergency department (EM) in 29%, and aombination of these departments in 36%Table 2). The percentage of EM involve-

ent in TBI has increased to 39% in tertiaryedical service centers (Table 2). Surgeryas performed by neurosurgeons at 90%

nd EM physicians in 4% of the facilitiesTable 2). In tertiary medical service cen-ers, operations were done by NS doctors5% of the time and by EM doctors 7% ofhe time (Table 2). However, all patientsho were managed only in EM were alsoperated on by EM neurosurgeons. Postop-rative management was performed by NShysicians in 76% and EM doctors in 11%Table 2). EM doctors managed postopera-ive patients in 19% of tertiary medical ser-ice centers (Table 2).

ontent of TBI Treatmentn 52% of the medical centers, magneticesonance imaging (MRI) was done on neu-otrauma patients in the acute stage (Table). An intracranial pressure (ICP) sensoras inserted in TBI patients in 55% of all

acilities, and in 73% of tertiary medicalervice centers (Table 3). This treatmentas not considered significant and notone in 26% of the treatment centers (Table). Other reasons for nontreatment were

ertiary Medicalervice Centers University Hospitals

108 (80%) 47 (66%)

26 (19%) 24 (34%)

1 (1%) 0 (0)

59 (44%) 39 (55%)

68 (50%) 26 (37%)

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RY, DOI:10.1016/j.wneu.2010.09.013

PEER-REVIEW REPORTS


Table 2. Departments Responsible for TBI Treatment


Service CentersTertiary MedicalService Centers University Hospitals

Initial treatment Emergency medicine 67 (29%) 15 (16%) 52 (39%) 28 (39%)

Neurosurgery 80 (34%) 56 (62%) 63 (46%) 10 (14%)

Combination 84 (36%) 19 (21%) 20 (15%) 33 (47%)

Blank 2 (1%) 1 (1%) 0 (0) 0 (0)

Surgery Emergency medicine 10 (4%) 0 (0) 10 (7%) 8 (11%)

Neurosurgery 210 (90%) 90 (99%) 114 (85%) 55 (78%)

Combination 11 (5%) 0 (0) 11 (8%) 8 (11%)

Blank 2 (1%) 1 (1%) 0 (0) 0 (0)

Postoperative management Emergency medicine 25 (11%) 0 (0) 25 (19%) 20 (28%)

Neurosurgery 177 (76%) 86 (95%) 86 (63%) 39 (55%)

ICU 7 (3%) 2 (2%) 5 (4%) 2 (3%)

Combination 22 (9%) 3 (3%) 18 (13%) 10 (14%)

Blank 2 (1%) 0 (0) 1 (1%) 0 (0)

TBI, traumatic brain injury; ICU, intensive care unit.

Table 3. Content of TBI Treatment


Service CentersTertiary MedicalService Centers University Hospitals

MRI in the acute stage Yes 120 (52%) 54 (60%) 62 (46%) 37 (53%)

No 99 (42%) 34 (37%) 63 (46%) 27 (38%)

Not possible 12 (5%) 3 (3%) 9 (7%) 6 (8%)

Blank 2 (1%) 0 (0) 1 (1%) 1 (1%)

ICP sensor Yes 126 (55%) 26 (29%) 98 (73%) 55 (77%)

No 106 (45%) 65 (71%) 37 (27%) 16 (23%)

Blank 1 (0) 0 (0) 0 (0) 0 (0)

SjO2 monitoring Yes 50 (21%) 6 (7%) 42 (31%) 30 (42%)

No 182 (79%) 85 (93%) 93 (69%) 41 (58%)

Blank 1 (0) 0 (0) 0 (0) 0 (0)

Hypothermia therapy Yes 109 (47%) 28 (31%) 79 (58%) 44 (62%)

No 122 (52%) 63 (69%) 55 (41%) 26 (37%)

Blank 2 (1%) 0 (0) 1 (1%) 1 (1%)

