Case Report

Acute Subdural Hematoma in a Judo Player with Repeated Head Injuries

Hiroshi Yokota and Yuki Ida

Key words - BACKGROUND: Acute subdural hematoma (ASDH) is the most important
- Acute subdural hematoma cause of severe head injuries occurring during judo practice in Japan. Repeated
- Concussion
- Head injury
head injuries have been reported as a cause of fatal ASDH, although the
- Judo mechanism remains unknown.
Abbreviations and Acronyms - CASE DESCRIPTION: A 16-year-old boy visited an emergency department
ASDH: Acute subdural hematoma with vomiting 3 days after a strong blow to the occipital region during judo
CT: Computed tomography practice. Although computed tomography was performed at that time, a small
SIS: Second impact syndrome
interhemispheric ASDH was overlooked. The patient sustained another head
Department of Neurosurgery, Nabari City Hospital, Nabari, injury 19 days after the first, which led to convulsions and disturbance of con-
Mie, Japan sciousness. The ASDH was increased in size on computed tomography. We
To whom correspondence should be addressed: performed a surgical evacuation, which revealed tearing of a bridging vein, after
Hiroshi Yokota, M.D.
[E-mail: hyokota0001@gmail.com] which the patient showed a good recovery.
Citation: World Neurosurg. (2016). - CONCLUSIONS: It is important to be aware of the possibility of a small ASDH
http://dx.doi.org/10.1016/j.wneu.2016.03.101
in concussed judo players after an initial impact, which may lead to subsequent
Journal homepage: www.WORLDNEUROSURGERY.org
fatal ASDH after another impact incident.
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2015 Elsevier Inc.
All rights reserved.

INTRODUCTION
The pathogenesis of fatal sport-related
repeated head injury cases in young ath-
letes is controversial. In Japan, fatalities
after a severe head injury during judo
practice are reported increasingly and
becoming an issue of public concern.1,2
In 2012, judo was introduced as a
required subject for junior high school
students, which has caused concern in
regard to safety2; however, physicians,
judo players, participants, and their
families, coaches, and school teachers
have not received adequate education
regarding potential problems associated
with repeated head injuries that occur
during judo practice. Here, we present
a case of acute subdural hematoma
(ASDH) that developed and increased in
size in a judo player with repeated head
injuries. In addition, the possibility of
fatal pathogenesis associated with
repeated head injuries occurring during
judo participation is discussed.
CASE DESCRIPTION
A 16-year-old boy who began judo
training 8 months previously received a
strong blow to the occipital region during
a practice session. Three days later, he
presented to the emergency department
because of vomiting, although the
attending emergency physician did not
note abnormal neurological findings and
allowed him to return home. A later re-
view of head computed tomography (CT)
findings obtained at that time (Figure 1)
demonstrated the presence of a thin
interhemispheric ASDH.
Nineteen days after the first injury,
another blow to the occipital region
occurred during judo practice, after which
the patient developed convulsions and lost
consciousness, which was regained 15
minutes later and he was transferred to
our hospital. On arrival, the Glasgow
Coma Scale score was E3V2M5, whereas
right hemiparesis (grade 4/5) and aniso-
coria, with the right (5 mm) larger than
the left (3 mm), were noted. CT of the
head demonstrated a right ASDH along
with a midline shift, brain edema, and
effacement of the basal cisterns (Figure 2).
Emergency surgery revealed tearing in a
bridging vein. After evacuation of the
ASDH, the brain surface was found to be
intact. The postoperative course was
uneventful, and the patient showed a
good recovery.
DISCUSSION
Saunders and Harbaugh3 have advocated
the importance of a CT examination
after an initial impact and avoidance of
further impact in their report of a case
of a football player who suffered from
postconcussion syndrome but soon
returned to play and received a second
impact, leading to diffuse brain swelling
and rapid death. That case highlighted
second impact syndrome (SIS), which
remains controversial, although
cerebrovascular auto-regulatory impair-
ment has been suggested as the underly-
ing pathogenesis.4 Controversy also exists
concerning the relationship between SIS
and ASDH. Cantu and Gean5 reported
10 cases of American football players
with SIS associated with a thin ASDH;
however, head CT was not performed
after the initial impact in most of those
cases. They speculated that catastrophic
brain swelling was not due to the ASDH
but rather dysautoregulation, whereas
Mori et al.6 suggested that the presence

WORLD NEUROSURGERY -: ---, MONTH 2016 www.WORLDNEUROSURGERY.org 1


HIROSHI YOKOTA AND YUKI IDA
Figure 1. Computed tomography imaging of the head obtained at the initial examination. Arrows show a thin interhemispheric acute
subdural hematoma.
of an ASDH was the main cause of brain
swelling in cases of sports-related repeti-
tive head injury.
Nishimura et al.7 was the first to publish a
report of ASDH in judo practitioners in 4
cases. They described the characteristics of
young adults who fell into a coma within a
short period of time due to a pure ASDH
without parenchymal contusion following
rupture of a bridging vein. A recent study
performed in Japan of 30 severe head injury
cases that occurred during judo practice
revealed that most patients suffered from a
pure ASDH and beginner practitioners,
especially first-year junior and senior high
school students, comprised the majority of
those tragic accidents.8 A blow to the
occipital region along with acceleration or
deacceleration force against the brain and
Figure 2. Computed tomography imaging of the head obtained at examination after the second injury.
2 www.SCIENCEDIRECT.com
ASDH IN A JUDO PLAYER WITH REPEATED HEAD INJURIES
subsequent tearing of a bridging vein were
suggested to be pathogenetic factors for
development of a pure ASDH. Importantly,
that report included 4 cases that were fatal
or had a poor prognosis associated with
repeated head injuries, though the details
were not described.
The present case highlights the fact that
a small ASDH could be overlooked even
after consultation with emergency and
neurosurgical physicians. Cantu and Gean5
reported a case similar to ours of a small
ASDH that was overlooked in the initial
CT scan, which had a fatal outcome.
Concussion is defined as functional rather
than structural abnormalities.9 Therefore,
a routine neuroimaging examination is
not practical for all concussed patients
because structural abnormalities are rarely
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.03.101
CASE REPORT
detected.9 For cases with persistent
concussion symptoms, coronal or thin-
slice brain-imaging studies are recom-
mended to detect a small ASDH around
a bridging vein.2 Although definitive
guidelines for judo-related head injuries
have yet to be established, once ASDH is
detected in a judo practitioner, return to
play should not be allowed.2
CONCLUSIONS
A small ASDH can develop as structural
brain damage in a judo player with
concussion symptoms, which may be
unrecognized or overlooked. Physicians
should be aware of the possibility of a
small ASDH associated with a judo-related
head injury in patients with persistent

HIROSHI YOKOTA AND YUKI IDA
concussion symptoms, which may lead to
subsequent fatal ASDH after an additional
impact incident.
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Clin J Sport Med. 2001;11:144-149.
WORLD NEUROSURGERY -: ---, MONTH 2016
ASDH IN A JUDO PLAYER WITH REPEATED HEAD INJURIES
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CASE REPORT
9. McCrory P, Meeuwisse WH, Aubry M, Cantu RC,
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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 11 February 2016; accepted 30 March 2016
Citation: World Neurosurg. (2016).
http://dx.doi.org/10.1016/j.wneu.2016.03.101
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2015 Elsevier Inc.
All rights reserved.
www.WORLDNEUROSURGERY.org 3