Penetrating wounds of the brain: Management in an Evacuation Hospital

Abstract

1. 1. One hundred twenty-two patients with penetrating wounds of the brain who underwent primary definitive surgery at an evacuation hospital during fourteen months of the Italian campaign are reported. Less than 2 per cent of battle casualties reaching this evacuation hospital had such an injury. The total mortality rate of all patients with penetrating wounds of the brain who reached the hospital alive was 29 per cent. The operative mortality rate was 12.3 per cent. 2. 2. The factors influencing the decrease in the operative mortality rate during World War II are thought to be chemotherapy, blood replacement and earlier primary definitive care. 3. 3. Aspiration of vomitus, blood or bronchial secretion was a frequent complication. Such a complication required vigorous treatment. Evacuation in the coma position was an aid in preventing aspiration. 4. 4. Surgery upon these patients was deferred until they presented the optimum preoperative condition. Decompression was seldom urgent. 5. 5. Local field block or endotracheal ether were the anesthetics of choice. 6. 6. In general, craniectomy was preferable to craniotomy. 7. 7. Débridement of all involved tissue was considered imperative. 8. 8. Dural closure was preferred in all cases in which a satisfactory débridement of the brain had been accomplished. 9. 9. The tissue used to close a dural defect did not appear to be an important factor in the development of post-traumatic brain abscess. Retained débris or bone fragments were apparently more important factors than the type of graft. 10. 10. Penicillin and sulfadiazine seemed to be about equally efficacious in preventing and controlling infection in craniocerebral wounds. 11. 11. Every effort was made to close the scalp over cranial defects. Drainage of scalp wounds would appear to be contraindicated. 12. 12. Except for injury of the mid-portion of the superior sagittal sinus, vascular injury was not a serious complication. 13. 13. The involvement of air sinuses in craniocerebral wounds was not a serious complication with respect to infection or mortality. 14. 14. Ventricular injury was a serious complication despite the chemotherapy available. 15. 15. The use of concentrated plasma did not objectively alter the postoperative course of these patients. 16. 16. No undesirable effects were noted from early postoperative ambulation.