Outcome prediction following penetrating craniocerebral injury in a civilian population: aggressive surgical management in patients with admission Glasgow Coma Scale scores of 6 to 15

How I do it: single-staged emergency neurosurgical management of frontal penetrating craniocerebral injury with depressed skull fracture

CONTEXT

Penetrating craniocerebral injury associated with depressed skull fracture is an infrequent yet timely neurosurgical emergency. Such injury frequently occurs in the frontal region during traffic accident or stone throw in the civilian setting. As military neurosurgeons, we present our experience in the surgical debridement and reconstruction of this peculiar type of traumatic brain injury.

METHODS

The patient lies supine, the head in neutral position heal by a Mayfield head clamp. The first step is the debridement of the frontal wound. Then, the depressed skull fracture is operated on using a tailored coronal approach through Merkel dissection plane, in order to keep a free pericranial flap. The bone flap is cut around the depressed skull fracture. Neuronavigation allows to locate the frontal sinus depending on whether it has been breached and thus requires cranialization. Brain and dura mater debridement and plasty are performed. Cranioplasty is performed using either native bone fragments fixed with bone plates or tailored titanium plate if they are too damaged.

CONCLUSION

Performing wounded skin closure first and then a tailored coronal approach with free pericranial flap and a craniotomy encompassing the depressed skull fracture allows to treat frontal penetrating craniocerebral injury in an easy-to-reproduce manner.

Penetrating Orbitocranial Injuries in the Republic of Korea

Objective

Penetrating brain injury occurs when an object enters the skull and pierces the brain. These injuries can damage small or large parts of the brain, are life-threatening, and require emergency care. This study is a summary of penetrating head injuries at our hospital and an analysis of their treatments and prognoses.

Methods

Patients with penetrating brain involving the orbit and/or cranial region were recruited among patients with trauma who visited our regional trauma center between 2019 and 2022.

Results

Eight patients with penetrating brain injuries were enrolled. One patient was female; the median age was 53 years (range, 24-72 years). Five patients with Glasgow Coma Scale (GCS) scores of 14 or 15 showed no major vessel injury or midline intracranial involvement on imaging and were discharged safely. The other three patients with suspected major vessel injuries and midline involvement did not survive.

Conclusion

The greatest influences on patient prognosis were the area of damage and level of consciousness, along with the GCS score at the time of the visit. The probability of survival is extremely low if the midline structure is damaged.

Simple Wound Closure for Civilian Cranial Gunshot Wounds: A Systematic Literature Review

Civilian cranial gunshot wounds are common injuries associated with significant morbidity and mortality. Simple wound closure has been previously proposed as an alternative treatment option for a small subset of patients, but the exact outcomes of this strategy are not well-defined. The objective of this paper was to describe the scientific literature reporting simple wound closure of civilian cranial gunshot wounds, its effect on short-term and long-term neurologic outcomes, and rates of seizures and infections. A systematic literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The strength of evidence was assessed using the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) criteria. Seventeen studies were found that met inclusion criteria. There was very low strength of evidence that patients treated with simple wound closure can achieve good short and long-term neurologic outcomes. There was very low strength of evidence that simple wound closure has a higher incidence of mortality compared to operative intervention, especially in patients with initial low Glasgow Coma Scale (GCS) scores. There was very low strength of evidence that patients treated with simple wound closure have a small risk of subsequently developing infections or seizures. In conclusion, under most circumstances, neurosurgical operative intervention should be viewed as the optimal treatment for salvageable civilian cranial gunshot wound patients. However, our literature review showed that simple wound closure is safe and viable. More data are needed to determine the appropriate clinical scenario for using this alternative option.

Day 14 intervention for penetrating brain injury with a good Glasgow Coma Scale score: A case report

Penetrating brain injury is a rare pathology generally requiring emergency surgical intervention. We discuss a case of penetrating brain injury by the umbrella in which surgical intervention was performed 14 days after the injury, and obtained good clinical results.

