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Principles for managing penetrating craniocerebral injuries caused by firearm missiles
Principles for managing penetrating craniocerebral injuries caused by firearm missiles
X i a n g Z h a n g MD S h e n g - Y u Yi MD W e i - P i n g Liu MD PhD Z h i - W e n Z h a n g MD PhD L i - G e n W a n g MD PhD A n - M i n Li MD Department of Neurosurgery,Xi-JingHospital of Fourth MilitaryMedical University,P.R. China.
Penetrating craniocerebral firearm injuries remain one of the most lethal causes of all trauma and are c o m m o n both in war or peace time. Data were reviewed for 4140 severely head-injured patients (Glasgow Coma Scale (GCS) scores 3-8) treated at Xi-Jing Hospital between 1973 and 1993; 51 of these patients had acute penetrating craniocerebral injuries caused by firearm missiles. These patients consisted of 46 males (90.2%) and 5 females (9.8%) ranging in age from 3 months to 48 years (median 22.4 years). The lesion types included 2 tangential wounds, 37 tubular wounds and 12 through-and-through wounds. All cases were urgent with the patients in severe and unstable states. After emergency treatment and operation, 5 cases died (9.8%). Follow up studies at three months showed that 23 cases (45.1%) had made a g o o d recovery. Moderate disability, severe disability and vegetative states in this series were 29.4%, 13.7% and 2.0% respectively. Long term follow up studies indicated that 32 were able to resume their occupation. The principles for managing penetrating craniocerebral firearm injuries and suggestions for operation are discussed. Journal of Clinical Neuroscience 1996, 3 (3):229-233
©Pearson Professional 1996
Keywords: Craniocerebral injury, Penetrating injury, Firearm wounds, M a n a g e m e n t , Head injury
Penetrating craniocerebral firearm injuries (PCCFI) are severe traumatic lesions, unavoidable consequences during war time, but also fairly c o m m o n during peace time.i, 2, 3, 4 Flying missiles emitted by explosive weapons (such as gunshot and b o m b fragments) often cause direct traumatic lesions to craniocerebral structures. T e m p o r a r y cavitation effects and dynamic shock waves cause laceration of the scalp, extensive cranial b o n e fractures and massive tissue crushing or contusion along the missile track often with intracranial haematoma. Missile brain lesions are usually extensive and severe, with a high rate of disability and high mortality?, 4, ~ This paper retrospectively analyses clinical experiences of 51 PCCFI cases in 20 years at our hospital. The principles for managing PCCFI and surgical techniques are discussed.
this analysis. The patient population included 46 males and 5 females, age range was 3 months to 48 years, mean age 22.4 years (Table 1).
Types of firearms a) 'Ordinary' weapon bullets (pistols, rifles and machine guns) : these missiles are large and high velocity. b) Dynamic air-gun missiles: these missiles are small with relatively low velocity. c) Shotgun missiles: land mines, multiple small high velocity missies. d) Bomb missiles: Hand grenade, mortar shell (see Table 2).
Table 1 Age distribution of 51 cases of PCCFI Clinical data
Age groups (years)
General i n f o r m a t i o n From 1973 to 1993, 4140 severely head-injured patients (Glasgow Coma Scale (GCS) s c o r e s 3--8) 6 were admitted to the D e p a r t m e n t of Neurosurgery in xi-Jing hospital. In 51 cases the p r e d o m i n a n t traumatic pathology was an acute penetrating craniocerebral injury caused by firearm missiles. Five additional cases with PCCFI who died during transfer to our hospital were excluded from
No.
<15 16
16-30 25
31-45 8
Total >46 2
51
Table 2 Missiletypes of 51 casesof PCCFI Type of traumatic lesion No.
Bomb
Gunshot
Shotgun
Airgun
Total
13
14
20
4
51
J. Clin. Neuroscience Volume 3 N u m b e r 3 July 1996
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Clinical studies
Penetrating craniocerebral injuries
Table 3 Lesion condition of 51 cases of PCCFI Complications %
Traumatic types
No.
Tangential wound Tubular wound Throughand-through wound No. (%)
2
3.9
37
72.6
18
37
10
4
12
23.5
4
12
3
2
22(43.1)
49(96.1) 14(27.5) 6(11.8)
51
100
Haematoma FB
II
Epilepsy
1
FB = retained foreign body, including metal and non-metal II = intracranial infection, three caseswere accompanied by brain abscess
T r a u m a t i c lesion classification a n d a c c o m p a n y i n g diseases
Using Ascroft's classification of flying missiles causing penetrating craniocerebral injuries, 7 we classified our patients into several groups. All patients had scalp injuries, fractures of the cranial bones, rupture of the dura mater and cerebral contusions. 22 patients also had intracranial haematomas. Among 49 cases with retained foreign bodies, most were tubular wounds with retained metal fragments; the lowest n u m b e r of such foreign bodies was 2, the highest n u m b e r 34, in the intracranial cavity of patients injured by shotgun missiles. Two cases with through-and-through wounds also had tubular wounds and retained foreign bodies in the brain (Table 3). Symptoms
Fig. 1 Bomb missile had caused a tubular wound. CT Scan: the missile had entered the left temporo-parietal region, there are foreign bodies in the track, haematoma in the falx.
a n d signs
U p o n entry of a missile into tissue, tissue moves both forward and sideways; the cross-sectional area affected may be as great as 30 times the diameter of the actual missile track. This often causes severe damage a r o u n d the missile track, resulting in an extensive neurological deficit. 37 patients had disturbance of conscious level after injury. 14 patients had no disturbance of consciousness Fig. 2 Gunshot injury caused a parietal through-and-through injury. CT scan: bone fragments and haematoma in the track and free air and haemorrhage in the brain and falx.