Positive normothermia therapy Yes 176 (76%) 54 (59%) 119 (89%) 62 (87%)

No 52 (22%) 36 (40%) 14 (10%) 7 (10%)

Blank 5 (2%) 1 (1%) 2 (1%) 2 (3%)

Barbiturate therapy Yes 162 (70%) 66 (73%) 92 (68%) 53 (75%)

No 70 (30%) 25 (27%) 43 (32%) 18 (25%)

Blank 1 (0) 0 (0) 0 (0) 0 (0)

TBI, traumatic brain injury; MRI, magnetic resonance imaging; ICP, intracranial pressure; SjO2, jugular venous oxygen saturation.

WORLD NEUROSURGERY 75 [3/4]: 563-568, MARCH/APRIL 2011 www.WORLDNEUROSURGERY.org 565

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PEER-REVIEW REPORTS


equipment shortages in 33%, and a lack ofneurosurgeons in 34% (Table 4). Jugularvenous oxygen saturation (SjO2) was mea-sured as a monitor of TBI in only 21% of allcenters, and even in only 31% of the tertiarymedical service centers (Table 3). The rea-sons for not using SjO2 measurement werethat it was considered to be of no signifi-cance in 29%, equipment shortages in 35%,and a lack of neurosurgeons in 26% (Table4). Hypothermia therapy for neuroprotec-tion in TBI was performed in 47% of thecenters, and in 58% of the tertiary medicalservice centers (Table 3). Reasons for notintroducing hypothermia therapy includethat it was considered of no significance in39%, equipment shortages in 20%, and alack of neurosurgeons in 32% (Table 4).The rate that the treatment was consideredof no significance increased to 52% in ter-tiary medical service centers (Table 4). Pos-itive normothermia therapy was adminis-

Table 4. Reasons for No Treatment

ICP sensor No significan

Equipment sh

Lack of docto

Blank

SjO2 monitoring No significan

Equipment sh

Lack of docto

Blank

Hypothermia therapy No significan

Equipment sh

Lack of docto

Blank

Positive normothermia therapy No significan

Equipment sh

Lack of docto

Blank

Barbiturate therapy No significan

Equipment sh

Lack of docto

Blank

ICP, intracranial pressure; SjO2, jugular venous oxygen sa

tered in 76% of all centers, and in 89% of a


ertiary medical service centers (Table 3).he reasons for not introducing positiveormothermia therapy seem to be the sames for hypothermia therapy—no signifi-ance in 35%, equipment shortages in 19%,nd a lack of neurosurgeons in 27% (Table). Barbiturate therapy was given to TBI pa-ients in 70% of centers (Table 3). However,he significance of this therapy was not ac-nowledged (Table 4).

uidelines for TBI Managementhe guidelines were acknowledged by 94%f the medical centers (Table 5), but only2% of the centers used protocols that con-ormed to the guidelines (Table 5). Theuidelines were conformed to by 81% of the

ertiary medical service centers (Table 5).easons that the medical centers did not orould not conform to the guidelines wereo significance in 14%, equipment short-


Service Centers

34 (26%) 17 (21%)

42 (33%) 31 (38%)

44 (34%) 29 (36%)

9 (7%) 4 (5%)

60 (29%) 20 (20%)

73 (35%) 45 (45%)

55 (26%) 27 (27%)

20 (10%) 8 (8%)

58 (39%) 22 (28%)

30 (20%) 23 (29%)

48 (32%) 28 (35%)

14 (9%) 6 (8%)

21 (35%) 11 (21%)

12 (19%) 19 (37%)

17 (27%) 12 (23%)

12 (19%) 10 (19%)

42 (61%) 15 (55%)

3 (4%) 3 (11%)

8 (11%) 5 (19%)

17 (24%) 4 (15%)

.

ges in 27%, and a lack of neurosurgeons in

WORLD NEUROSURGE

3% (Table 5). Percentages in tertiary med-cal service centers were no significance in2%, equipment shortages in 19%, and aack of neurosurgeons in 50% (Table 5).

