Brain Injury
ISSN: 0269-9052 (Print) 1362-301X (Online) Journal homepage: http://www.tandfonline.com/loi/ibij20
Surgical management and outcomes of nonmissile open head injury: Report of 44 cases from a single trauma centre Lei Chen, Yinghui Bao, Yumin Liang, Yong Wang & Jiyao Jiang To cite this article: Lei Chen, Yinghui Bao, Yumin Liang, Yong Wang & Jiyao Jiang (2016): Surgical management and outcomes of non-missile open head injury: Report of 44 cases from a single trauma centre, Brain Injury, DOI: 10.3109/02699052.2015.1113565 To link to this article: http://dx.doi.org/10.3109/02699052.2015.1113565
Published online: 01 Feb 2016.
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Date: 22 February 2016, At: 23:35
http://tandfonline.com/ibij ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, 2016; 00(00): 1–6 © 2016 Taylor & Francis Group, LLC. DOI: 10.3109/02699052.2015.1113565
Surgical management and outcomes of non-missile open head injury: Report of 44 cases from a single trauma centre Lei Chen, Yinghui Bao, Yumin Liang, Yong Wang, & Jiyao Jiang
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Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P.R. China Abstract
Keywords
Objective: To retrospectively analyse the surgical management and outcomes of non-missile open head injuries (NMOHI). Methods: Forty-four patients who suffered from NMOHI were included. The Glasgow outcome score (GOS), computed tomography (CT), aetiology and outcomes and complications at discharge and during a 6-month follow-up were analysed. All patients underwent debridement. Intracranial haematoma evacuation, decompressive craniectomy (DC) or replacement were performed. Results: Motor vehicle accident and struck by/against were the most common causes (43.2% each). At admission, 33 patients had Glasgow coma scores (GCS) > 8 and 27 of them had a GCS score of > 13. Mean follow-up was 8.7 ± 4.3 months. All patients underwent debridement, 20 underwent bone fracture replacement and 27 underwent haematoma evacuation; 11 patients underwent haematoma evacuation and DC and one had bilateral DC. Twenty-seven patients showed good recovery; 11 patients had moderate disability; three patients had severe disability; and three patients died. After 6 months, 32 patients had good recovery and the morbidity of severe disability had decreased to 13.6%. Thirteen patients developed intracranial infection. Post-traumatic epilepsy and hydrocephalus was detected in three patients. Cerebrospinal fluid fistula was found in five patients. Only one patient developed a brain abscess after 6 months. Conclusions: NMOHI yielded satisfactory recovery and achieved good outcomes.
Non-missile, open head injury, surgical management, outcome
Introduction Open head injury is uncommon in civilian populations, but results in significant morbidity and mortality. Open head injuries mostly result from firearms, while non-missile causes include criminal assault, motor vehicle accident, struck by/against and falling. In the US, firearms are the leading cause of open head injury [1]. In China, motor vehicle-, motorcycle- and bicycle-related causes account for 80.14% of severe traumatic brain injuries, whereas firearms (which are forbidden) account for only 0.44% of cases [2]. The degree of primary injury to the brain is related to the ballistics (kinetic energy, mass, velocity, shape, etc.) of the projectile and any secondary projectiles such as bone or metallic fragments. The ability to penetrate the intracranial space is determined by the energy and shape of the object, the angle of approach and the characteristics of tissues (skull, muscle, mucosa, etc.). A high-velocity projectile, such as a bullet, will move deeply through brain tissue and produce heat associated with the high kinetic energy. The temporary cavity will rapidly collapse Correspondence: Yinghui Bao, Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, P.R. China. Email: [email protected]
History Received 21 May 2015 Revised 21 October 2015 Accepted 25 October 2015 Published online 27 January 2016
in a pulsatile manner and the retraction will suck bone fragments, skin and adjacent brain tissue into the cavity, resulting in extensive damage to brain tissues and vascular structures [3]. However, objects such as knives or bone fragments from skull fractures have a lower velocity and are more superficial and so cause direct disruption and laceration of superficial cerebral cortex. The remaining bone fragments may move around and injure brain tissue after the initial trauma. Most previous head trauma studies have examined outcomes of patients with firearm-related brain injuries and have shown consistently high mortality rates ranging from 51–92% [4–7]. However, open head injuries in civilians caused by non-missile, low-velocity trauma represent a different pathology, with better outcomes and widely variable mortality rates of 0–75% [8–11]. Despite the differences between firearm-related and non-missile open head injuries, both types may share surgical management approaches. The aim of the present study was to retrospectively analyse the surgical management and outcomes of nonmissile open head injuries in Shanghai, China.
