Craniocerebral Missile Injuries Research Articles

Craniocerebral missile injuries in a combat zone: spectrum of injuries and lessons learnt

BackgroundHigh-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. MethodsThe 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. ResultsFive 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 in the faciocranial area. Ten patients had Glasgow Coma Scale (GCS) less than 8 at 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. ConclusionAn 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.

10.4314/ajns.v9i2.70402

Background The missile injuries of the cranium and brain in the modern era have shifted from soldiers to the civilians and from the battle grounds to the populated zones due to increase in the terrorist and military strikes. The management of the victims depends on the resuscitation at the site of injury and the distance and transportation to the tertiary care centre. This article presents the details of the missile injuries to the brain, the third-world problems and the management. Material and methods A retrospective analysis of 3794 craniocerebral missile injuries, managed by the Department of Neurosurgery at Sher-I-Kashmir Institute of Medical Sciences (SKIMS) Kashmir, India, over a period of more than 21 years from September 1988 to September 2009. Patients were triaged in emergency CT-room, resuscitated and operated. Statistical software programme SPSS 11.5 was used to derive the numerical significance. Results Revealed an overall mortality of 87.69% (3327 out of 3794). Most of the deaths 79.14% (2633 out of 3327) occurred within 30 minutes of the patient’s arrival to the hospital and only 694 patients lived beyond one hour of arrival. Conclusion Presently the quantum of outcome i.e, survival and good recovery in craniocerebral missile injuries appears a meager heap compared to the huge amount of death and disability. And the situation will continue to be so unless tertiary care hospitals are set up within and around the armed and conflict zones, war torn areas and battle fields, rather than risking transportation, time of resuscitation, intervention and the results. Key words: Craniocerebral, Kashmir, Missile Injuries, Outcome.

Paradigm Shift in Management Strategies of Craniocerebral Missile Injuries Improving Survival Rates and Functional Outcome Score

Introduction With development of firearms, civilian violence, ethnic clashes, militancy, terrorist attack, and military operations there is a worldwide increase in incidence of craniocerebral missile injuries. The mortality of patients with craniocerebral missile injuries is high, and if the victim survives, functional outcome is poor. In spite of high mortality, no proper attention was given in last five decades in improving surgical techniques and resuscitation patterns of patients with craniocerebral missile injuries. Problems Considered The problems are many, but the two problems highlighted are decreased survival because of the inadequate pre-op resuscitation and poor functional outcome due to aggressive surgery. Therefore, the study was performed to evaluate the outcome of early and less aggressive surgical strategy and aggressive preoperative resuscitation in patients with penetrating injuries and also to look for factors prognosticating outcome. Methods A series of 96 patients with craniocerebral missile injuries to head were managed at a single center over a period of 3 years is presented. Aggressive resuscitation was done in all hemodynamically unstable patients and patients with coagulopathy either with blood products, hyperosmolar therapy or ionotropic support on protocols of damage control resuscitation. Blood product therapy consisted of packed red blood corpuscles, fresh frozen plasma (FFP) and platelets. Hypertonic saline was used for hyperosmolar resuscitation, and for ionotropic support dopamine, adrenalin, and vasopressin were used. Minimum debridement of the missile tract was done and maximum cortical tissue was preserved. Results Neurosurgical procedures contemplated on 78 patients. Criteria for craniotomy were—Glasgow Coma Scale (GCS) of 8 with intracranial bone fragments/significant clot, and raised intracranial pressure. Surgical approach were frontotemporal exposure (41%, n = 32/78), frontoparietal exposure (22%, n = 18/78), retrosigmoid exposure (2%, n = 2/78), combined middle and posterior fossa approach (2%, n = 2/78), and decompressive craniectomy (43%, n = 24/78). Procedures done were debridement of devitalized tissue (100%, n = 78/78), extraction of bone fragment (43%, n = 17/39), extraction of metallic pellet (62%, n = 42/67), lax duraplasty (100%, n = 78/789), debridement of missile tract (100%, n = 78/78). Overall, 36 patients were operated within 8 hours and 22 patients were operated within 14 hours. Median age group were 26 years, 81% were male, surgical mortality of 18%, and overall mortality was 33%. Conclusion This study indicates the factors prognosticating outcomes and supports that less aggressive surgery and aggressive preoperative resuscitation has decreased surgical mortality rates and improved functional outcomes.