DiscussionLarge amounts of medical resources andmanpower are necessary for the treatmentof severe TBI. Therefore, it is worrisomethat neurosurgeons are parting from TBItreatment because prognosis in severe TBIis difficult and TBI treatments are complex(1). Complex TBI conditions deteriorateeasily under general medical control. Theexclusive knowledge and the experience ofneurosurgeons are crucially important forTBI treatment. The alleviation of busyschedules and improvement in labor condi-tions for neurosurgeons are needed to solvethese problems. An efficient system of TBItreatment is needed. In the present study,

ertiary MedicalService Centers University Hospitals

15 (35%) 2 (11%)

10 (23%) 6 (32%)

14 (33%) 8 (41%)

4 (9%) 3 (16%)

39 (37%) 13 (29%)

27 (26%) 12 (27%)

27 (26%) 15 (33%)

11 (11%) 5 (11%)

34 (52%) 16 (54%)

6 (9%) 3 (10%)

18 (28%) 7 (23%)

7 (11%) 4 (13%)

8 (49%) 3 (30%)

2 (13%) 3 (30%)

3 (19%) 2 (20%)

3 (19%) 2 (20%)

26 (64%) 12 (75%)

0 (0) 0 (0)

3 (7%) 1 (6%)

12 (29%) 3 (19%)

T

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we surveyed the current state of Japanese

RY, DOI:10.1016/j.wneu.2010.09.013

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PEER-REVIEW REPORTS


TBI treatment by questionnaire so as to gar-ner information that can be used to build anew system of TBI treatment.

The majority of respondents to this ques-tionnaire survey were tertiary medical servicecenters. As such, it seemed that this question-naire survey was able to sample enough severeTBI centers to provide representative viewsand practices. The high recovery percentagefor all centers was obtained as well in thisquestionnaire survey, which indicates that theresults of the survey reflect the current state ofTBI treatment in Japan.

Tertiary medical service centers have emer-gency centers more frequently than do sec-ondary medical service centers. A numerousstaff including doctors and nurses of variousspecialties and current-enhanced medicaltreatment instrumentation are needed tomanage and maintain emergency centers.Therefore, it seemed that only large-scalehospital tertiary medical service centers areable to operate emergency centers. Stroke,cardiac infarction, and severe trauma are of-ten looked after in emergency centers. Neuro-surgeons and circulatory surgeons have im-portant roles in emergency centers. Thelikelihood for the need of a neurosurgeon isvery great in emergency centers. However,only 29% of the emergency centers have anexclusively dedicated neurosurgeon on staff.This observation is indicative of the low sup-ply of available neurosurgeons in emergencycenters despite the high need for the neuro-surgeon’s skills in Japan.

Neurosurgeons often took charge of ini-tial TBI treatment alone, even in tertiary

Table 5. Guidelines

Emphasis on guidelines Yes

No

Blank

Conformance to guidelines Yes

No

Blank

Reasons for not conformingto guidelines

No significance

Equipment sho

Lack of doctors

Blank

medical service centers that have EM doc- o

WORLD NEUROSURGERY 75 [3/4]: 563-5

ors. The minimum goal of trauma treat-ent is to evade “preventable trauma

eath.” Initial treatment of trauma is verymportant to gain high recovery rates afterifesaving methods. When two or more dif-erent departmental doctors, with high de-rees of specialization, gather in the initial

reatment phase, there is confusion. Initialreatment of trauma should be performedy a medical team that centers around theM doctors. They have the most extensive

rauma treatment training. Such systemicoles are necessary to improve the busychedules of the neurosurgeons. On thether hand, a high degree of professional-

sm, specialization, and experience is de-anded to operate on TBI patients. It is

enerally considered that a TBI operation issimple craniotomy that can be performedy young neurosurgeons. However, it is noto simple. The pathophysiology of TBI dif-ers according to individual cases and isomplex (1). Even in cases where imagesook similar, factors outside the cranium,uch as hypotension, hypoxia, and hyper-apnia, or factors inside the cranium areifferent. If surgeons performing the oper-tions do not understand all these factorsefore surgery, the control of factors, suchs acute brain edema or sudden cardiac ar-est, can become difficult during surgery.his questionnaire survey revealed that TBIperations were only performed by EM doc-

ors in 10 facilities. However, all of theseoctors were specialists in neurosurgery.BI operations were performed mainly byeurosurgery specialists in Japan. Yet post-