Table 4 Clinical manifestations of 51 casesof PCCFI Symptoms and signs Headache,vomiting Disturbance of consciousness lethargy haziness hemicoma coma Hemiplegia Aphasia Meningeal irritation Epilepsy Pupil changes unilateral mydriasis bilateral mydriasis bilateral miosis Decerebraterigidity Lesionsto paranasalsinus Rupture of eye ball Shock Psychotic disorder Pyramidalsigns
230
No. of cases 38 37 12 15 7 3 12 4 9 6 10 5 3 2 3 5 2 3 5 18
Percentage 74.5 72.6 23.5 29.4 13.7 5.9 23.5 7.8 17.7 11.8 19.6 9.8 5.9 3.9 5.9 9.8 3.9 5.9 9.8 35.3
(17.7%), including 4 cases of airgun injury and 10 of 20 cases of shotgun injury. 16 patients were hemiplegic and aphasic. Among the 10 cases of gunshot injuries with an entry wound in the craniofacial region there was simultaneous rupture of the eyeball, open injury of the frontal and sphenoid sinuses and rupture of the paranasal sinuses (Table 4). Brain abscess occurred in 3 cases of tubular wound; these patients had received only superficial wound d e b r i d e m e n t at a local clinic after injury. When admitted to our hospital these patients were very ill with deep cerebral abscesses. Investigations
All patients underwent X-ray examination which included plain X-rays or CT scan. Before 1980 (when there were 6 patients with signs of brain compression) we used cerebral angiography and ultrasonic wave examination.
J. Clin. N e u r o s c i e n c e V o l u m e 3 N u m b e r 3 July 1996
Penetrating craniocerebral injuries
Clinical studies
Using these methods of examination, we could accurately determine the location of metallic foreign bodies or bone fragments (Fig. 1). Early diagnosis ofintracranial h a e m a t o m a and brain o e d e m a was also possible (Fig. 2). Treatment
Resuscitation was begun at the scene or immediately after reaching the emergency d e p a r t m e n t of our hospital, with p r o m p t cleaning of the superficial wound, haemostasis and wound toilet. For some severely injured patients, sedation, analgesia, antibiotics and continued supply of crystalline a n d / o r colloid solutions was necessary. Blood transfusion is essential for shocked patients, and attention should be paid to provision of a clear airway. Intubation and ventilation is desirable and mannitol may be used if raised intracranial pressure occurs. Immediately after resuscitation patients should be taken for X-ray and CT scan examination to determine the degree of brain damage, to determine if there are any metallic foreign bodies or b o n e fragments retained in the missile tracks and to identify intracranial h a e m a t o m a and intraventricular haemorrhage. T h r e e cases of PCCFI showed obvious signs of brain compression and were rushed to operating theatre for craniotomy. Large intracerebral haematomas were cleared along the injury tracks. A plan of treatment for PCCFI patients should be d e t e r m i n e d mainly according to the wound and results of X-ray and CT scan examination. Early d e b r i d e m e n t is always desirable. The goal of surgery is the d e b r i d e m e n t of o p e n craniocerebral wounds with drainage of haemorrhage or infection. Devitalised tissues and various foreign bodies are removed to achieve a clean wound with complete haemostasis (Fig. 3). For deeply placed intracerebral foreign bodies (e.g. in the thalamus or internal capsule-basal ganglia region), we suggest that no effort is made to locate or remove bone or metal fragments visualised on the preoperative CT scan. Only those fragments which present themselves during irrigation and haemostatis maneouvres should be removed, s Surgery should be carefully controlled to avoid unnecessary removal of normal brain tissue, and the wound area should be thoroughly washed with saline, metronidazole and hydrogen peroxide. The dura must be tightly sutured. In general, drains were removed 24-48 h after operation. If infection occurs, drains could be kept for a longer period, say 3-5 days. In some PCCFI patients with intracranial h a e m a t o m a and intraventricular blood clots, the craniotomy should be large e n o u g h to allow complete d e b r i d e m e n t and removal of any haematoma. Generally speaking, d e b r i d e m e n t should be carried out within 72 h after injury. In this study, 9 cases had only had superficial wound d e b r i d e m e n t in their local clinics, and when admitted to our unit the wound was contaminated and intracranial infection had developed. A m o n g these patients, 3 cases were f o u n d with intracranial foreign bodies on CT scan and delayed yet complete debridem e n t was p e r f o r m e d (bone fragments, foreign bodies and deep brain abscess removed). 14 cases of missile wounds with missile entry wounds in the facial and cranial
base area had injuries to the eye ball, facial region, nasal canal and paranasal sinuses with fracture and deficits of the cranial base. Early repair and reconstruction of the cranial base was carried out in addition to wound debridement. This prevented CSF leakage and brain extrusion. After d e b r i d e m e n t antibiotics were routinely given for 7-10 days, usually penicillin and metronidazole. In recent years, we have also used Fortum or Claforan. Nerve nutrition agents such as choline, cytophosphate and Cerebrolysin were also used. When patients recovered consciousness, antiepileptic agents were also given. Results