Pediatric intracranial gunshot wounds: the Memphis experience

OBJECTIVE Penetrating brain injury in civilians is much less common than blunt brain injury but is more severe overall. Gunshot wounds (GSWs) cause high morbidity and mortality related to penetrating brain injury; however, there are few reports on the management and outcome of intracranial GSWs in children. The goals of this study were to identify clinical and radiological factors predictive for death in children and to externally validate a recently proposed pediatric prognostic scale. METHODS The authors conducted a retrospective review of penetrating, isolated GSWs sustained in children whose ages ranged from birth to 18 years and who were treated at 2 major metropolitan Level 1 trauma centers from 1996 through 2013. Several standard clinical, laboratory, and radiological factors were analyzed for their ability to predict death in these patients. The authors then applied the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a scoring algorithm that was designed to provide rapid prognostic information for emergency management decisions. The scale's sensitivity, specificity, and positive and negative predictability were determined, with death as the primary outcome. RESULTS Seventy-one children (57 male, 14 female) had a mean age of 14 years (range 19 months to 18 years). Overall mortality among these children was 47.9%, with 81% of survivors attaining a favorable clinical outcome (Glasgow Outcome Scale score ≥ 4). A number of predictors of mortality were identified (all p < 0.05): 1) bilateral fixed pupils; 2) deep nuclear injury; 3) transventricular projectile trajectory; 4) bihemispheric injury; 5) injury to ≥ 3 lobes; 6) systolic blood pressure < 100 mm Hg; 7) anemia (hematocrit < 30%); 8) Glasgow Coma Scale score ≤ 5; and 9) a blood base deficit < -5 mEq/L. Patient age, when converted to a categorical variable (0-9 or 10-18 years), was not predictive. Based on data from the 71 patients in this study, the positive predictive value of the St. Louis scale in predicting death (score ≥ 5) was 78%. CONCLUSIONS This series of pediatric cranial GSWs underscores the importance of the initial clinical exam and CT studies along with adequate resuscitation to make the appropriate management decision(s). Based on our population, the St. Louis Scale seems to be more useful as a predictor of who will survive than who will succumb to their injury.

Current concepts in penetrating and blast injury to the central nervous system

Aim

To review the current management, prognostic factors and outcomes of penetrating and blast injuries to the central nervous system and highlight the differences between gunshot wound, blast injury and stabbing.

Methods

A review of the current literature was performed.

Results

Of patients with craniocerebral GSW, 66–90 % die before reaching hospital. Of those who are admitted to hospital, up to 51 % survive. The patient age, GCS, pupil size and reaction, ballistics and CT features are important factors in the decision to operate and in prognostication. Blast injury to the brain is a component of multisystem polytrauma and has become a common injury encountered in war zones and following urban terrorist events. GSW to the spine account for 13–17 % of all gunshot injuries.

Conclusions

Urgent resuscitation, correction of coagulopathy and early surgery with wide cranial decompression may improve the outcome in selected patients with severe craniocerebral GSW. More limited surgery is undertaken for focal brain injury due to GSW. A non-operative approach may be taken if the clinical status is very poor (GCS 3, fixed dilated pupils) or GCS 4–5 with adverse CT findings or where there is a high likelihood of death or poor outcome. Civilian spinal GSWs are usually stable neurologically and biomechanically and do not require exploration. The indications for exploration are as follows: (1) compressive lesions with partial spinal cord or cauda equina injury, (2) mechanical instability and (3) complications. The principles of management of blast injury to the head and spine are the same as for GSW. Multidisciplinary specialist management is required for these complex injuries.

Predictors of outcome in civilians with gunshot wounds to the head upon presentation

OBJECT

Prediction of outcome from initial presentation after a gunshot wound to the head (GSWH) is essential to further clinical decision making. The authors' goals are to report the survival and functional outcomes of these patients, to identify prognostic factors, and to propose a scoring system that can predict their outcome.

METHODS

The records of 199 patients admitted with a GSWH with dural penetration between 1990 and 2008 were retrospectively reviewed. The inclusion criterion was a CT scan available for review. Patients declared brain dead on presentation were excluded, which yielded a series of 119 patients. Statistical analysis was performed using a logistic regression model.

RESULTS

Fifty-eight (49%) of the 119 patients died. Twenty-three patients (19%) had a favorable outcome defined as a 6-month Glasgow Outcome Scale (GOS) score of moderate disability or good recovery, 35 (29%) had a poor outcome (GOS of persistent vegetative state or severe disability), and 3 (3%) were lost to follow-up. Significant prognostic factors for mortality were age older than 35 years, nonreactive pupils, bullet trajectory of bihemispheric (excluding bifrontal), and posterior fossa involvement compared with unihemispheric and bifrontal. Factors that were moderately associated with higher mortality included intracranial pressure (ICP) above 20 mm Hg and Glasgow Coma Scale (GCS) score at presentation of 3 or 4. Upon multivariate analysis, the significant factors for mortality were bullet trajectory and pupillary response. Variables found to be significant for good functional outcome were admission GCS score greater than or equal to 5, pupillary reactivity, and bullet trajectory of unihemispheric or bifrontal. Factors moderately associated with good outcome included age of 35 years or younger, initial ICP 20 mm Hg or lower, and lack of transventricular trajectory. In the multivariate analysis, significant factors for good functional outcome were bullet trajectory and pupillary response, with age moderately associated with improved functional outcomes. The authors also propose a scoring system to estimate survival and functional outcome.

