Cranial Wounds Research Articles

Munchausen's Syndrome in Neurosurgery: Report of Two Cases and Review of the Literature

Munchausen's syndrome is a rare psychiatric condition, in which patients seek medical treatment for factitious or self-induced medical problems. Reports in the literature of postoperative Munchausen's syndrome are extremely rare. The major obstacle to improving management of the patients with Munchausen's syndrome is increasing physicians' awareness and recognition of the disease. Although Munchausen's syndrome is rare, physicians probably will encounter at least one such patient at some point during their career and therefore should be aware of this disorder. We report two documented cases of postoperative Munchausen's syndrome in patients who underwent cranial neurosurgery. Both patients received complex flaps for closure of their cranial defects. Both patients later admitted to deliberately reopening their cranial wounds because of a psychological desire to continue their illness. The primary therapeutic objective is to achieve wound healing and stop the cycle of surgical procedures. Immediate confrontation with the patient often does more harm than good. Instead, psychiatric consultation, with the potential for nonsurgical management and behavior modification, should be obtained. Munchausen's syndrome is a rare psychiatric diagnosis, especially in the postoperative patient. The common clues to diagnosis are: 1) a nonhealing wound in the absence of risk factors for wound failure, 2) a history of psychiatric illness, 3) repeated bleeding from the wound site, and 4) a desire to continue the sick role. Early detection will allow proper psychiatric referral to prevent injuries to the patient, abuses to the medical system, and unnecessary operations.

Reconstruction of complex cranial wounds with demineralized bone matrix and bilayer artificial skin.

Complex wounds involving loss of both cranium and scalp are difficult to reconstruct. Current solutions include both autogenous and alloplastic materials. Tissue engineering provides interesting alternatives for reconstruction of missing bone and soft tissue. Demineralized bone matrix and Integra, artificial bilayer skin substitute, have been used successfully to reconstruct bone and skin as isolated defects, but never in combination. This study investigates the possibility of using demineralized bone matrix in a gel carrier and Integra for combined cranial and scalp defects. The study was divided into two parts. In the first, demineralized bone matrix in the forms of Grafton Flex (n = 12) and Grafton putty (n = 12) was used to reconstruct 15-mm critical size cranial defects in female adult New Zealand White rabbits. In the control group (n = 6), the defect was left empty. The second part of the study investigated the use of Integra and Grafton Flex to reconstruct a 15-mm cranial defect with an overlying full-thickness scalp defect (n = 6). The first study revealed bony healing of the critical-size cranial defect with demineralized bone matrix. The second study demonstrated successful reconstitution of scalp and cranium with both demineralized bone matrix and Integra. We conclude that complex cranial defects involving bone and soft tissue may be successfully reconstructed with their tissue-engineered substrates, demineralized bone matrix (Grafton) and Integra artificial skin.

Consultation with the specialist. Brain abscess.

1. D. Douglas Cochrane, MD* 1. 2. *Division of Neurosurgery, Section of Surgery, British Columbia’s Children’s Hospital; Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada. Brain abscess is relatively uncommon in clinical practice in 1999, yet it remains a serious and life-threatening disease among children and adolescents despite technological advances made in the second half of this century. These advances include aggressive treatment of primary infections, detailed understanding of causative organisms, and improved antibiotics and sensitivity testing techniques. Neuroradiologic imaging, specifically computed tomography (CT), now can reveal the infective process before an abscess forms and can demonstrate the effects of both the primary infection and the treatment accurately. To manage the patient who has a brain abscess with minimal morbidity and mortality, aggressive medical and surgical therapies, singly or in combination, are required. Brain abscess results from seeding of microorganisms into an area of injured cerebral parenchyma by direct spread of infection from soft tissues of the neck and face, sinuses, or cranium or following bacterial implantation resulting from penetrating cranial wounds or operative interventions. Hematogenous seeding from a remote focus also may result in abscess formation. The development of cerebral infection depends on the number of organisms to which the patient is exposed and their virulence, the immunologic competence of the patient, and the timeliness of clinical diagnosis and treatment. Brain abscess is a focal, intracerebral infection evolving from an area of cerebritis into a collection of purulent material enveloped in a vascularized capsule. The most common cause of intracerebral abscess formation is direct or indirect spread from infection in paranasal sinuses, middle ear, and teeth in children and teenagers. Frontal, ethmoid, sphenoid, and maxillary sinusitis give rise to abscess formation in the frontal (Fig. 1⇓). and parietal lobes; mastoiditis results in temporal or cerebellar abscess formation. Metastatic spread from remote foci of infection remains an important pathogenic mechanism in children and adults who have congenital cardiac or pulmonary right-to-left shunts as …

Suicide Involving Multiple Cranial Gunshot Wounds

ABSTRACTA 58 year-old-man was found dead with three gunshot wounds of the head due to a.38 calibre revolver. Post-mortem examination showed that all of the entry wounds were contact range. This observation was supported by subsequent firearms residue analysis. Only one of the wound tracks penetrated the brain. These findings and information gathered by the police and coroner regarding the scene and circumstances of the death confirmed the manner of death as suicide.Review of the literature reveals that suicides involving more than two gunshot wounds, particularly of the head, are unusual.