In this series 5 patients died (9.8%) during their acute hospitalisation. The 46 surviving patients were followed up at three months and the outcome was graded according to the Glasgow Outcome Scale? Outcome was most strongly influenced by the type of initial wound and the patient's condition on arrival at our hospital. Patients with bilateral fixed dilated pupils or decerebrate rigidity had a significantly worse outcome than patients with a GCS greater than 8 or unilateral pupil mydriasis on admission. 23 (45.1%) of these patients made a good recovery, and the proportion of patients with moderate disability, severe disability and persistent vegetative state were 29.4%, 13.7% and 2.0% respectively. We also made a long term follow up survey of the survivors, some of whom were discharged h o m e and some transferred to rehabilitation hospital. The follow up time from injury to re-evaluation was 3-16.7 years, with a median follow up interval of 4.5 years. No patients suffered neurological deterioration, 32 were completely i n d e p e n d e n t at the time of follow up consultation, and 26 were able to resume their occupation.
Fig. 3 Gunshot injury causing through-and-through injury. CT scan: two weeks after debridement. Note: there are no foreign bodies, yet signs of local brain oedema persist.
J. Clin. Neuroscience
Volume 3 Number 3 July 1996
231
Clinical studies Discussion Characteristics and damage of PCCCFI High velocity flying missiles often cause direct d a m a g e to the scalp, cranial bones and cerebral tissue. Penetrating lesions, cavitation effects and dynamic shock waves cause direct a n d indirect t r a u m a to the s u r r o u n d i n g brain adjacent to the missile track. 1'2'3'4'1°'11 T h e diameter of the cavitation effect on the brain tissue may be 3-10 times greater than the diameter of the missile track itself, greatly increasing the hazard of the injury. 12 37 (72.6%) of patients with PCCFI had a disturbed conscious state, a m o n g which 15 (29.4%) patients had hemiplegia and decerebrate rigidity indicating severe brain damage. Following imaging a n d operation we f o u n d the features of this kind of missile injury to be very characteristic: a) Gunshot injury often leads to massive brain contusion, especially if the weapon is fired from close range; b) Shotgun injury may cause multifocal craniocerebral lesions, with simultaneous injury to i m p o r t a n t structures such as brain stem, thalamus or m o t o r areas of the cortex; c) If the lesion includes blood vessels (arteries, veins or venous sinus) intracranial h a e m a t o m a and subarachnoid h a e m o r r h a g e are detected; and d) In patients presenting late after injury, intracranial infections or brain abscess were often found. W h e n a PCCFI patient arrives we aim to make a clear classification of the lesion a n d the missile type. Further efforts are then m a d e to d e t e r m i n e the extent and degree of the lesion and establish if there is any infection. A plan of t r e a t m e n t is formed.
Management of retained foreign bodies in PCCFI T h e r e are almost always some foreign bodies retained along the missile track, regardless of whether it is a tangential, tubular wound or t h r o u g h - a n & t h r o u g h injury. Autopsy studies have shown that the retained foreign bodies in tangential wounds are usually non-metallic; the main objects are pieces of hair, scalp and b o n e fragments. In tubular wounds, the main objects are metallic, sometimes with non-metallic bodies as well. It is generally accepted that foreign bodies retained in the w o u n d are a potential cause of intracranial infection. 13 During World War II researchers f o u n d that a bacterial growth could be cultured f r o m the retained intracranial bodies. 14' 15 In an experimental study in dogs Piblyk found that both the sterile b o n e fragments and non-sterile b o n e fragments could cause brain abscess, but the percentages were 4% and 8% respectively. 16If the b o n e fragments were retained with pieces of scalp or hair, the rate of intracranial abscess increased to as high as 70%. Rish made a five year follow up of head injured patients from the Vietnam War. 11T h e r e were 37 cases of brain abscess, 11 (29.7%) associated with retained intracranial b o n e fragments: these cases showed no other possible routes of intracranial infection such as entry from the facio-orbital region, CSF fistula, wound complications, prolonged coma state or multiple surgical
232
Penetrating craniocerebral injuries procedures. In our study 14 patients developed intracranial infection; the main reason for this complication was that the initial d e b r i d e m e n t was not adequate and the patients had waited too long before transfer to our hospital. T h r e e cases n e e d e d re-operation when deep brain abscesses were removed with impacted b o n e fragments and hairs. T h e r e f o r e timely, adequate and complete initial debridem e a t is crucial to avoid intracranial infection. This must be kept in m i n d whenever a PCCFI patient presents.