CONCLUSIONS

Age, pupils, GCS score, and bullet trajectory on CT scan can be used to determine likelihood of survival and good functional outcome. The authors advocate assessing patients based on these parameters rather than pronouncing a poor prognosis and withholding aggressive resuscitation based upon low GCS score alone.

Management of pediatric intracranial gunshot wounds: predictors of favorable clinical outcome and a new proposed treatment paradigm

OBJECT

There has been an increase in civilian gun violence since the late 1980s, with a disproportionately high increase occurring within the pediatric population. To date, no definite treatment paradigm exists for the management of these patients, nor is there a full understanding of the predictors of favorable clinical outcome in this population.

METHODS

The authors completed a retrospective review of all victims of intracranial gunshot injury from birth to age 18 years at a major metropolitan Level 1 trauma center (n = 48) from 2002 to 2011. The predictive values of widely accepted adult clinical and radiographic factors for poor prognosis were investigated.

RESULTS

Eight statistically significant factors (p < 0.05) for favorable outcome were identified. These factors include single hemispheric involvement, absence of a transventricular trajectory, < 3 lobes involved, ≥ 1 reactive pupil on arrival, systolic blood pressure > 100 mm Hg on arrival, absence of deep nuclei and/or third ventricular involvement, initial ICP < 30 mm Hg when monitored, and absence of midline shift. Of these 8 factors, 5 were strong predictors of favorable clinical outcome as defined by Glasgow Outcome Scale score of 4 or 5. These predictive factors included absence of a transventricular trajectory, < 3 lobes involved, ≥ 1 reactive pupil on arrival, absence of deep nuclei and/or third ventricular involvement, and initial ICP < 30 mm Hg. These findings form the basis of the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a novel metric to inform treatment decisions for pediatric patients who sustain these devastating injuries.

CONCLUSIONS

The pediatric population tends to demonstrate more favorable outcomes following intracranial gunshot injury when compared with the adult population; therefore some patients may benefit from more aggressive treatment than is considered for adults. The St. Louis Scale for Pediatric Gunshot Wounds to the Head may provide critical data toward evidence-based guidelines for clinical decision making.

Missile injury to the pediatric brain in conflict zones

OBJECT

This study was conducted both prospectively and retrospectively at one center over a period of 8 years. The population consisted of all patients with both an age 18 years or younger and a diagnosed penetrating missile injury (PMI) during the study interval. The authors analyzed factors determining outcome and demographic trends in this population, and they compared them with those in the more developed world.

METHODS

Fifty-one patients were the victims of armed conflict, although no one was directly a party to any battle. This mechanism of injury is in strong opposition to data in the literature from developed countries, in which most missile injuries are the result of suicide or homicide or are even sports related. Moreover, all previous studies on the pediatric population have considered only injuries from gunshots, but authors of the current study have included injuries from other penetrating missiles as well.

RESULTS

On cross tabulation analysis using the chi-square test, the factors shown to correlate with outcome included the Glasgow Coma Scale (GCS) score, pupillary abnormalities, patient age, hemodynamic status, and bihemispheric damage. On multinomial regression analysis, the two strongest predictors of death were GCS score and pupillary abnormalities. The GCS score and hemodynamic status were the strongest predictors of disability.

CONCLUSIONS

There was no difference in the prognostic factors for PMI between developing or more developed countries. Glasgow Coma Scale score, pupillary abnormalities, and hemodynamic status were the strongest predictors of outcome. In conflict zones in developing countries the victims were mostly innocent bystanders, whereas in the more developed countries homicides and suicides were the leading etiological factors.

Vagoglossopharyngeal-associated syncope due to a retained bullet in the jugular foramen

Gunshot wounds (GSWs) to the head are frequently fatal. Rarely, the bullet may lodge in the skull base and not cause significant brain injury. Typically, the bullet fragments are felt to be inert and do not require operative extirpation if they are within the bony confines of the skull base. We report the case of a bullet in the jugular foramen causing recurrent syncope that resolved after surgical removal of the bullet. The medical records from a patient who suffered a GSW to the head were retrospectively reviewed and the treatment and outcome documented. In 2000, a 20-year-old man suffered a GSW to the head. Immediate evaluation revealed the bullet in the right skull base at the jugular foramen, but no parenchymal brain injury. One year after the GSW, he began to experience stereotypical spells resulting in loss of consciousness. Extensive cardiovascular workup was normal. In 2002, the patient underwent removal of the bullet. He has been syncope-free since the operation and returned to his career in the military. We believe the retained bullet in this patient was irritating the IX-X cranial nerves, resulting in syncope, similar to the mechanism in vagoglossopharyngeal neuralgia. Removing the bullet relieved the irritation and stopped the syncopal spells.

