Complex craniomaxillofacial gunshot wounds A step-by-step multidisciplinary approach

BACKGROUND

Gunshot injuries of the viscerocranium are rarely reported. Penetrating wounds to the cranio-maxillofacial region pose a significant challenge for surgeons as they often comprise serious soft tissue, bone and cerebral defects. We present a case report of a 42-year old female with a gunshot wound to the viscerocranium after suicidal attempt. Series of image of the disease course are available.

CASE DESCRIPTION

A 42-year-old female presented with gunshot wound to the viscerocranium after a suicidal attempt. At the arrival GCS was 8/15 and general examination showed the inlet wound in the submental region whereas the outlet one in the left temporal skull area. After first rescue procedures, ICP was monitored before proceeding surgically. Due to massive hemorrhage, embolization of ianternal maxillary artery was performed. Afterwards, tracheostomy, surgical reduction of multiple maxillo-facial fractures and ocular avulsion were performed. In a second time, ICP monitoring and CT scan revealed ICH signs due to intraparenchimal injures. The patient underwent to a second surgical procedure, consisting of bifrontal decompressive craniectomy. The patient was discharged on 20th post-op day to a rehabilitation center. She returned to our department after 4 months to perform a craniomaxillofacial recostruction. She presented 15 in GCS, left ptosis, left VII cranial nerve deficit, decannulated, KPS 100%.

CONCLUSION

A step-to-step multidisciplinary approach both with Neurosurgeons and Maxillo-facial surgeons is mandatory in Cranial Gunshot Injuries where extensive damage is linked to a higher mortality.

KEY WORDS

Cranial gunshot inuuries, Cranial reconstruction, Maxillofacial reconstruction.

Multiple simultaneous intracerebral hemorrhages: Clinical presentations and risk factors

OBJECTIVE

Multiple simultaneous intracerebral hemorrhages (MSICH) are a rare clinical entity. The mechanism and risk factors have yet to be elucidated. The purpose of this study was to clarify clinical presentations and risk factors of MSICH compared with solitary intracerebral hemorrhages (ICH).

PATIENTS AND METHODS

Medical records of 313 consecutive patients with ICH admitted to our institution between April 2011 and September 2014 were retrospectively reviewed. Seventeen cases of MSICH were identified, and 10 clinical and neuroimaging variables were compared between MSICH cases and solitary ICH cases using the unpaired t-test, chi-square test, and multiple logistic regression analysis.

RESULTS

There were significant differences in size between larger hematomas (mean 59.2±69.1mL) and smaller hematomas (mean 1.7±2.1mL) in patients with MSICH (p=0.001). Larger hematoma volume was the only independent risk factor for MSICH in multiple logistic regression analysis (OR=1.012, 95%CI 1.004-1.021, p=0.004).

CONCLUSIONS

Patients with MSICH have clinical characteristics and outcomes similar to patients with solitary ICH. They present with two significantly different hematoma sizes, both of which are significantly larger than patients with solitary ICH, suggesting that a larger hematoma can trigger smaller hematomas. A future prospective study with a larger number of patients will explore the precise mechanism of this rare entity.

Internal haemorrhagic pachymeningiosis: specific disease or complication of chronic subdural hematoma? Report of five cases surgically treated and literature review

BACKGROUND

Internal haemorrhagic pachymeningiosis (IHP) is a rare disease characterized by a fibrous thickening and inflammatory infiltration in dural space mimicking chronic subdural hematoma. The pathogenesis of IHP is not entirely clear yet and treatment is still controversial.

OBJECTIVE

We want to emphasize the importance of differentiating pachymeningiosis from chronic subdural hematoma as distinct pathological entities.

PATIENTS AND METHODS

The records of five selected cases of IHP histologically confirmed were reviewed, focusing onset, neuroimaging, surgery and outcomes.

CONCLUSIONS

IHP is most likely underestimated. Only through multidisciplinary approach it is possible to plane the proper therapeutic strategy. The diagnosis of IHP is confirmed by definitive histology but in some cases is possible with intraoperative frozen section.