Diameter of Cranial Gunshot Wounds as a Function of Bullet Caliber

Determination of bullet caliber becomes increasingly important in homicides where the bullet is missing. In cases with entrance wounds to bone that are circular and well defined it may be tempting to measure the defect and offer suggestions about bullet caliber. For this reason, the relationship between wound diameter and bullet caliber was examined using cranial bones from autopsy cases. The minimum diameter of 35 cranial wounds produced by .22, .25, and .38-caliber bullet was measured. The relationship of minimum wound diameter to bullet caliber was examined using a one way analysis of variance. Fisher's least significant difference test revealed no significant difference between .22-caliber and .25-caliber wounds, while the .38-caliber wounds were significantly different (P < .001) from .22-caliber and .25-caliber wounds. Variation in wound size resulting from such factors as bullet shape, surface treatment, strength characteristics, loss of gyroscopic stability, intermediate targets, tangential impacts, and existing fractures are discussed. Also, the large variety of calibers available are noted as complicating the prediction of caliber from wound size. In view of these factors caution is recommended in any attempt to determine precise bullet caliber from the minimum dimensions of the cranial gunshot entrance wound.

Cranial gunshot wounds best managed in specialized trauma centers

Cranial gunshot wounds best managed in specialized trauma centers

Penetrating Craniocerebral Trauma

The authors review the pathophysiology of penetrating and perforating cranial wounds. Radiologic evaluation includes computed tomography and angiography. Operative technique and perioperative critical care are discussed, with special emphasis on the control of the intracranial pressure. Other problems such as fluid and electrolyte disorders and nutrition are discussed in relation to neurosurgery.

Cranial tangential gunshot wounds

(1991). Cranial tangential gunshot wounds. British Journal of Neurosurgery: Vol. 5, No. 5, pp. 525-525.

Cranial tangential gunshot wounds

The effects of high velocity missiles are described. A series of cases of craniocerebral tangential gunshot wounds over a 6 year period is presented with unsuspected cerebral contusion shown by CT. Tangential wounds are defined and classified into four groups. The associated brain damage, often unsuspected prior to CT, and in some cases without radiographic changes, of the four groups is compared. The short- and long-term sequelae and the extent of cerebral damage belie the innocent appearance of the scalp wound. This influences the management of this unusual type of head injury.

Cranial gunshot wounds.

Cranial gunshot wounds frequently produce devastating injuries to central nervous system structures. This article reviews pertinent principles of ballistics to explain several mechanisms of injury to the brain. A series of 21 consecutive cases of cranial gunshot wounds is presented outlining a protocol for management and identifying factors of prognostic significance.

X-ray diagnosis of blind skull wounds

Both during the Great Patriotic War and in the postwar years, many works were devoted to the radiological study of blind gunshot wounds of the skull, but only a small number of these works refer to blind brain wounds (I.S. Babchin and H.S. Kosinskaya, M.B. Kopylov, G.N. Traister and P.N. Smelyansky and others). Although these works contributed to the improvement of precise X-ray diagnostics of blind wounds, a unified method of X-ray examination of the skull and brain injuries has not been developed yet; also there is no generally accepted form of presenting the results of X-ray examination. This circumstance prompted us to publish the present report, devoted to the technique of interpreting and logging radiographs for blind cranial wounds, based on the results of many years of work in wartime and peacetime neurosurgical institutions and on the study of the existing radiological literature.

The Early Pneumoencephalographic Findings Following Penetrating Wounds of the Brain

Neurological sequelae which are the result of penetrating wounds of the brain may call for pneumoencephalography at various periods after the initial injury. This report is based upon studies made upon patients during postoperative care while in the theater of operations. Roentgen examination was done, as a rule, in an attempt to assist in the diagnosis or localization of subdural hematomata or complicating brain abscesses when clinical studies alone were inconclusive. The purpose of this presentation is to record the degree and rapidity with which hydrodynamic effects are manifested in the ventricular system. Such observations may aid in the evaluation of the roentgen findings in later periods of convalescence, or in the explanation of late neurologic sequelae. Material The 23 pneumoencephalographic studies reported were made during the care of 256 patients with penetrating cranial wounds at the 36th General Hospital, in the European theater. Dural penetrations occurred in 206 of this group. The majority...

III. The Possibility of Successive Self-inflicted Cranial and Heart Wounds

III. The Possibility of Successive Self-inflicted Cranial and Heart Wounds