Principles for managing PCCFI PCCFI are often severe, needing urgent t r e a t m e n t because of rapid neurological deterioration. T h e r e f o r e resuscitation and t r e a t m e n t should be p r o m p t . We conclude with the following principles for managing PCCFI patients: 1) Resuscitation at the scene is very important. Reliable haemostasis should be c o m p l e t e d very quickly, efforts should be m a d e to k e e p the airway p a t e n t to avoid hypoxia. 2) Quickly d e t e r m i n e if there are craniocerebral injuries, their location, extent and severity by using adequate imaging methods. 3) Early and radical d e b r i d e m e n t should be p e r f o r m e d to remove all d a m a g e d brain tisue, b o n e fragments, foreign bodies and intracranial h a e m a t o m a s . T h e w o u n d should be washed thoroughly. Repair of the dura m a t e r must be water tight. T h e scalp should be sutured without tension. T h e aim is to make the open, c o n t a m i n e d w o u n d track b e c o m e a closed clean area. 4) In the case of deep intracerebral foreign bodies (e.g. in the thalamus or internal capsule-basal ganglia region), no effort should be m a d e to locate or remove entrance b o n e or metal fragments visualised on the preoperative CT scan. Only those fragments which present themselves during gentle irrigation and haemostatic manoeuvres should be removed. 5) If the entry of the missile is located in the facioorbital region, cranial base reconstruction should be carried out simultaneously with d e b r i d e m e n t to prevent CSF leakage and extrusion of brain. 6) Postoperative t r e a t m e n t is of equal i m p o r t a n c e as d e b r i d e m e n t . Large doses of antibiotics should be given. Anti-epileptic agents and nerve nutrition agents should also be administered to ensure early recovery. In our study all patients were treated according to these principles. We achieved a high survival rate (90.2%), with the death rate only 9.8%, a result we believe is satisfactory. Received 6 December 1994 Accepted for publication 28 September 1995
Correspondenceand requestsfor offprints: Dr X. Zhang Director Department of Neurosurgery, Xi-Jing Hospital West Chang-Le Road, No 15, Xian 710032, P.R. China Te1:86-29-3224506 Fax:86-29-3242236
J. Clin. Neuroscience Volume 3 Number 3 July 1996
Penetrating craniocerebral injuries
Clinical studies
References 1. Graham TW, Williams FC, HArrington T, Spetzler RF. Civilian gunshot wounds to the head: A prospective study. Neurosurgery 1990; 27: 696-700. 2. Kaufman HH. Civilian gunshot wounds to the head. Neurosurgery 1993; 32: 962-964. 3. Levy ML, Masri LS, Levy KM, Hohnson FL, MartinThomson E, Couldwel WT, McCombJG, Weiss MH, Apuzzo MLJ. Penetrating craniocerebral injury resultant from gunshot wounds: Gan-related injury in children and adolescents. Neurosnrgery 1993; 33: 1018-1025. 4. Siccardi D, Cavaliere R, Pau A, Lubinu F, Turtas S, Viale GL. Penetrating craniocerebral missile injuries in civilians. A retrospective analysis of 314 cases. Surg Neurol 1991; 35: 455-460. 5. Practical Neurosurgery. Edited by PLA General Hospital and Fourth Military Medical University. Soldier's Publishing, Beijing, 1978, pp 448-481. 6. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2: 81-84. 7. Ascroft PB. Treatment of head wounds due to missile. Analysis of 500 cases. Lancet 1945; 2: 211-218. 8. Brandvold B, Levi L, Feinsod M, et al. Penetrating craniocerebral injuries in the Israeli involvement in the Lebanese conflict, 1982-1985: Analysis of a less aggressive surgical approach. J Neurosurg 1990; 72:15-21.
9. Jennett B, Bond M. Assessment of outcome after severe brain damage. A practical scale. Lancet 1975; 1: 482-489. 10. Crockard HA, Brown FD,Johns LM, Mullan S. An experimental cerebral missile injury model in primates. J Neurosurg 1977; 46: 776-781. 11. Rish BL, Caveness WF, DillonJD, KistlerJP, MohrJP, Weiss GH. Analysis of brain abscess after penetrating craniocerebral injuries in Vietnam. Neurosurgery 1981; 9: 535-541. 12. Duan GS. Mechanisms of traumatic cerebral injury. In: Craniocerebral Traumatology, Medical PLA Publishing, Beijing, 1992, pp 84-92. 13. Xue QC. Open craniocerebral injury. In: Neurosurgery, Tiang-Jing Science and Technology Publishing, Tiang-Jing, ER. China, 1990, pp 164-184. 14. Ecker AD. A bacteriologic study of penetrating wounds of the brain, from the surgical point of view.J Neurosurg 1946; 3: 1-6. 15. WebsterJE, Schneider RC, LofstromJE. Observations on early type brain abscess following penetrating wounds of the brain.J Neurosurg 1946; 3: 7-14. 16. Piblyk PJ, Tolchin S, Stewart W. The experimental significance of retained intracranial bone fragments. J Neurosurg 1970; 33: 19-24.
