Massive penetrating brain injury combined with open skull fracture- response strategies for complex head injuries

doi:10.21203/rs.3.rs-3746796/v1

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Massive penetrating brain injury combined with open skull fracture- response strategies for complex head injuries

https://doi.org/10.21203/rs.3.rs-3746796/v1

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Purpose:

Penetrating traumatic brain injury (PTBI) is an extremely serious and fatal trauma. Proper primary evaluation and prompt surgical management will improve patient survival rates. However, this condition is rare in Taiwan, and there are no updated standards and guidelines to deal with this condition.

Materials and Methods:

A 67-year-old male, worker, fell from a height of 3 meters. His head was inserted into the metal structure at the site. The emergency medical technician cut off a piece of metal to deliver the patient to my emergency room under the protection of a neck collar. Brain CT in E1V1M5 status shows a metallic foreign body penetrating through the left high fronto-parietal lobe into Lt parietal lobe with associated open skull fracture, pneumocephalus, and adjacent intracerebral hemorrhage (ICH). Depressed skull pieces with traumatic subarachnoid hemorrhage complicated the neurological conditions. We provide experience with possible steps in setting up PTBI.

Results:

After initial resuscitation, emergency personnel prescribed ceftriaxone and metronidazole to control central nervous system infection. A loading dose of depakine is also given to prevent seizures. We arranged an emergency craniectomy to remove the foreign body, ICH, and bone fragments inserted into the brain parenchyma with a microscope. After bleeding control and debridement, a subdural drain was inserted as an intracranial pressure monitor. Following antibiotics control and anticonvulsant agent continued at neurosurgery intensive care unit. Cranioplasty was performed 2 weeks later. He was transferred to the rehabilitation department under E4V2M5 status with right hemiplegia. Now, the patient's coma scale has recovered to E4V3M6, and the muscle power of the right lower limb has recovered to 2 in the bottom of this September.

Conclusions:

In the era of the ongoing war between Ukraine and Russia, the possibility of PTBI occurring may continue to increase. As a neurosurgeon, you must be prepared for danger in times of crisis and know how to deal with PTBI efficiently. When faced with many injuries or a war situation, our cases can provide valuable experience.

penetrating traumatic brain injury

open skull fracture

craniectomy

urgent operation

CNS infection

epilepsy

Penetrating traumatic brain injury (PTBI) is an extremely serious and often fatal trauma. Current guidelines have not been well developed and updated to reflect the changing times (1–3). I encountered a patient with a severe penetrating brain injury associated with a complex open skull fracture who was able to recover well. We attempted to develop a PTBI management algorithm based on our treatment experience to address the potentially large number of head injury patients during wartime.

A 67-year-old male worker fell from a height of 3 meters, experiencing blunt force trauma to his head from a metal structure at the scene. Emergency medical technicians removed a section of the metal and transported the patient to my emergency room while securing his neck with a cervical collar (Fig. 1A, B). Following initial resuscitation, the emergency team administered ceftriaxone and metronidazole to prevent central nervous system infection. Additionally, a loading dose of depakine was administered to mitigate the risk of seizures. A brain CT scan revealed a metallic foreign body penetrating the left high fronto-parietal lobe, extending into the parietal lobe, accompanied by an open skull fracture, pneumocephalus, and adjacent intracerebral hemorrhage (ICH). The neurological complications were further complicated by depressed skull pieces and traumatic subarachnoid hemorrhage (see Fig. 1C, D).

We arranged an urgent craniectomy to remove the foreign bodies, ICH, and bone fragments embedded in the brain parenchyma with artificial dural protection under a microscope (Fig. 1E, F). After hemostasis, a subdural drain was inserted as both a drainage tube and an intracranial pressure monitor. Antibiotics and anticonvulsant agent were continued in the neurosurgery intensive care unit. A CT examination scan 3 days post-PTBI revealed residual bone fragments deep in the previous surgical site, but no apparent intracranial infection lesions were identified (Fig. 1G). 8 days post-PTBI, a second craniotomy was performed with the assistance of a navigation system to remove any remaining fractures over the dominant hemisphere (Fig. 1H). As there was no obvious evidence of infection, cranioplasty and dural repair were subsequently executed. The patient was then transferred to the rehabilitation department under E4V2M5 status with right hemiplegia. Two months post the second operation, the patient's coma scale has recovered to E4V4M6, and the muscle power of the right lower limb has recovered to 3. Additionally, all antibiotics were discontinued 17 days after PTBI. In the final follow-up visit under supervision, the patient demonstrated the ability to walk and articulate some simple sentences. (Supplementary Video)

Timing of neurosurgery:

Since vascular complications are not uncommon in PTBI (4, 5), neurointerventional specialists should be included on the new-age trauma team. Urgent craniectomy should be considered under the support of a hybrid operation room (OR) to reduce infection rates. Massive PTBI with open skull fractures may particularly benefit in this setting. Prior literature suggested that early decompressive craniectomy for severe penetrating and closed head injuries during wartime may be beneficial in controlling brain swelling (6). However, there is still no consensus on craniotomy or craniotomy in PTBI. Our experience supports that emergency craniectomy not only reduces recovery time but also enhances functional outcomes. The incorporation of craniectomy with subdural drainage not only provides a window for drainage of the source of infection and controls possible secondary injuries, but also facilitates secondary debridement. In a wartime context, craniotomy emerges as a more cost-effective and time-effective option. During the neurocritical phase, navigation systems are useful tools for precise removal of residual foreign bodies, especially in PTBI patients with initial brain swelling. (Table 1).