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Methods Patients’ characteristics
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This was a retrospective analysis of patients with traumatic brain injury (TBI) admitted between April 2004 and March 2012 to the Neurosurgery department of the hospital affiliated to a university school of medicine. The study protocol was approved by the ethics committee of the hospital and all participants provided written informed consent. After admission, all patients were immediately transferred to the emergency room and diagnosed as non-missile open head injury based on the clinical presentation and computed tomography (CT). Inclusion criteria were: (1) aetiology of non-missile TBI; and (2) scalp laceration and a comminuted, depressed or linear skull fracture (> 1 cm) combined with dural penetration and epidural damage.
Radiological study Patients with unstable blood pressure or signs of cerebral hernia at admission were administered appropriate fluids (crystalloid, colloid, blood products or mannitol) before CT. If necessary, patients were intubated and received mechanical ventilation. The aim of the initial CT scan was to assess the site of penetration, the extent of skull and brain injury and the presence of any large foreign bodies, intracranial haematoma and intracranial air. The development of substantial and otherwise unexplained subarachnoid haemorrhage or delayed haematoma hinted toward a vascular injury and angiography was performed [12].
Medical and surgical management Medical management of non-missile open head injuries includes: (1) control of intracranial hypertension; (2) maintenance of adequate cerebral circulation and oxygenation; and (3) prevention of secondary complications. This study followed the guidelines for the surgical management of penetrating brain injury (PBI): (1) treatment of extensive wounds with debridement of non-viable scalp, bone and dura before primary closure or grafting to secure a watertight wound; (2) in patients with significant fragmentation of the skull, debridement of the cranial wound with either craniectomy or craniotomy; (3) in the presence of a significant mass effect, debridement of necrotic brain tissue and safely accessible bone fragments; (4) evacuation of intracranial haematomas with a significant mass effect; and (5) repair of an open-air sinus injury with watertight closure of the dura. For stab injuries, which obviously differ from firearm-related injuries, this study ensured that movements of the protruding objects during withdrawal were minimized, to avoid further damage to the brain, and these objects were withdrawn in a direct reverse path [13]. The indications for bone fragment replacement were: (1) open (compound) cranial fractures depressed greater than the thickness of the cranium were treated surgically to prevent infection; and (2) open (compound) depressed cranial fractures were treated non-surgically if there was no clinical or
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radiographic evidence of dural penetration, significant intracranial haematoma, depression > 1 cm, frontal sinus involvement, gross cosmetic deformity, wound infection, pneumocephalus or gross wound contamination [14]. Indications for decompressive craniectomy (DC) were: (1) the appearance of unilateral massive cerebral contusion and/or swelling with a midline shift of > 1.0 cm on CT scan, with correlating clinical deterioration; (2) unilateral or bilateral papillary dilation with lack of response to light before operation; (3) an initial Glasgow coma score (GCS) of 4–8; (4) age 15–70 years; and (5) vital signs, including blood pressure and respiration, within the normal range [15]. If the patients met the following additional conditions, a bilateral decompressive craniectomy (BDC) was performed: (1) intracranial pressure (ICP) increased to > 30 mmHg for more than 15 minutes and failure to respond to maximal conservative medical treatment [16]; and (2) CT scan showing bilateral diffuse brain swelling (compressed or obliterated ventricle and basal cisterns) along with clinical deterioration or a decline in Glasgow outcome score (GOS) [17]. Patients who experienced increased ICP were implanted with ICP probes, according to the Guidelines for the Management of Severe Head Injury and revision [16,18]. Treatment protocol Patients were treated according to the principles described in the AANS guidelines for the management of severe head injury [16]. The cerebral perfusion pressure was maintained above 70 mmHg at all times by keeping the mean arterial pressure at 90–120 mmHg and the ICP at < 25 mmHg. Pressors were used as needed to maintain normal blood pressure. Bolus intravenous infusions of mannitol (25–50 g every 6–12 hours) and furosemide (20–40 mg every 6–12 hours) were given to reduce intracranial hypertension. Corticosteroids were not used. Body temperature, respiratory rate, heart rate, blood pressure, cardiac rhythm and oxygen saturation were monitored continuously. Serum glucose, blood gases and serum electrolyte values were measured regularly and kept within the respective normal ranges. This study used a broad-spectrum antibiotic regimen before surgery and for at least 7–14 days [19]. Assessment of neurological outcome Neurological outcomes were evaluated using the GOS: (1) death; (2) vegetative state; (3) severe disability; (4) moderate disability; or (5) good recovery. Statistical analysis Only descriptive statistics were used. Continuous variables are presented as mean ± standard deviation (SD). Categorical variables are presented as numbers and proportions.
Results Participants Between April 2004 and March 2012, 2172 patients with TBI were admitted to the neurosurgery department. Among these,
Non-missile open head trauma
DOI: 10.3109/02699052.2015.1113565
112 patients (5.2%) had non-missile open head injury. Sixtyeight of these 112 patients were excluded due to absence of dural penetration and epidural damage; therefore, 44 patients were included in the analysis.
