Management of penetrating brain injury

Abstract

Penetrating brain injury (PBI), though less prevalent than closed head trauma, carries a worse prognosis. The publication of Guidelines for the Management of Penetrating Brain Injury in 2001, attempted to standardize the management of PBI. This paper provides a precise and updated account of the medical and surgical management of these unique injuries which still present a significant challenge to practicing neurosurgeons worldwide. The management algorithms presented in this document are based on Guidelines for the Management of Penetrating Brain Injury and the recommendations are from literature published after 2001. Optimum management of PBI requires adequate comprehension of mechanism and pathophysiology of injury. Based on current evidence, we recommend computed tomography scanning as the neuroradiologic modality of choice for PBI patients. Cerebral angiography is recommended in patients with PBI, where there is a high suspicion of vascular injury. It is still debatable whether craniectomy or craniotomy is the best approach in PBI patients. The recent trend is toward a less aggressive debridement of deep-seated bone and missile fragments and a more aggressive antibiotic prophylaxis in an effort to improve outcomes. Cerebrospinal fluid (CSF) leaks are common in PBI patients and surgical correction is recommended for those which do not close spontaneously or are refractory to CSF diversion through a ventricular or lumbar drain. The risk of post-traumatic epilepsy after PBI is high, and therefore, the use of prophylactic anticonvulsants is recommended. Advanced age, suicide attempts, associated coagulopathy, Glasgow coma scale score of 3 with bilaterally fixed and dilated pupils, and high initial intracranial pressure have been correlated with worse outcomes in PBI patients.

Keywords: Medical management; penetrating brain injury; surgical management.

Figure 1

The skull X - ray (antero - posterior view) is of a neurologically intact, young male patient who presented after a bomb exploded near a political rally. The patient was asymptomatic except for a small puncture wound on scalp, causing minimal bleeding. The skull X - ray was carried out to screen for foreign bodies. The patient was managed conservatively, and at 6 months clinical and radiological follow - up, he remained stable with no displacement of the intracranial shrapnel

Figure 2

The computed tomography (CT) scan of brain showing left frontal penetrating injury causing multiple fractures and pneumocranium. Multiple bone fragments are displaced within brain parenchyma resulting in contusion and edema. This male patient, a blast victim, at presentation was localizing to pain and had right hemiparesis. He underwent craniotomy, debridement, including removal of superficial intracranial bone fragments, wound refashioning, and primary closure. Post - operative course was unremarkable and at 6 months follow - up, the patient was completely independent, although he had persistent mild hemiparesis

Figure 3

(a) Axial computed tomography (CT) scan of the brain showing compound expansile skull fracture with multiple bone fragments along the trajectory and global cerebral edema. Basal cisterns are totally effaced. This 35 - year old patient came to us within 20 mins of gunshot injury. On examination, he had Glasgow coma scale (GCS) score of 3, with open herniating brain through a complex scalp defect. (b) The patient underwent decompressive craniectomy, repair of superior sagittal sinus, wound debridement, and expansile duroplasty using pericranium and temporalis fascia. Post-operative CT scan of the brain revealed swollen brain herniating through craniectomy defect. (c) Post-operative axial CT scan of the brain (2 months after surgery) showing normal appearance of ventricles and sunken scalp flap. At that time, the patient was electively admitted for cranioplasty. He was awake and alert, speaking spontaneously, following commands, and moving all four limbs