Experiences with 156 Penetrating Wounds of the Head

Nonmissile Anterior Skull-Base Penetrating Brain Injury: Experience with 22 Patients

Background:

Nonmissile anterior skull-base penetrating brain injuries (NASBPBIs) have specific characteristic features that are different from missile injuries. Our study presents our experiences on the characteristic features as well as management of NASBPBI.

Materials and Methods:

We retrospectively reviewed 22 consecutive patients with NASBPBI managed at our institute during a 13-year period. The mechanism of injury, clinical investigations, and complications were analyzed, with more emphasis on diagnostic and treatment regimen.

Results:

The 22 cases included in our study comprise of 20 males and 2 females. Majority (72.7%) of the patients were adults with a mean age of 27.5 years. The mechanisms of injury often include accidental fall, either onto a small-diameter sharp object (10 cases) or while carrying such an object in the hand (4 cases). The other common mechanisms were stabbing, accident, or during an altercation (8 cases). Clinical manifestations included periorbital hematoma (10 cases, 45.5%) and cerebrospinal fluid rhinorrhea or orbitorrhea (4 cases, 18.2%) as well as signs of embedded foreign object (8 cases, 36.4%). We performed emergency craniotomy in 21 cases and skin debridement in one case. Postoperative complications were abscess (1 case), epilepsy (1 case), and traumatic carotid-cavernous fistula (1 case).

Conclusion:

Nonmissile injuries are generally on the rise and therefore deserve more attention. We observed that clinical outcomes were excellent in 14 (Glasgow Outcome Scale [GOS] score of 5) and good in the remaining 8 patients (GOS of 4) during 6-month–10-year (mean 4.6 years) follow-ups.

An historical context of modern principles in the management of intracranial injury from projectiles

The contemporary management of projectile head injuries owes much to the lessons neurosurgeons have distilled from their experiences in war. Through early investigation and an increasingly detailed account of wartime clinical experience, neurosurgeons—including the field's early giants—began to gain a greater understanding not only of intracranial missile pathophysiology but also of appropriate management. In this paper, the authors trace the development of the principles of managing intracranial projectile injury from the Crimean War in the 19th century through the Vietnam War to provide a context that frames a summary of today's core management principles.

Mortality in missile wounds of the head

In a series of 250 patients with missile wounds of the head treated at the University College Hospital, Ibadan, Nigeria, 35 died after admission, a mortality of 14 per cent. Forty-three per cent of the deaths occurred within a week of wounding and were predominantly due to severe anatomical damage; among the 34 per cent who died at least 4 weeks after wounding there was evidence of intracranial infection. Surgical operation did not improve the outcome in the group with severe anatomical damage. A serious disturbance of the level of consciousness on admission, namely coma, was a bad prognostic sign.