J. Clin. Neuroscience Volume 3 Number 3 July 1996
233
X i a n g Z h a n g MD S h e n g - Y u Yi MD W e i - P i n g Liu MD PhD Z h i - W e n Z h a n g MD PhD L i - G e n W a n g MD PhD A n - M i n Li MD Department of Neurosurgery,Xi-JingHospital of Fourth MilitaryMedical University,P.R. China.
Penetrating craniocerebral firearm injuries remain one of the most lethal causes of all trauma and are c o m m o n both in war or peace time. Data were reviewed for 4140 severely head-injured patients (Glasgow Coma Scale (GCS) scores 3-8) treated at Xi-Jing Hospital between 1973 and 1993; 51 of these patients had acute penetrating craniocerebral injuries caused by firearm missiles. These patients consisted of 46 males (90.2%) and 5 females (9.8%) ranging in age from 3 months to 48 years (median 22.4 years). The lesion types included 2 tangential wounds, 37 tubular wounds and 12 through-and-through wounds. All cases were urgent with the patients in severe and unstable states. After emergency treatment and operation, 5 cases died (9.8%). Follow up studies at three months showed that 23 cases (45.1%) had made a g o o d recovery. Moderate disability, severe disability and vegetative states in this series were 29.4%, 13.7% and 2.0% respectively. Long term follow up studies indicated that 32 were able to resume their occupation. The principles for managing penetrating craniocerebral firearm injuries and suggestions for operation are discussed. Journal of Clinical Neuroscience 1996, 3 (3):229-233
©Pearson Professional 1996
Keywords: Craniocerebral injury, Penetrating injury, Firearm wounds, M a n a g e m e n t , Head injury
Penetrating craniocerebral firearm injuries (PCCFI) are severe traumatic lesions, unavoidable consequences during war time, but also fairly c o m m o n during peace time.i, 2, 3, 4 Flying missiles emitted by explosive weapons (such as gunshot and b o m b fragments) often cause direct traumatic lesions to craniocerebral structures. T e m p o r a r y cavitation effects and dynamic shock waves cause laceration of the scalp, extensive cranial b o n e fractures and massive tissue crushing or contusion along the missile track often with intracranial haematoma. Missile brain lesions are usually extensive and severe, with a high rate of disability and high mortality?, 4, ~ This paper retrospectively analyses clinical experiences of 51 PCCFI cases in 20 years at our hospital. The principles for managing PCCFI and surgical techniques are discussed.
this analysis. The patient population included 46 males and 5 females, age range was 3 months to 48 years, mean age 22.4 years (Table 1).
Types of firearms a) 'Ordinary' weapon bullets (pistols, rifles and machine guns) : these missiles are large and high velocity. b) Dynamic air-gun missiles: these missiles are small with relatively low velocity. c) Shotgun missiles: land mines, multiple small high velocity missies. d) Bomb missiles: Hand grenade, mortar shell (see Table 2).
Table 1 Age distribution of 51 cases of PCCFI Clinical data
Age groups (years)
General i n f o r m a t i o n From 1973 to 1993, 4140 severely head-injured patients (Glasgow Coma Scale (GCS) s c o r e s 3--8) 6 were admitted to the D e p a r t m e n t of Neurosurgery in xi-Jing hospital. In 51 cases the p r e d o m i n a n t traumatic pathology was an acute penetrating craniocerebral injury caused by firearm missiles. Five additional cases with PCCFI who died during transfer to our hospital were excluded from
No.
<15 16
16-30 25
31-45 8
Total >46 2
51
Table 2 Missiletypes of 51 casesof PCCFI Type of traumatic lesion No.
Bomb
Gunshot
Shotgun
Airgun
Total
13
14
20
4
51
J. Clin. Neuroscience Volume 3 N u m b e r 3 July 1996
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Clinical studies
Penetrating craniocerebral injuries
Table 3 Lesion condition of 51 cases of PCCFI Complications %
Traumatic types
No.
Tangential wound Tubular wound Throughand-through wound No. (%)
2
3.9
37
72.6
18
37
10
4
12
23.5
4
12
3
2
22(43.1)
49(96.1) 14(27.5) 6(11.8)
51
100
Haematoma FB
II
Epilepsy
1
FB = retained foreign body, including metal and non-metal II = intracranial infection, three caseswere accompanied by brain abscess
T r a u m a t i c lesion classification a n d a c c o m p a n y i n g diseases
Using Ascroft's classification of flying missiles causing penetrating craniocerebral injuries, 7 we classified our patients into several groups. All patients had scalp injuries, fractures of the cranial bones, rupture of the dura mater and cerebral contusions. 22 patients also had intracranial haematomas. Among 49 cases with retained foreign bodies, most were tubular wounds with retained metal fragments; the lowest n u m b e r of such foreign bodies was 2, the highest n u m b e r 34, in the intracranial cavity of patients injured by shotgun missiles. Two cases with through-and-through wounds also had tubular wounds and retained foreign bodies in the brain (Table 3). Symptoms
Fig. 1 Bomb missile had caused a tubular wound. CT Scan: the missile had entered the left temporo-parietal region, there are foreign bodies in the track, haematoma in the falx.
a n d signs
U p o n entry of a missile into tissue, tissue moves both forward and sideways; the cross-sectional area affected may be as great as 30 times the diameter of the actual missile track. This often causes severe damage a r o u n d the missile track, resulting in an extensive neurological deficit. 37 patients had disturbance of conscious level after injury. 14 patients had no disturbance of consciousness Fig. 2 Gunshot injury caused a parietal through-and-through injury. CT scan: bone fragments and haematoma in the track and free air and haemorrhage in the brain and falx.