Duration of antibiotics:

The timeliness of craniectomy with extensive debridement in PTBI patients directly correlates with a reduced necessity for prolonged broad-spectrum antibiotic courses [6]. The secondary craniotomy also offers a valuable opportunity to assess intracranial infection and brain parenchymal conditions. If there is no subjective or objective evidence of intracranial infection, antibiotic de-escalation or only oral antibiotic control can be considered. Once the brain swelling is relieved and the infection is properly controlled, there is a chance that cranioplasty can be performed earlier. Furthermore, as PTBI patients recover from neurological critical illness, they have a higher likelihood of entering recovery and returning to normal daily life.

In the ongoing conflict between Ukraine and Russia and the new emergence of Israel-Palestinian war, it is critical that surgeons understand the treatment policies for dealing with penetrating brain trauma. In the midst of numerous injuries or the exigencies of a war scenario, our treatment approach not only contributes to the collective understanding but also offers a valuable reservoir of experience for medical practitioners confronted with similar challenges.

AED: antiepilepsy drug

CSF: cerebrospinal fluid

CT:computed tomography

CTA: computed tomography angiography

EMT: emergency medical technician

ER: emergency room

ICH: intracerebral hemorrhage

ICP: intracranial pressure

IV: intravenous

MRA: magnetic resonance angiography

MRI: magnetic resonance imaging

PTBI: penetrating traumatic brain injury

NS: neurosurgeon

TBI: traumatic brain injury

Ethics approval and consent to participate:

Written informed consent was obtained from the patient and their closest relatives before the study. This study was performed in accordance with the local medical ethics policies for the study of humans. (IRB file No. 202301537B0, see the uploaded related file). –

Consent for publication:

The patient has provided consent for the publication of information pertaining to the photographs and video in the journal. The official Chinese-language patient information consent form is enclosed in the related files for your review.

Availability of data and materials:

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request

Competing interests:

I declare that they have no competing interests.

Funding:

I declare that: 1. no support, financial or otherwise, has been received from any organization that may have an interest in the submitted work; and 2. there are no other relationships or activities that could appear to have influenced the submitted work.

Authors' contributions:

Yun-cong Zheng wrote the main manuscript text, and prepared the figure and the table.

Yun-Cong Zheng contributed to all the data collection, conception, and design of the study.

Provenance and peer review:

Not commissioned; externally peer reviewed

Supplemental material:

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request

Acknowledgements:

The author would like to thank the clinicians, the patient, and all investigators contributed to this study. We also thank Janice Tania, for her excellent support.

Mansour A, Loggini A, El Ammar F, Ginat D, Awad IA, Lazaridis C, et al. Cerebrovascular Complications in Early Survivors of Civilian Penetrating Brain Injury. Neurocrit Care. 2021;34(3):918-26.
Takahashi CE, Virmani D, Chung DY, Ong C, Cervantes-Arslanian AM. Blunt and Penetrating Severe Traumatic Brain Injury. Neurologic clinics. 2021;39(2):443-69.
Kazim SF, Shamim MS, Tahir MZ, Enam SA, Waheed S. Management of penetrating brain injury. J Emerg Trauma Shock. 2011;4(3):395-402.
Bodanapally UK, Shanmuganathan K, Boscak AR, Jaffray PM, Van der Byl G, Roy AK, et al. Vascular complications of penetrating brain injury: comparison of helical CT angiography and conventional angiography. Journal of neurosurgery. 2014;121(5):1275-83.
Vakil MT, Singh AK. A review of penetrating brain trauma: epidemiology, pathophysiology, imaging assessment, complications, and treatment. Emergency radiology. 2017;24(3):301-9.
Bell RS, Mossop CM, Dirks MS, Stephens FL, Mulligan L, Ecker R, et al. Early decompressive craniectomy for severe penetrating and closed head injury during wartime. Neurosurgical focus. 2010;28(5):E1.

Table 1 is available in the Supplementary Files section.

No competing interests reported.

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Version 1

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Massive penetrating brain injury combined with open skull fracture- response strategies for complex head injuries

Status:

Version 1

Abstract

Figures

Background

Case Presentation

Results

Discussion

Timing of neurosurgery:

Duration of antibiotics:

Conclusion

Abbreviations

Declarations

References

Table

Additional Declarations

Supplementary Files

Status:

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