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Patients’ characteristics The clinical characteristics of the patients are presented in Table I. Motor vehicle accident and struck by/against each accounted for 43.2% of causes. Mean age was 41.4 ± 16.6 years (range = 18–83 years). Thirty-two patients were male (72.7%). GCS scores ranged from 3–14, including 11 patients with a GCS score of 3–8 (27.3%) and 33 patients with a GCS score of 9–14 (75%). Six patients had unilaterally fixed and dilated pupils with a lack of response to light and three patients had bilaterally fixed and dilated pupils at admission. Among all patients, 93.2% arrived at the emergency room less than 48 hours after trauma. Three patients were sent to the emergency room 3–5 days after head injury, due to mild headache; initial CT scans demonstrated depressed skull fracture; two had no intracranial haemorrhage and one had a subdural haematoma. All patients were sent to the operating room within 6 hours after their initial CT scan. Two patients were in shock at admission, and three had brain tissue exposed to air. An intra-parenchymal or intra-ventricular ICP probe was implanted into the right frontal lobe or lateral ventricle of 11 patients after admission. As listed in Table II, 32 patients (72.7%) had comminuted and depressed skull fracture shown by initial CT and 11 patients (25%) had linear skull fracture. Basilar fracture was seen in 10 patients (22.7%). Five patients (11.4%) had an Table I. Clinical characteristics of 44 patients with non-missile open head injury. Variable Mean age (years), mean ± SD Male gender, n (%) Cause Motor vehicle accident Struck by/against Falling Penetrating Admission GCS score 3–5 6–8 9–12 13–15 Pupillary size and light response Normal Unilateral Bilateral Time interval from to admission < 48 hours 2–7 days Clinical presentation Coma Shock at admission Brain tissue outflow Follow up (months), mean ± SD GCS, Glasgow coma score.
Value 41.4 ± 16.6 32 (72.7%) 19 19 2 4
(43.2%) (43.2%) (4.5%) (9.1%)
5 (11.4%) 6 (13.6%) 6 (13.6%) 27 (61.4%) 35 (79.5%) 6 (13.6%) 3 (6.8%) 41 (93.2%) 3 (6.8%) 12 (27.3%) 2 (4.5%) 3 (6.8%) 10.7 ± 4.3
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Table II. CT findings in 44 cases with open head injury at admission. CT findings Comminuted and depressed skull fracture Linear fracture Basilar fracture Intracranial foreign body Contusion Intracranial haematoma Epidural haematoma Subdural haematoma Intraparenchymal haematoma Intraventricular haematoma tSAH Pneumocephalus
n (%) 32 (72.7%) 11 (25%) 10 (22.7%) 5 (11.4%) 10 (22.7%) 21 (47.7%) 11 (25%) 8 (18.2%) 6 (13.6%) 1 (2.3%) 20 (45.5%) 10 (22.7%)
tSAH, traumatic subarachnoid haemorrhage.
intracranial foreign body. Initial CT also showed contusion (22.7%), intracranial haematoma (47.7%), traumatic subarachnoid haemorrhage (tSAH) (45.5%) and pneumocephalus (22.7%). One patient had intraventricular haemorrhage after surgical management and angiography showed arteriovenous malformation (AVM) beside the right ventricle. Medical and surgical management Two patients had low blood pressure and received appropriate fluids and/or blood products to ensure a normal circulating blood volume and pressure. Two patients had decreased GCS and brain hernia before CT scan; they received 1 g kg–1 mannitol on the way to the operating room. Intravenous antibiotics were started and empiric antibiotic coverage was appropriate. Cultures from the wound and foreign body were performed to guide subsequent antibiotic therapy. Only one patient developed early post-traumatic epilepsy and anticonvulsants were given before surgery. All 44 patients underwent debridement of non-viable scalp, bone, dura or necrotic brain tissue. Intracranial haematomas or contusions with a significant mass effect were evacuated in 27 patients. Eleven patients underwent haematoma evacuation and DC and one had bilateral DC. Twenty patients with comminuted and depressed skull fracture underwent replacement. Clinical outcomes Twenty-seven patients (61.4%) showed good recovery; 11 (25%) had moderate disability; three (6.8%) had severe disability; and three (6.8%) died. No patients suffered from a sustained vegetative state. Mean follow-up was 10.7 ± 4.3 months. Thirty-two patients (72.7%) had good recovery, two (4.5%) remained with severe disability and six (13.6%) had moderate disability (Table III). Complications of non-missile open head injury The most common complications of non-missile open head injury were intracranial infections (Table IV). Thirty-one patients (70.5%) developed intracranial infection, detected as
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Table III. Clinical outcomes of non-missile open head injury at discharge and at 6 months. Outcomes Death (GOS 1) Vegetative state (GOS 2) Severe disability (GOS 3) Moderate disability (GOS 4) Good recovery (GOS 5)
Discharge, n (%) 3 0 3 11 27
6 months, n (%)
(6.8%) (0%) (6.8%) (25%) (61.4%)
3 (6.8%) 0 (0%) 2 (4.5%) 6 (13.6%) 32 (72.7%)
GOS, Glasgow outcome score.