Non-metallic and metallic craniocerebral missile injuries: Varied outcome

We studied the comparative outcome related to 694 non-metallic and metallic craniocerebral missile injuries who lived at 2 hours and beyond the time of injury in a retrospective and prospective analysis in the Department of Neurosurgery at Sher-I-Kashmir Institute of Medical Sciences (SKIMS) Kashmir, India, over a period of 21 years from September 1988 to March, 2010. The study revealed an overall mortality of 32.70% (227 out of 694). A total of 664 adults and 30 children (mostly teenagers) were studied. The 79.1% (549 out of 694) patients were metallic missile injuries whereas 20.8% (145 out of 694) patients were non-metallic missile injuries. The non-metallic missile injury group mostly (72.4% i.e.; 105 out of 145) had low GCS score and overall worse prognosis with zero good-recovery, 47.5% disabilities and 52.4% mortality as compared to the metallic missile injury group. The non-metallic group comprised of 60% (18 out of 30) children with one death. Non-metallic missile injuries accounted for 10.95% (76 out of 694 patients) of total deaths. Predictors of poor outcome were low admission GCS score, non-metallic penetrating injury due to tear-gas cartridges, rubber bullets and stone-bullets, perforating metallic missile injuries and delayed and maltransportation. Most complications in non-metallic missile injuries were infective and had poor outcome. The common non-metallic missiles used were stone bullets (balls) fired by Gulail (modified catapult) or slingshot, red rubber bullets, plastic tear gas shells and cartridges, wooden (pulped mulberry stem) and card-board wads used in shotguns. The stone pelting, throwing stone projectiles (stone-bullets) by Gulail and manually has become a common way to inflict head injuries in Kashmir. The non-metallic missiles are not less-lethal and have high disabling, killing and infective potential.

Penetrating craniocerebral missile injuries in the civil disturbances in Northern Ireland.

Abstract The management of 93 patients with craniocerebral gunshot wounds is reviewed. The contrast between the injuries of urban guerilla warfare, conventional warfare and civilian life is outlined. Emphasis is placed on the need for early and adequate transfusion and for immediate airway control to limit cerebral oedema. Principles of wound surgery evolved in other conflicts were followed and developed.

Nature and Management of Penetrating Craniocerebral Missile Injuries at Shree Birendra Hospital From November 2001 to November 2002

Nature and Management of Penetrating Craniocerebral Missile Injuries at Shree Birendra Hospital From November 2001 to November 2002

Civilian infratentorial gunshot injuries: outcome analysis of 26 patients

BACKGROUND Craniocerebral missile injuries have steadily increased to become the most common form of penetrating neurotrauma in our environment resulting in continued morbidity and neuropsychological sequelae. Civilian infratentorial gunshot injuries are uncommon but generally regarded as fatal injuries, with many patients dying before reaching hospital. METHODS A retrospective analysis of 1,069 patients with civilian gunshot wounds (GSW), admitted to our unit over a 14-year period (1986–2000), identified 26 patients with infratentorial gunshot injuries (2.4%). A detailed analysis of these patients was carried out, which included demographic factors, clinical and anatomic correlation, computed tomography scans, surgical management, and outcome. RESULTS All patients were male. The mean age was 26.5 ± 11.5 years and the mean admission Glasgow Coma Score 11.8 ± 2.7. Twenty-four of 26 patients required cerebrospinal fluid (CSF) diversion to control secondary hydrocephalus. The second commonest surgical procedure was posterior fossa decompression. Five of 26 patients died (19.2%). Severe morbidity was noted in 9 of 21 surviving patients (42.8%). Significant predictors: good outcome was associated with primary missile entry of the infratentorial compartment ( p = 0.005), while patients with supratentorial to infratentorial missile trajectory were noted to have a poorer outcome ( p = 0.041). Location of cerebellar injury (lateral or medial) and missile caliber had no significant influence on patient outcome. CONCLUSION Early control of incipient or established hydrocephalus and aggressive surgical management where appropriate, with careful postoperative monitoring, is necessary for good outcome in patients with civilian infratentorial missile injuries.

