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- Med J Armed Forces India
- v.77(4); 2021 Oct
- PMC8459072
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Med J Armed Forces India. 2021 Oct; 77(4): 382–389.
Published online 2021 Aug 16. doi:10.1016/j.mjafi.2021.03.023
PMCID: PMC8459072
PMID: 34594064
Manish Sharma,a,∗ Anand Gupta,b Anil Kumar,c Rajnish Talwar,d and Rakesh Kumare
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Abstract
Background
High-velocity missile injuries are commonly encountered in war or war-like situations. Aggressive resuscitation, early evacuation to neurosurgical center, and application of neurosurgical principles remain tenets of success.
Methods
The spectrum of injuries and clinical profile of 14 such cases with craniocerebral missile injuries managed at our center in the northern sector were included. Site of injury, GCS at presentation, associated injuries, surgical intervention, duration of hospitalization, and recovery of the patient were analyzed.
Results
Five patients had sustained gunshot wounds, and nine patients had sustained shrapnel injuries. Thirteen patients were deeply comatose, and one patient was conscious.The entry wound was in frontal lobe in eight patients, and in four patients, it was inthefaciocranial area. Ten patients had Glasgow Coma Scale (GCS) less than 8at presentation. Surgical intervention was required in 13 patients, including 11 decompressive craniectomies and anterior skull base repair in four patients with faciocranial entry wound. One patient expired during initial resuscitation, and one patient died in the postoperative period. Location of injury was the single most important determinant of outcome.
Conclusion
An early decompressive craniectomy provides a reasonable chance of recovery. Aggressive debridement involving track explorations, lobectomies, or removal of retained shrapnels is not beneficial. Injuries to the skull base and violation of sinus spaces predispose these patients to cerebrospinal fluid leaks and infective sequelae. All these patients require aggressive postoperative intensive care and rehabilitation.
Keywords: Craniocerebral, Missile, Penetrating injuries, Gunshot wounds, Shrapnels
Introduction
Craniocerebral missileinjuries in combat zone are a significant cause of morbidity and mortality and jeopardize operational activity. Despite the advances made in the protective gear, they remain fairly common. An understanding of the biomechanics of injury and improvements in surgical principles and nuances along with advancements in critical care providea fair chance of survival to the victims of these high-velocity missile injuries to the head. The understanding of the impact of high-velocity penetrating missile on the brain and refinement of the surgical techniques is certain to improve the outcome in the days to come and herein lies the reason for the data on these injuries to be brought together. It is expected that a better understanding of the factors highlighted will not only lead to improvements in surgical techniques but also in refining protective gear for better efficacy.
Material and methods
A total of 14 patients with craniocerebral missile injuries were managed at a single hospital from January 2018 to June 2019 (Table 1). Injuries were sustained from gunshots or shrapnels from either mortars or grenades. All patients were air evacuated after initial resuscitation and stabilization. Initial care was provided either by the medical officer at location or the surgical specialist. One patient was operated on at a forward surgical center before being transferred. Initial evaluation was done as per the ATLS guidelines, and an Non-Contrast Computed Tomogram (NCCT) head was performed in all cases at the earliest to understand the trajectory, retained splinters/nature of injury to the brain and location of hematoma/contusions, if any. Small superficial wounds with no injury to the brain were managed with local wound debridement. Any injury to the brain causing cerebral edema required decompressive craniectomy. In case of faciocranial wounds, simultaneous skull base repair was done using tensor facia lata. Postoperatively, these patients were managed in the intensive care unit. Depending on their clinical progress, they were gradually weaned off the ventilator and started on oral nutrition. Antibiotic cover was given as per the hospital policy. Metronidazole was added for all cases with craniofacial entry, as the sinuses were breached. Prophylactic antiepileptics were started at admission and administered for atleast a period of 1 month. A repeat NCCT was done after 48hunless an early scan was clinically warranted.