Service Centers

217 (94%) 83 (91%)

15 (6%) 8 (9%)

1 (0) 0 (0)

168 (72%) 53 (58%)

63 (27%) 37 (41%)

2 (1%) 1 (1%)

10 (14%) 6 (13%)

20 (27%) 14 (31%)

31 (43%) 17 (38%)

12 (16%) 8 (18%)

perative management was performed only n

68, MARCH/APRIL 2011 ww

y EM in 19% of the tertiary medical serviceenters. Such a role for the neurosurgeonsoes contribute to effective systems of treat-ent. However, re-craniotomy of TBI pa-

ients is common due to of exacerbation ofrain edema or rebleeding of the injuredrain. Neurosurgeons should at least jointly

ake part in postoperative management.Next, the content of TBI treatment in Ja-

an was examined. The rate of ICP moni-oring was not high, even in universityospitals. ICP measurement during TBI treat-ent is recommended in standard guide-

ines for management of severe TBI in Ja-an. The management of ICP is important

n that ICP influences TBI outcome (7, 13).ur survey reveals a disconnect between the

eality of practice and the ideal. One reasonor this disconnect is that the ICP monitor-ng instrument cannot be purchased, evenn university hospitals, because the inclu-ive payment system has been introducedor acute medical treatment in Japan. The

ore advanced medical treatment these fa-ilities perform, the more they show a loss,herefore, advanced medical treatment haseen simplified. Furthermore, doctors at

ertiary medical service centers do not be-ieve that measuring ICP is important. Theyhink that repeated computed tomographyxaminations are enough to manage ICP inhe TBI treatment. As a result, we need tonlighten practitioners as to the effective-ess of ICP monitoring in TBI treatment.n the other hand, it has been noted that

he enforcement rate of SjO2 monitoringas been low, and that such monitoring has

ertiary Medicalervice Centers University Hospitals

128 (95%) 68 (96%)

7 (5%) 3 (4%)

0 (0) 0 (0)

110 (81%) 66 (93%)

25 (19%) 5 (7%)

0 (0) 0 (0)

3 (12%) 0 (0)

5 (19%) 1 (17%)

13 (50%) 4 (66%)

5 (19%) 1 (17%)

TS

rtage

ot become common. The reasons are the

w.WORLDNEUROSURGERY.org 567

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PEER-REVIEW REPORTS


same as in the case of the ICP monitoring.Education as to the effectiveness of SjO2

monitoring and the improvement of costperformance are necessary. The enforce-ment rate of MRI use in the acute stage ofTBI exceeds half and it has been noted thatMRI examination is now a common prac-tice for TBI in Japan. Recently the effective-ness of MRI in diffuse axonal injury hasbeen reported (5, 15). It seemed that diffuseaxonal injury is positively diagnosed in theacute stage in Japan. Therapeutic hypother-mia for TBI is not commonly performed inJapan, due to the strong influence of nega-tive trial results for therapeutic hypother-mia (2). However, 62% and 75% of the uni-versity hospitals are still using hypothermiaand barbiturate therapy for TBI, respec-tively, because there is no other treatmentmethod for ICP management. Positive nor-mothermia therapy was commonly done,especially at tertiary medical service cen-ters. Positive normothermia therapy has be-come a standard treatment for TBI patientsin Japan. The importance of brain tempera-ture management has been universally rec-ognized (11). It is now a settled issue to usenormothermia therapy to avoid the compli-cation of hypothermia. Positive normother-mia therapy data and future reports on theoutcome of positive normothermia from Ja-pan are greatly anticipated.