Craniocerebral missile injuries

Gun shot wounds to the brain are among the most devastating causes of morbidity and mortality in the civilian population. The majority of the victims will not survive and for a great number of survivors life becomes an uphill battle with permanent deficits and complications. While the fundamental surgical care of these patients is essentially unchanged, our scientific understanding of the pathophysiological changes and the post-injury care of the victims has been evolving. The purpose of this article is to provide an overview of the current clinical and laboratory advances in understanding and treating gun shot injuries to the brain. [Neurol Res 2001; 23: 210-218]

Neuroradiological aspects of experimental traumatic missile injury in sheep

Radiological assessment of ovine brains subjected to experimental gunshot injury was performed using computed tomography. This imaging procedure enabled precise localisation of the projectile and metal and bony fragments, and depicted parenchymal damage, distortion and displacement of the brain, and skull fractures. Computed tomography scanning was found to be useful in the clinical evaluation of craniocerebral missile injuries and confirmed the acceptability of the 0.22 calibre rifle and 12-gauge shotgun for the euthanasia of sheep.

Penetrating craniocerebral missile injuries in civilians: A retrospective analysis of 314 cases

Analysis of 314 cases of penetrating craniocerebral missile injuries in civilians revealed a high rate of early mortality, with 228 victims having died at the scene and a further 38 dead within 3 hours. Surgery was performed in 44 patients who had a preoperative Glasgow Coma Score of at least 4. Out of the 26 survivors, all operated upon, 19 had an adequate recovery (score of 0–3 on the expanded Glasgow Outcome Scale). Vigorous resuscitation and early surgery often resulted in useful survivals and occasionally in spectacular recoveries. However, the high mortality rate on the scene or soon after the injury restricted the possibility of effective management to a minority of cases.

Penetrating craniocerebral missile injuries.

Penetrating craniocerebral missile injuries.

Craniocerebral missile injuries in the monkey: an experimental physiological model.

✓ Experiments were carried out on rhesus monkeys to determine what physiological parameters were most closely correlated with death due to craniocerebral missile injuries. Observations of intracranial pressure, blood pressure, carotid flow, blood gases, respiratory rate, depth and volume, and electroencephalograms were made. These parameters were compared in survivors and nonsurvivors as were the pathological injuries. The most important single parameter that correlated with death was the drop in carotid flow. As this same correlation has been observed in epidural compression experiments in the monkey, there is a strong suspicion that reduced blood flow to the brain as measured by carotid flow is a common factor in craniocerebral missile injuries and epidural compression injuries.

Craniocerebral missile injuries in civilian Kashmir – India

Background The missile injuries of the cranium and brain in the modern era have shifted from soldiers to the civilians and from the battle grounds to the populated zones due to increase in the terrorist and military strikes. The management of the victims depends on the resuscitation at the site of injury and the distance and transportation to the tertiary care centre. This article presents the details of the missile injuries to the brain, the third-world problems and the management. Material and methods A retrospective analysis of 3794 craniocerebral missile injuries, managed by the Department of Neurosurgery at Sher-I-Kashmir Institute of Medical Sciences (SKIMS) Kashmir, India, over a period of more than 21 years from September 1988 to September 2009. Patients were triaged in emergency CT-room, resuscitated and operated. Statistical software programme SPSS 11.5 was used to derive the numerical significance. Results Revealed an overall mortality of 87.69% (3327 out of 3794). Most of the deaths 79.14% (2633 out of 3327) occurred within 30 minutes of the patient’s arrival to the hospital and only 694 patients lived beyond one hour of arrival. Conclusion Presently the quantum of outcome i.e, survival and good recovery in craniocerebral missile injuries appears a meager heap compared to the huge amount of death and disability. And the situation will continue to be so unless tertiary care hospitals are set up within and around the armed and conflict zones, war torn areas and battle fields, rather than risking transportation, time of resuscitation, intervention and the results.Key words: Craniocerebral, Kashmir, Missile Injuries, Outcome.