Prospective evaluation of a predictive model of mortality in patients with isolated head injury

BACKGROUND

In a previous retrospective study, we developed a predictive model of survival in isolated head injuries based on easily available parameters such as age, mechanism of injury, Glasgow Coma Scale, and head Abbreviated Injury Scale (AIS). The purpose of the present study is to prospectively evaluate this predictive model.

METHODS

Isolated head injuries admitted to a Level I urban trauma center were prospectively accrued from May 1, 2006 through April 30, 2007. Age, mechanism of injury, Glasgow Coma Scale, head AIS, and survival status were recorded for each patient. Patients with extracranial AIS >3, head AIS = 6, or hypotension were excluded. These data were entered into our previously developed predictive model and the percentage of correct classification was used to measure how well the predictive model predicted outcome. Sensitivity, specificity, positive and negative predictive values, and their 95% confidence intervals were calculated and compared with values obtained from our original, retrospective study.

RESULTS

Seven hundred eighty-six patients met the criteria for inclusion in the study with an overall mortality of 5.8% (46 patients). When entered into our predictive model, the percentage of correct classification rate was 92% compared with the 94% rate seen in the original study, which is better than other available predictive tools based on combined scoring systems such as the Trauma and Injury Severity Score methodology.

CONCLUSION

When evaluated prospectively, our predictive model has similar accuracy in predicting survival of all patients with head trauma as our original retrospective study and performs better than other predictive models such as the Trauma and Injury Severity Score methodology. This study demonstrates that a simple table based on easily obtained admission patient characteristics can rapidly provide information about the probability of survival in patients with head injuries.

Gunshot Wounds to the Head in Civilian Practice

Gunshot wounds to the head are associated with poor outcome. We reviewed data to identify prognostic factors. We performed a retrospective study of all patients admitted to a Level 1 trauma center with isolated gunshot injury to the head during 6% years. Data collected included demographics, mechanism of injury, prehospital and resuscitation room data, and initial CT scan characteristics. The primary outcome measure was the Glasgow Outcome Scale. Seventy-two patients with isolated gunshot wounds to the head were admitted. Overall mortality was 58 per cent. The mortality for patients with an initial Glasgow Coma Scale score of ≤8 was 81 per cent versus 14 per cent for those with initial Glasgow Coma Scale score > 8 ( P ≤ 0.0001). Fifty per cent had pupillary abnormalities on arrival at the Emergency Department. Mortality in this group was 78 per cent versus 53 per cent in those with normal pupillary reflexes ( P = 0.06). Elevated plasma lactate was associated with nonsurvival. Thirteen per cent of survivors were assessed as able to live independently after their injury. Civilian gunshot injury to the head is related to high mortality. Indicators of outcome are the admission Glasgow Coma Scale score, pupillary abnormality, metabolic acidosis, and CT pattern of severe injury. The majority of deaths occur at an early stage. Among survivors the functional outcome can be acceptable.

Missile injuries of the anterior skull base

Missile injuries of the anterior skull base usually occur during war or war-like situations. These injuries may be isolated or associated with multiple traumatic injuries. We report 23 such cases managed during military conflicts and peacekeeping operations. All were adult males. Four of these patients sustained bullet injuries; the rest were injured from shrapnel. Eighteen patients had injury to the visual apparatus with permanent blindness. Proptosis was seen in 16, cerebrospinal fluid (CSF) leak from the wound in seven, and CSF orbitorrhea in three patients. Sixteen had irreparable injury to the eye necessitating evisceration/enucleation, and two had retrobulbar optic nerve injury. Three patients were comatose [Glasgow Coma Scale (GCS) 3/15], and 14 had altered sensorium. Six patients were fully conscious. All were investigated by computed tomography (CT), which revealed injury to the eyeball and skull base, orbital fracture, frontal hematoma, contusion, and pneumocephalus. Seventeen patients underwent emergency surgery, and six patients were initially managed conservatively. Neurosurgical management consisted of making bifrontal flaps, craniotomy/craniectomy, debridement, and repair of the base with fascia lata. Reconstruction of the orbital rim was required in three cases. All were managed postoperatively with cerebral decongestants and antibiotics in anti-meningitic dosages. There was one death in the postoperative period; outcome was good in 16 and moderate in four patients. Twelve patients had retained intracranial splinters; three of these developed recurrent suppurative meningitis. Of the six patients initially managed conservatively, three were subsequently operated for CSF rhinorrhea. Gross communition, dural loss, and injury to the frontal scalp often preclude the use of pericranial repair of the skull base. Fascia lata is extremely useful for reconstruction and repair. Anterior cranial fossa injury probably carries a better prognosis; however, there is increased risk of suppurative complications due to breach of air-filled sinuses by the missile and contamination of the intradural compartment, as compared with supratentorial vault injuries not involving the orbit or paranasal sinuses. Three patients who underwent no operative procedure and remain asymptomatic are under follow-up.