Table 4 Clinical manifestations of 51 casesof PCCFI Symptoms and signs Headache,vomiting Disturbance of consciousness lethargy haziness hemicoma coma Hemiplegia Aphasia Meningeal irritation Epilepsy Pupil changes unilateral mydriasis bilateral mydriasis bilateral miosis Decerebraterigidity Lesionsto paranasalsinus Rupture of eye ball Shock Psychotic disorder Pyramidalsigns
230
No. of cases 38 37 12 15 7 3 12 4 9 6 10 5 3 2 3 5 2 3 5 18
Percentage 74.5 72.6 23.5 29.4 13.7 5.9 23.5 7.8 17.7 11.8 19.6 9.8 5.9 3.9 5.9 9.8 3.9 5.9 9.8 35.3
(17.7%), including 4 cases of airgun injury and 10 of 20 cases of shotgun injury. 16 patients were hemiplegic and aphasic. Among the 10 cases of gunshot injuries with an entry wound in the craniofacial region there was simultaneous rupture of the eyeball, open injury of the frontal and sphenoid sinuses and rupture of the paranasal sinuses (Table 4). Brain abscess occurred in 3 cases of tubular wound; these patients had received only superficial wound d e b r i d e m e n t at a local clinic after injury. When admitted to our hospital these patients were very ill with deep cerebral abscesses. Investigations
All patients underwent X-ray examination which included plain X-rays or CT scan. Before 1980 (when there were 6 patients with signs of brain compression) we used cerebral angiography and ultrasonic wave examination.
J. Clin. N e u r o s c i e n c e V o l u m e 3 N u m b e r 3 July 1996
Penetrating craniocerebral injuries
Clinical studies
Using these methods of examination, we could accurately determine the location of metallic foreign bodies or bone fragments (Fig. 1). Early diagnosis ofintracranial h a e m a t o m a and brain o e d e m a was also possible (Fig. 2). Treatment
Resuscitation was begun at the scene or immediately after reaching the emergency d e p a r t m e n t of our hospital, with p r o m p t cleaning of the superficial wound, haemostasis and wound toilet. For some severely injured patients, sedation, analgesia, antibiotics and continued supply of crystalline a n d / o r colloid solutions was necessary. Blood transfusion is essential for shocked patients, and attention should be paid to provision of a clear airway. Intubation and ventilation is desirable and mannitol may be used if raised intracranial pressure occurs. Immediately after resuscitation patients should be taken for X-ray and CT scan examination to determine the degree of brain damage, to determine if there are any metallic foreign bodies or b o n e fragments retained in the missile tracks and to identify intracranial h a e m a t o m a and intraventricular haemorrhage. T h r e e cases of PCCFI showed obvious signs of brain compression and were rushed to operating theatre for craniotomy. Large intracerebral haematomas were cleared along the injury tracks. A plan of treatment for PCCFI patients should be d e t e r m i n e d mainly according to the wound and results of X-ray and CT scan examination. Early d e b r i d e m e n t is always desirable. The goal of surgery is the d e b r i d e m e n t of o p e n craniocerebral wounds with drainage of haemorrhage or infection. Devitalised tissues and various foreign bodies are removed to achieve a clean wound with complete haemostasis (Fig. 3). For deeply placed intracerebral foreign bodies (e.g. in the thalamus or internal capsule-basal ganglia region), we suggest that no effort is made to locate or remove bone or metal fragments visualised on the preoperative CT scan. Only those fragments which present themselves during irrigation and haemostatis maneouvres should be removed, s Surgery should be carefully controlled to avoid unnecessary removal of normal brain tissue, and the wound area should be thoroughly washed with saline, metronidazole and hydrogen peroxide. The dura must be tightly sutured. In general, drains were removed 24-48 h after operation. If infection occurs, drains could be kept for a longer period, say 3-5 days. In some PCCFI patients with intracranial h a e m a t o m a and intraventricular blood clots, the craniotomy should be large e n o u g h to allow complete d e b r i d e m e n t and removal of any haematoma. Generally speaking, d e b r i d e m e n t should be carried out within 72 h after injury. In this study, 9 cases had only had superficial wound d e b r i d e m e n t in their local clinics, and when admitted to our unit the wound was contaminated and intracranial infection had developed. A m o n g these patients, 3 cases were f o u n d with intracranial foreign bodies on CT scan and delayed yet complete debridem e n t was p e r f o r m e d (bone fragments, foreign bodies and deep brain abscess removed). 14 cases of missile wounds with missile entry wounds in the facial and cranial
base area had injuries to the eye ball, facial region, nasal canal and paranasal sinuses with fracture and deficits of the cranial base. Early repair and reconstruction of the cranial base was carried out in addition to wound debridement. This prevented CSF leakage and brain extrusion. After d e b r i d e m e n t antibiotics were routinely given for 7-10 days, usually penicillin and metronidazole. In recent years, we have also used Fortum or Claforan. Nerve nutrition agents such as choline, cytophosphate and Cerebrolysin were also used. When patients recovered consciousness, antiepileptic agents were also given. Results