Although the standard guidelines for man-agement of severe TBI were well known inJapan, the percentage of facilities that con-form to the guidelines was low. The conform-ing rate was only as high as 81%, even in ter-tiary medical service centers. There weremany facilities where a lack of neurosurgeonsand equipment shortages were cited as thereason for nonconformance. As described atthe beginning of this article, many medicalresources and a high number of staff are nec-essary for neurotrauma treatment. However,the more that a facility accommodates pa-tients under the current medical insurance re-gime in Japan, the more such a facility willshow a loss. As a result, facilities are not ableto invest in the needed medical equipment. Itis understood to not give priority to neu-rotrauma treatment with such little profit,while neurosurgeons are run down by theroutine. Therefore future measures areneeded to develop and support the ability tocarry out neurotrauma treatment. The keyconcepts are fulfillment of equipment needs
and a reversal of the manpower shortage. One

olution is to secure fiscal resources by revis-ng the medical insurance regime. The estab-ishment of specific trauma centers and theonsolidation of patients and medical staff touch trauma centers are necessary for efficientperation.

The frequency of monitoring or confor-ance to guidelines was not high in other

ountries as well (6, 9, 10). In United Statesrauma centers, routine ICP monitoring useas 50.8%, and conformance to the guide-

ines was 33% in 2000 (6). Furthermore, ac-ording to a survey in the United Kingdomnd Ireland, ICP was only monitored routinelyt a rate of 57% and SjO2 monitoring was

rarely used (10). Only 68% of the centers had aprotocol for the treatment of ICP (10). How-ever, decreased mortality and improved out-come for severe TBI patients was reportedwith the use of the guidelines (4, 8, 12, 14).Since the implementation of guidelines inUnited States (6), the use of the ICP monitor-ing has increased to 77.4%. Savings in costswith the use of the guidelines were also re-ported (3). A similar verification is necessaryfor Japan if the guidelines are to be inforced.

Neurotrauma treatment in Japan wasfirmly and positively performed by neuro-surgeons at its medical centers. However,appropriate roles are necessary to define inthe context of EM and NS to develop a newand effective neurotrauma treatment sys-tem. It was difficult for centers to conformto the guidelines because of equipmentshortages and the manpower shortage. It isnecessary to fulfill equipment needs and re-verse the manpower shortage to improveneurotrauma treatment in Japan. To achievethis, maintenance of the medical insuranceregime and neurosurgeon consolidationare recommended.

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2. Clifton GL, Miller ER, Choi SC, Levin HS, McCauleyS, Smith KR Jr, Muizelaar JP, Wagner FC Jr, MarionDW, Luerssen TG, Chesnut RM, Schwartz M: Lackof effect of induction of hypothermia after acutebrain injury. N Engl J Med 344:556-563, 2001.

3. Faul M, Wald MM, Rutland-Brown W, Sullivent EE,Sattin RW: Using a cost-benefit analysis to estimate
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WORLD NEUROSURGE

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1. Puccio AM, Fischer MR, Jankowitz BT, Yonas H,Darby JM, Okonkwo DO: Induced normothermia at-tenuates intracranial hypertension and reduces feverburden after severe traumatic brain injury. NeurocritCare 11:82-87, 2009.

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onflict of interest statement: The authors declare that therticle content was composed in the absence of anyommercial or financial relationships that could beonstrued as a potential conflict of interest.

eceived 02 June 2010; accepted 13 September 2010

itation: World Neurosurg. (2011) 75, 3/4:563-568.OI: 10.1016/j.wneu.2010.09.013

ournal homepage: www.WORLDNEUROSURGERY.org

vailable online: www.sciencedirect.com

878-8750/$ - see front matter © 2011 Elsevier Inc.
ll rights reserved.
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Survey of Current Neurotrauma Treatment Practice in Japan