Cerebral contusions and traumatic intracerebral hematomas, where the brain tissue itself is damaged by a strong impact, are life-threatening emergencies that profoundly affect a patient’s future. Treatment proceeds according to the severity of the injury, evaluated using the Glasgow Coma Scale (GCS). Depending on the size of the hematoma, emergency surgery may be mandatory.
This article focuses on direct brain tissue injuries, detailing GCS-based treatment principles and surgical indications. Furthermore, we discuss the practicalities of the Japanese medical fee system regarding rehabilitation time limits and the prognosis of long-term aftereffects, such as Higher Brain Function Disorders.
Direct Brain Tissue Injury (Cerebral Contusion & Traumatic Intracerebral Hematoma)
1. Treatment Principles
Management varies significantly based on the severity of the injury (consciousness level and imaging findings). The Glasgow Coma Scale (GCS) is the global standard for this evaluation.
| Severity (GCS) | Management & Treatment |
| Mild (GCS 13–15) | Observation (Conservative Treatment): Bed rest, medication for headache/nausea, and strict neurological monitoring for changes in consciousness. |
| Moderate (GCS 9–12) | Strict Hospital Observation: Management to prevent increased intracranial pressure (ICP), fluid restriction, and consideration for ICP monitoring or prophylactic surgery. |
| Severe (GCS 3–8) | Intensive Care (ICU) & Surgery: Intubation, mechanical ventilation, and pharmacological treatment for ICP (e.g., osmotic diuretics). Immediate surgery if indicated. |
Surgical Indications
Surgery (such as hematoma evacuation or decompressive craniectomy) is considered for traumatic intracerebral hematomas or contusions under the following conditions:
- Hematoma diameter is 1–2 cm or larger, or volume is 20–30 ml or more.
- Presence of a midline shift (displacement of the brain’s center line).
- Progressive or worsening neurological symptoms.
- Severe impairment of consciousness (GCS 3–8).
2. Medical Fees and Hospitalization (Japan Context)
In the Japanese medical fee system, cerebral contusions are treated as Traumatic Brain Injuries (TBI). The maximum number of days for insurance-covered rehabilitation is a critical factor:
- Acute Phase Hospitalization: While it depends on severity, data suggests roughly 16 days as a general benchmark.
- Recovery Phase Rehabilitation Ward: For conditions classified as “Cerebrovascular Disease, etc.,” the standard limit for calculating rehabilitation fees is 150 days.
- Complex Cases: If accompanied by multiple trauma, the limit may extend to 180 days.
- Note: Since cerebral contusions fall under “Head Trauma,” disputes sometimes arise regarding whether the patient can secure the same rehabilitation duration as cerebrovascular stroke patients, especially when Higher Brain Function Disorders are present.
3. Prognosis and Aftereffects
The long-term outlook depends heavily on the initial GCS score and the presence of associated injuries.
Prognosis Outlook:
- High Initial GCS: Generally correlates with a better recovery.
- Mild Contusions: Typically recover within weeks to months.
- Moderate to Severe Contusions: Often require long-term treatment and rehabilitation, with a high likelihood of permanent disability.
Major Aftereffects (Disabilities):
Depending on the location and extent of the damage, the following neurological symptoms may persist:
| Type of Disability | Examples of Symptoms |
| Higher Brain Function Disorder | Memory impairment, attention deficit, executive dysfunction (difficulty planning), emotional dysregulation, and personality changes. |
| Motor Disorders | Hemiplegia (paralysis on one side), gait disturbance, or loss of coordination. |
| Sensory Disorders | Visual field constriction or sensory numbness. |
| Others | Traumatic epilepsy, chronic headaches, and dizziness. |
Disability Ratings (e.g., Traffic Accidents):
In cases involving traffic accidents, a Disability Grade is assigned once the condition has stabilized (Symptom Fixation).
- Serious Higher Brain Function Disorders may be assigned severe grades (Grade 1 to 7).
- For example, a Grade 12 rating generally represents a 14% loss of labor capacity.
Summary
The diagnosis and treatment of cerebral contusions are not only medical emergencies but also require a long-term plan for rehabilitation and social reintegration.