In this series 5 patients died (9.8%) during their acute hospitalisation. The 46 surviving patients were followed up at three months and the outcome was graded according to the Glasgow Outcome Scale? Outcome was most strongly influenced by the type of initial wound and the patient's condition on arrival at our hospital. Patients with bilateral fixed dilated pupils or decerebrate rigidity had a significantly worse outcome than patients with a GCS greater than 8 or unilateral pupil mydriasis on admission. 23 (45.1%) of these patients made a good recovery, and the proportion of patients with moderate disability, severe disability and persistent vegetative state were 29.4%, 13.7% and 2.0% respectively. We also made a long term follow up survey of the survivors, some of whom were discharged h o m e and some transferred to rehabilitation hospital. The follow up time from injury to re-evaluation was 3-16.7 years, with a median follow up interval of 4.5 years. No patients suffered neurological deterioration, 32 were completely i n d e p e n d e n t at the time of follow up consultation, and 26 were able to resume their occupation.
Fig. 3 Gunshot injury causing through-and-through injury. CT scan: two weeks after debridement. Note: there are no foreign bodies, yet signs of local brain oedema persist.
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Clinical studies Discussion Characteristics and damage of PCCCFI High velocity flying missiles often cause direct d a m a g e to the scalp, cranial bones and cerebral tissue. Penetrating lesions, cavitation effects and dynamic shock waves cause direct a n d indirect t r a u m a to the s u r r o u n d i n g brain adjacent to the missile track. 1'2'3'4'1°'11 T h e diameter of the cavitation effect on the brain tissue may be 3-10 times greater than the diameter of the missile track itself, greatly increasing the hazard of the injury. 12 37 (72.6%) of patients with PCCFI had a disturbed conscious state, a m o n g which 15 (29.4%) patients had hemiplegia and decerebrate rigidity indicating severe brain damage. Following imaging a n d operation we f o u n d the features of this kind of missile injury to be very characteristic: a) Gunshot injury often leads to massive brain contusion, especially if the weapon is fired from close range; b) Shotgun injury may cause multifocal craniocerebral lesions, with simultaneous injury to i m p o r t a n t structures such as brain stem, thalamus or m o t o r areas of the cortex; c) If the lesion includes blood vessels (arteries, veins or venous sinus) intracranial h a e m a t o m a and subarachnoid h a e m o r r h a g e are detected; and d) In patients presenting late after injury, intracranial infections or brain abscess were often found. W h e n a PCCFI patient arrives we aim to make a clear classification of the lesion a n d the missile type. Further efforts are then m a d e to d e t e r m i n e the extent and degree of the lesion and establish if there is any infection. A plan of t r e a t m e n t is formed.
Management of retained foreign bodies in PCCFI T h e r e are almost always some foreign bodies retained along the missile track, regardless of whether it is a tangential, tubular wound or t h r o u g h - a n & t h r o u g h injury. Autopsy studies have shown that the retained foreign bodies in tangential wounds are usually non-metallic; the main objects are pieces of hair, scalp and b o n e fragments. In tubular wounds, the main objects are metallic, sometimes with non-metallic bodies as well. It is generally accepted that foreign bodies retained in the w o u n d are a potential cause of intracranial infection. 13 During World War II researchers f o u n d that a bacterial growth could be cultured f r o m the retained intracranial bodies. 14' 15 In an experimental study in dogs Piblyk found that both the sterile b o n e fragments and non-sterile b o n e fragments could cause brain abscess, but the percentages were 4% and 8% respectively. 16If the b o n e fragments were retained with pieces of scalp or hair, the rate of intracranial abscess increased to as high as 70%. Rish made a five year follow up of head injured patients from the Vietnam War. 11T h e r e were 37 cases of brain abscess, 11 (29.7%) associated with retained intracranial b o n e fragments: these cases showed no other possible routes of intracranial infection such as entry from the facio-orbital region, CSF fistula, wound complications, prolonged coma state or multiple surgical
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Penetrating craniocerebral injuries procedures. In our study 14 patients developed intracranial infection; the main reason for this complication was that the initial d e b r i d e m e n t was not adequate and the patients had waited too long before transfer to our hospital. T h r e e cases n e e d e d re-operation when deep brain abscesses were removed with impacted b o n e fragments and hairs. T h e r e f o r e timely, adequate and complete initial debridem e a t is crucial to avoid intracranial infection. This must be kept in m i n d whenever a PCCFI patient presents.