Table 1
Summary of cases.
| S. No | Age (Yrs) | Mode of injury | Entry location | GCS at admission | Pupils | Time to reach | CT findings | Surgery | GOS |
|---|---|---|---|---|---|---|---|---|---|
| 1 | 24 | GSW | High frontal | E1VtM3 | NSNR | 3h | Multiple fractures (Rt) frontal bone with contusions Thin SDH | Debridement Decompressive craniectomy+loose duraplasty | 5 |
| 2 | 34 | Shrapnel from mortar | Faciocranial | E1VtM1 | B/L sluggishly reacting | <1h | Fracture of bones of skull base Bifrontal contusions Retained shrapnel | Debridement Decompressive craniectomy+loose duraplasty | 4 |
| 3 | 31 | Shrapnel from Mortar | (Rt) Frontal | E1VtM4 (Lt) hemiplegia | (Lt) Pupil sluggishly reacting | <1h | Bony defect at entry wound. IVH Bleed along wound track Shrapnel lodged in (Rt) occipital lobe | Debridement Decompressive craniectomy+loose duraplasty | 3 |
| 4 | 25 | GSW | (Lt) High frontal | E4V5M6 | NSNR | 1 day | Depressed fracture (Rt) frontal | Wound debridement Elevation of fracture | 5 |
| 5 | 37 | GSW | (Rt) Frontal | E1VtM1 | Non reacting | 6h | Not done | Not done | 1 |
| 6 | 25 | GSW | Faciocranial | E1VtM1 | Non reacting | 3 days | Bifrontal contusions (Rt) Temporal contusions | Bilateral decompressive craniectomy Loose duraplasty | 1 |
| 7 | 30 | Shrapnel from Grenade | (Lt) Frontal | E3VtM4 (Rt) hemiparesis | NSNR | 8h | (Lt) Frontal contusion Shrapnel retained (Lt) frontal | Wound debridement+(Lt) frontal decompressive craniectomy+loose duraplasty | 4 |
| 8 | 37 | GSW | (Lt) Frontal | E1VtM4 (Rt) upper limb GD 3/5 | Sluggishly reacting | 5h | (Lt) Frontal contusion with bone pieces buried deep inside | Wound debridement+(Lt) frontal decompressive craniectomy+loose duraplasty | 5 |
| 9 | 28 | Splinter | Faciocranial | E1 VtM4 (Lt) hemiplegia | Sluggishly reacting | 1 day | Fracture bones of facial skeleton+shrapnel lodged in (Lt) cavernous sinus | Endoscopic transnasal removal of shrapnel | 4 |
| 10 | 30 | Shrapnel from grenade | (Rt) Frontal | E2VtM4 (Lt hemiparesis) | (Rt) Dilated and nonreacting | 1 day | (Rt) frontal contusion Shrapnel lodged in occipital lobe IVH | Wound debridement+(Rt) frontal decompressive craniectomy+loose duraplasty | 4 |
| 11 | 35 | Shrapnel | (RT) Parietal | E1VtM3 | NSNR | 8h | (Rt) Parietal contusion with bone fragments and shrapnel lodged in parietal lobe | (Rt) Frontoparietal decompressive craniectomy+loose duraplasty | 3 |
| 12 | 24 | Shrapnel | (Lt) Frontal | E2VtM4 | Sluggishly reacting | 4h | (Lt) frontal and parietal contusion with IVH. | Decompression+decompressive craniectomy+loose duraplasty | 4 |
| 13 | 33 | Shrapnel | Faciocranial | E1VtM4 | NSNR | 9h | Fracture skull base with (Rt) frontal lobe contusion and hemorrhage along track | (Rt) Fronto-temporo-parietal decompressive craniectomy+loose duraplasty | 4 |
| 14 | 31 | Shrapnel | (Rt) Parietal | E2VtM2 (Lt) hemiplegia | Sluggishly reacting | 1 day | Fracture (Rt) parietal bone+contusion (Rt) parietal | (RT) FTP decompressive craniectomy+loose duraplasty | 3 |
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Representative cases
Case 1
A 24-year-old male sustained a gunshot wound to the head. The entry wound was about 4cm to the right of the midline at the level of (Rt) coronal suture (Fig.1). The exit wound was just above the (Rt) eye. Bullet had exited, but a piece of it had retained deep inside the (Rt) frontal lobe. The patient was brought with a Glasgow Coma Scale (GCS) of E1VtM3 after initial stabilization at a forward surgical center within 3hof injury. He was immediately taken up for emergency surgery wherein (RT) fronto-temporo-parietal (FTP) decompressive craniotomy, and wound debridement along with loose duraplasty was done. The patient had a steady recovery and was following commands by the seventh day but had Gd-2 power on the left side. He was started on orals by the third postoperative day. Aggressive physiotherapy was continued, and by the end of 4 weeks, he was ambulant with support, and by the sixth week, he was independent for all activities.
Fig.1
(a)Lateral view of skull in a reconstructed 3D image showing multiple fractures of (Rt) frontal bone. (b)Intraoperative image showing swollen brain. (c)Axial cut of NCCT head showing contusion in (Rt) frontal lobe and retained foreign body. (d)Postoperative computed tomography scan showing resolving contusion and edema.
