806 Penetrating Head Injuries from Terrorist Bomb Blasts: The Jerusalem Experience

Abstract

INTRODUCTION: From December 2000 to March 2004, we treated 24 patients with penetrating head injuries caused by terrorist bomb blasts. A variety of objects are placed in these bombs to maximize tissue damage and penetrate the cranium, including ball bearings, metal bolts, hexagonal nuts, segments of metal rods, and nails. METHODS: Data on consective injured patients were collected prospectively. Three patients presented with a Glasgow Coma Scale (GCS) score of between 3 and 5, six patients with a GCS score of 6 to 9, four patients with a GCS score of 10 to 12, and 11 patients with a GCS score of 13 to 15. Fifteen patients underwent craniotomy, ventriculostomy, intracranial pressure (ICP) monitoring, or a combination immediately after injury. RESULTS: Of the 13 patients who underwent ICP monitoring, the mean ICP at insertion was 20.3 mm Hg, with a range of 8 to 30 mm Hg. The peak ICP in these patients was 33.5 mm Hg and ranged from 12 to 70 mm Hg. Of the patients who did not obey commands at presentation, the mean time to return to consciousness was 5.4 days (range, 2–12 d). Three patients died, and 21 survived. At a mean follow-up of 18.2 months (range, 2–28 mo), 14 surviving patients achieved a GOS score of 5, six a GOS score of 4, and one patient had a GOS score of 3. Two patients developed a traumatic intracranial aneurysm, and two patients had documented migration of a metallic fragment within the brain. One patient developed a fatal ventriculitis. Four patients underwent delayed removal of a metallic fragment with the aid of an image-guided surgical navigation system with good results. CONCLUSION: Patients with penetrating head injuries from bomb blasts can achieve good functional outcomes. Complications including infection, traumatic intracranial aneurysm, and migration of fragments must be anticipated and treated aggressively. In a subgroup of patients, delayed removal of metallic fragments may be warranted.