Principles for managing PCCFI PCCFI are often severe, needing urgent t r e a t m e n t because of rapid neurological deterioration. T h e r e f o r e resuscitation and t r e a t m e n t should be p r o m p t . We conclude with the following principles for managing PCCFI patients: 1) Resuscitation at the scene is very important. Reliable haemostasis should be c o m p l e t e d very quickly, efforts should be m a d e to k e e p the airway p a t e n t to avoid hypoxia. 2) Quickly d e t e r m i n e if there are craniocerebral injuries, their location, extent and severity by using adequate imaging methods. 3) Early and radical d e b r i d e m e n t should be p e r f o r m e d to remove all d a m a g e d brain tisue, b o n e fragments, foreign bodies and intracranial h a e m a t o m a s . T h e w o u n d should be washed thoroughly. Repair of the dura m a t e r must be water tight. T h e scalp should be sutured without tension. T h e aim is to make the open, c o n t a m i n e d w o u n d track b e c o m e a closed clean area. 4) In the case of deep intracerebral foreign bodies (e.g. in the thalamus or internal capsule-basal ganglia region), no effort should be m a d e to locate or remove entrance b o n e or metal fragments visualised on the preoperative CT scan. Only those fragments which present themselves during gentle irrigation and haemostatic manoeuvres should be removed. 5) If the entry of the missile is located in the facioorbital region, cranial base reconstruction should be carried out simultaneously with d e b r i d e m e n t to prevent CSF leakage and extrusion of brain. 6) Postoperative t r e a t m e n t is of equal i m p o r t a n c e as d e b r i d e m e n t . Large doses of antibiotics should be given. Anti-epileptic agents and nerve nutrition agents should also be administered to ensure early recovery. In our study all patients were treated according to these principles. We achieved a high survival rate (90.2%), with the death rate only 9.8%, a result we believe is satisfactory. Received 6 December 1994 Accepted for publication 28 September 1995
Correspondenceand requestsfor offprints: Dr X. Zhang Director Department of Neurosurgery, Xi-Jing Hospital West Chang-Le Road, No 15, Xian 710032, P.R. China Te1:86-29-3224506 Fax:86-29-3242236
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Clinical studies
References 1. Graham TW, Williams FC, HArrington T, Spetzler RF. Civilian gunshot wounds to the head: A prospective study. Neurosurgery 1990; 27: 696-700. 2. Kaufman HH. Civilian gunshot wounds to the head. Neurosurgery 1993; 32: 962-964. 3. Levy ML, Masri LS, Levy KM, Hohnson FL, MartinThomson E, Couldwel WT, McCombJG, Weiss MH, Apuzzo MLJ. Penetrating craniocerebral injury resultant from gunshot wounds: Gan-related injury in children and adolescents. Neurosnrgery 1993; 33: 1018-1025. 4. Siccardi D, Cavaliere R, Pau A, Lubinu F, Turtas S, Viale GL. Penetrating craniocerebral missile injuries in civilians. A retrospective analysis of 314 cases. Surg Neurol 1991; 35: 455-460. 5. Practical Neurosurgery. Edited by PLA General Hospital and Fourth Military Medical University. Soldier's Publishing, Beijing, 1978, pp 448-481. 6. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2: 81-84. 7. Ascroft PB. Treatment of head wounds due to missile. Analysis of 500 cases. Lancet 1945; 2: 211-218. 8. Brandvold B, Levi L, Feinsod M, et al. Penetrating craniocerebral injuries in the Israeli involvement in the Lebanese conflict, 1982-1985: Analysis of a less aggressive surgical approach. J Neurosurg 1990; 72:15-21.
9. Jennett B, Bond M. Assessment of outcome after severe brain damage. A practical scale. Lancet 1975; 1: 482-489. 10. Crockard HA, Brown FD,Johns LM, Mullan S. An experimental cerebral missile injury model in primates. J Neurosurg 1977; 46: 776-781. 11. Rish BL, Caveness WF, DillonJD, KistlerJP, MohrJP, Weiss GH. Analysis of brain abscess after penetrating craniocerebral injuries in Vietnam. Neurosurgery 1981; 9: 535-541. 12. Duan GS. Mechanisms of traumatic cerebral injury. In: Craniocerebral Traumatology, Medical PLA Publishing, Beijing, 1992, pp 84-92. 13. Xue QC. Open craniocerebral injury. In: Neurosurgery, Tiang-Jing Science and Technology Publishing, Tiang-Jing, ER. China, 1990, pp 164-184. 14. Ecker AD. A bacteriologic study of penetrating wounds of the brain, from the surgical point of view.J Neurosurg 1946; 3: 1-6. 15. WebsterJE, Schneider RC, LofstromJE. Observations on early type brain abscess following penetrating wounds of the brain.J Neurosurg 1946; 3: 7-14. 16. Piblyk PJ, Tolchin S, Stewart W. The experimental significance of retained intracranial bone fragments. J Neurosurg 1970; 33: 19-24.
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