Case 2
A 34-year-old male sustained injury with a shrapnel from a mortar, which had entered just to the (Lt) of the root of nose and had traversed through the ethmoid sinus, (Lt) frontal lobe into the (Lt) parietal lobe where it was lodged (Fig.2). The patient reached us within 1hof the injury. There was an entry wound with herniated brain matter along with dirt and gravel. There were no exit wounds. He had poor neurological status with a GCS of E1VtM1 with reacting pupils. Both eyes were spared, and optic pathway was intact. An urgent NCCT head revealed shattered bones of skull base, bifrontal contusions, and shrapnel lodged in (Lt) parietal region with blood along the track. There was no associated injury, and the patient was hemodynamically stable. He had been intubated before being evacuated to the neurosurgical center. He was immediately taken up for surgery, wherein wound debridement and removal of bone chips from frontal lobe were taken. Bifrontal craniotomy was done. A small strip of bone was left over sagittal sinus because of a fracture segment over the sinus with the possibility of an underlying tear of sagittal sinus.
Fig.2
(a)Entry wound as seen on reconstructed 3D ON NCCT. (b)Axial NCCT head showing bifrontal contusions. (c)Coronal section showing skull base destruction. (d)Entry wound. (e)Fascia lata cut in pantaloons shape before. (f)Postoperative NCCT head showing bifrontal craniotomy.
Case 3
A 31-year-old male sustained injury with a shrapnel from mortar blast. The entry wound was at outer aspect of (Lt) eyebrow (Fig.3). There was no exit wound, and the shrapnel had traveled to the occipital lobe traversing the ventricles, and there was blood in the ventricles and along the track of the wound. The patient reached the neurosurgical center within 1hof the injury. He had been intubated at the site of injury. After aggressive resuscitation and evaluation, he was urgently taken up for wound debridement (Rt), decompressive craniectomy, and duraplasty. The patient had a steady recovery. He, however, had (Lt) hemiparesis with lower limb having Gd 3/5 power and upper limb with 2/5 power.
Fig.3
(a)Entry wound. (b)Axial section of NCCT head showing bleed along track line and intraventricular hemorrhage. (c)Intraoperative appearance of entry wound and skull fractures. (d)Sagittal bony cut showing skull base fracture.
Results
A total of 14 patients with craniocerebral missile injuries were managed. All patients were young healthy males. Nine had been injured with shrapnels, and five had been injured with bullets (Table 1).
Transportation
All patients were air evacuated from forward location either from the site of the incident or from the nearest hospital where they were provided initial care. All except one patient, who was fully conscious, were intubated and transferred. Three patients reached our center in less than 1h of injury. Seven patients reached between 1 and 8h. One patient after surgery at forward surgical center was held there for 3 days till he was fit for air evacuation. Other patients reached within 1 day of injury (Table 1).
Entry and exit wounds
Entry wounds of bullet injuries were small and slit like. Exit wound, if present, was larger in size with herniation of brain matter. Shrapnel injuries had entry wounds depending on the size of shrapnel. Invariably, the bone pieces were lodged inside along with the shrapnels.
Site of entry wounds and trajectory
The entry wound was present in the frontal lobe in eight patients, and in four patients, it was in the faciocranial area. In two patients, it was in the parietal area. The bullets in the gunshot wounds had exited in all cases; however, the shrapnels were invariably retained inside the cranium. Three patients had trajectory in the coronal plane, injuring both hemispheres, and of these, two had a fatal outcome. Eleven other patients had trajectory along the sagittal plane.
Lobes involved
Frontal lobe was the most common lobe involved. Multiple lobes were involved in eight patients. Intraventricular hemorrhage was present in three patients (Table 2).
Table 2
Lobes involved and outcome.
| Lobes involved | Total | GOS 5 | GOS 4 | GOS 3 | GOS 2 | GOS 1 | |
|---|---|---|---|---|---|---|---|
| Single lobe | Frontal | 5 | 4 | 1 | |||
| Parietal | 1 | 1 | |||||
| Multilobar (excluding bihemispheric) | 4 | 1 | 3 | ||||
| Bihemispheric | 3 | 1a | 2b | ||||
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aBifrontal.
bBiparietal/frontoparietal.
Neurological status at presentation
All except .one patient was deeply comatose. All patients except the one conscious patient had been intubated before transfer. Ten patients had GCS less than 8, three patients had GCS between 8 and 12, and one patient was fully conscious and alert. Ten patients had hemiparesis/hemiplegia at initial evaluation. Three patients had GCS of 3at initial examination, so no motor response could be elicited. Only one patient was without any neurological deficit (Table 3).
Table 3
Initial GCS and outcome.
| GCS | Total | GOS 5 | GOS 4 | GOS 3 | GOS 2 | GOS 1 |
|---|---|---|---|---|---|---|
| 3–8 | 10 | 2 | 3 | 3 | 2 | |
| 9–12 | 3 | 3 | ||||
| 13–15 | 1 | 1 |
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Surgical intervention
Eleven patients were operated on as emergencies after aggressive resuscitation. One patient with depressed fracture was taken up as an elective case, as initially only wound debridement was done and the patient was fully conscious. One patient with shrapnel lodged in cavernous sinus was taken up for delayed surgery and its removal as part of endoscopic skull base repair for Cerebro-Spinal Fluid (CSF) leak. One patient was inamoribund condition with poor hemodynamic status andexpired before any intervention. Wide unilateral FTPdecompressive craniectomy was done in eight patients along with wound debridement and loose duraplasty. Bilateral FTP craniectomy was done in one patient, bifrontal craniotomy was done in one patient, and limited frontal craniectomy was done in one patient. Three patients required open anterior skull base repair using fascia lata. One of these had a CSF leak after 2 months, for which he had to be operated on again.
Postoperative recovery
Of the 13 patients operated on, one died in the postoperative period because of the severity of injuries. Glasgow Outcome Scale (GOS) was assessed at periodic intervals. At the end of 6 months, three patients had a GOS of 3, and a total of nine patients had a good recovery (Table 4).
Table 4
Outcome of patients.
| GOS | Numbers |
|---|---|
| 5 | 3 |
| 4 | 6 |
| 3 | 3 |
| 2 | 0 |
| 1 | 2 |
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Discussion
Craniocerebral missileinjuries remainone of the most life-threatening injuries in conventional and proxy war. Its management has evolved over the period with lessons learnt during various military conflicts of the past.1 With the adoption of less aggressive exploration of the wound, the track number of retained foreign bodies has increased.2 Location of injuries and the associated injuries are the most important determinants of the outcome.3 Over the period, numerous lessons have been learnt from various conflicts world over. From a surgical tenet of no intervention in earlier times to aggressively chasing and removing the retained foreign bodies in World War II to limited intervention as learnt during Vietnam and Lebanese conflicts.1,4 Aggressive superficial wound debridement and wide decompression and duraplasty are the currently accepted surgical interventions.5
An early transfer to a surgical center equipped for definitive care remains a challenge but improves prognosis.5 Over a period, transportation services have improved significantly. Three of our patients reached within 1h and were operated on soon thereafter and had a good recovery. A well-streamlined and motivated team for evacuation is important to achieve this aim.
Initial GCS is an important prognostic indicator for long-term outcome in any kind of head injury.5 However, in the spectrum of patients in the present study, even patients with poor initial GCS had a relatively good outcome. This can be explained by patients in the present study being young and healthy individuals. Also that the low initial GCS could be spurious because of concussion like effect of blast impact on the brain. As more and more patients are being evacuated early to centers with neurosurgical facility, it is not recommended that patients with poor GCS, even between 3 and 5, be deprived of surgical decompression.1 We as a policy offer surgical decompression to all victims having cerebral edema that may hamper their recovery irrespective of poor GCS, unless there are signs of brain stem death. Three of our patients reached within 1h and were taken up for emergent surgery despite a low recorded GCS and have had a favorable outcome.
In our study, the entry wound was seen in frontal lobe in eight patients and in faciocranial area in another four patients. Only two patients had injuries in the parietal lobe. The injuries in parietal and temporal lobe are generally devastating, and fewer patients survive to be evacuated to the hospital. Also, the trajectory along the sagittal suture is less devastating than if the trajectory is along the coronal, which is likely to injure more vital areas and vessels. Involvement of a single lobe has better prognosis than multilobar involvement. If the trajectory involves both hemispheres, especially areas other than frontal lobe, the prognosis is worse.
Surgical intervention has to be done aggressively. However, the extent of surgery has to be kept to minimal possible. No attempt should be made to debride the missile track or remove the foreign body at the cost of causing further damage to the viable brain. However, the problem of cerebral edema because of injuries can be addressed by a wide decompressive craniectomy and duraplasty.6 Foreign bodies can be safely left behind if inaccessible, as the probability of infection and abscess formation is remote.
Patients with faciocranial entry wounds are contaminated and have the dual risk of infection early on in the course of disease and CSF rhinorrhea either early or delayed delaying the recovery and increasing the morbidity.2,7
As in any field of medicine, prevention remains better than the cure. Combat helmets play a pivotal role in preventing soldier's head but not one such exists, which offers complete protection against the diverse array of injuries in the battlefield. Measures to increase the ballistic protection offered by helmets invariably lead to reduced compliance by the users. A lot has been done in the field of protective gear in the battlefield, and a lot of research is being done. Kevlar helmet shell with webbing and padding on inside, the addition of face shields, helmet sensors, and improved aerodynamic shapes are likely to offer better protection not only against shrapnels but also bullets and blast waves.8 Despite the availability of superlative equipment, it can be useful only if it is used. It can become challenging for the soldier to wear these heavy helmets in battlefield for long periods.9 Ensuring compliance of wearing helmets, especially in the face of enemy certainly has a role in saving more than just the valuable life of a soldier.
Recommendations
Although a detailed review of recommendations is out of the scope of this article, it is felt prudent to highlight certain points based on existing literature and personal experience. In craniocerebral missile injuries sustained in the battlefield, the challenge remains to rapidly evacuate the patient to a specialized center and while doing so to achieve resuscitation. Rapid evacuation of patients from battlefield to specialized centers is a reality, and an evolved system should rapidly embrace it.10
Site of injury
Care is to be provided as per the tenets of ATLS care and involves maintenance of airway, proper ventilation, and ensuring circulation after safeguarding from any further injury. Hypoxia and hypotension should be avoided at any cost to prevent secondary brain injury. A well-trained paramedic team is an absolute requirement in achieving this goal.
Forward surgical center
It is likely and also recommended that if possible, patient be evacuated from the site of injury directly to the nearest neurosurgical center. However, if he is retained at forward surgical center, either because of inability to evacuate or if mandated by patient's condition, it is recommended that:
1)
aggressive resuscitation with blood products and hyperosmolar fluids be done.11
2)
patients with GCS 6–9 should be aggressively resuscitated. At the same time, poor GCS between 3 and 5 should not be a reason to deprive aggressive resuscitation.
3)
acute traumatic coagulopathy is a life-threatening condition and should be looked for and early steps are taken to prevent and correct it.12,13
4)
surgical specialist at this forward location should have the expertise to provide basic neurosurgery care such as handling of brain tissue, use of bipolar cautery to achieve cerebral hemostasis, decompressive craniectomy, and duraplasty if required.
Antibiotics
Broad-spectrum antibiotics, preferably a cephalosporin in combination with Amikacin for a period of 5–7 days, is the minimum requirement. Metronidazole should be added if the foreign body has traversed the sinuses or if the wound is contaminated.
Antiepileptics
1)
Prophylactic antiepileptics either phenytoin or levetiracetam should be given for atleast a period of 7 days.
2)
If the patient has had seizure, then antiepileptics should be administered as per the established guidelines for immediate, early, and delayed seizure after head injuries.
Surgical recommendations
1)
Minor pellet injuries:
a)
Local debridement and closure of wound with antibiotics.
2)
Focal injuries with hemorrhage: (without any significant radiological features).
a)
Local exploration with or without a limited craniotomy.
3)
Severe penetrating injuries (with cerebral edema/infarct/ parenchymal hemorrhage).
a)
Aggressive decompression in the form of decompressive craniectomy.
b)
Conservative debridement.
c)
Foreign bodies, either shrapnels or bone pieces, are best left alone as attempts to remove the same can lead to more damage than benefit.
d)
Evacuation of hematoma, if any.
e)
Watertight duraplasty preferably with hom*ologous graft such as pericranium/temporalis facia or fascia lata.
Conclusion
Craniocerebral missile injuries are formidable injuries with high threat to life. An aggressive resuscitation and rapid transport to a center well equipped with neurosurgical and critical facilities is of paramount importance. Superficial debridement and a wide decompressive craniectomy are standard of care. Retained splinters pose only minimal threat of abscess formation and should not be chased at the cost of causing further damage to the viable brain. In case of anterior skull base fractures, a primary repair using fascia lata reduces the chances of CSF leakage. Broad-spectrum antibiotics along with metronidazole in case of skull base fractures are required. Antiepileptics should be used in all penetrating injuries.
Disclosure of competing interest
The authors have none to declare.
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