Table IV. Complications of non-missile open head injury.
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Complications Intracranial infection Post-traumatic epilepsy CSF fistula Hydrocephalus Brain abscess
n (%) 13 3 5 3 1
(29.5%) (6.8%) (11.4%) (6.8%) (2.3%)
CSF, cerebrospinal fluid.
increased white blood cells in CSF puncture. Post-traumatic epilepsy occurred in three patients (6.8%): before surgery in one and during the 24-hour period after surgery in two. Three patients (6.8%) developed hydrocephalus (diagnosed by CT) and were treated with a ventriculoperitoneal shunt (V-P shunt). One patient (2.3%) had a CSF fistula 2 weeks after operation and underwent dural repair. One patient (2.3%) was identified during follow-up as having an abscess in the wounded brain lobe and good recovery was achieved after surgical management.
Discussion The aim of the present study was to retrospectively analyse the surgical management and outcomes of patients with nonmissile open head injuries in Shanghai, China. Non-missile open brain injury accounted for 5.2% of all patients with TBI in Shanghai and 39.3% of these patients needed surgery. Motor vehicle accident and struck by/against were the main causes of non-missile open head injury. More than 90% of patients survived and 32 (72.7%) showed a satisfactory recovery 6 months after surgical management. These results suggest that non-missile open head injury may achieve good outcomes. Although advances in acute emergency care and increased awareness of protective measures have contributed to a significant decrease in the number of deaths associated with motor vehicle brain injuries, the improvements in mortality and morbidity associated with penetrating head injuries have been less promising. Studies have documented consistently high mortality and morbidity rates from firearm-related brain injuries [4,5]. In the US, incidents involving firearms accounted for 44% of all deaths due to TBI in 1992, while motor vehicle accidents accounted for 34% [20]. In China, vehicle-related causes account for 80.14% of all severe cases of TBI [2]. Accordingly, in this series, motor vehicle accident and struck by/against each accounted for 43.2% of open brain injury cases.
The mortality of penetrating brain injuries is higher for firearm injuries than for other causes due to the high kinetic energy of bullets [21–23]. In this study, > 90% of patients survived following surgical management and only three patients with GCS ≤ 8 died from refractory intracranial hypertension. These results suggest that non-missile open head injuries lead to outcomes that are very different to those after gun TBI. The few studies of non-missile open head injury have suggested that the outcomes may be expected to be good. McDonaldl [9] reported that 20 of 23 patients with non-missile open head injury had surprisingly good recovery following surgical management. Miller et al. [8] reported a mortality rate of 25% in 28 cases with intracranial wooden pieces, whereas Nathoo et al. [24] reported that 23.5% of 17 patients with transcranial brainstem stab injuries survived. More surprisingly, Chibbaro and Tacconi [11] reported no deaths in 18 patients after orbito-cranial injuries caused by penetrating non-missile foreign bodies. In the present study, only four patients had cerebral hernia at admission and 75% of patients had a GCS > 8. The most common injury site is the frontoparietal region [25]. Temporal wounds are more likely to lead to neurological deficits due to the thinness of the temporal bone and the short distance to deeper, vital brain and vascular structures. Breaking of the skull exposes the delicate tissues of the brain to further harm from infections or additional injury during subsequent blows. Stab injury to the carotid artery may lead to carotid cavernous fistula, false aneurysm of the artery and injury to the cavernous sinus [26]. In addition, an open head injury can lead to more severe side-effects such as seizures, dementia or even paralysis. Specific aspects of management Intravenous prophylactic broad-spectrum antibiotic therapy is recommended in all cases [27]. Haines [28,29] showed a significant reduction in post-operative infections with the use of pre-operative antibiotic prophylaxis. The aim of surgery is to remove any mass lesions, debride the wound tract and necrotic brain tissue, remove bone fragments and close any dural openings. The removal of bone fragments or foreign bodies lodged distantly from the entry site is not recommended; although this may decrease the risk of post-traumatic epilepsy and infection and formation of abscesses, it has been documented to correlate with worse outcomes and higher morbidity [30–33]. Complications Infections Most enrolled patients (35/44) underwent surgical treatment within 6 hours of admission to hospital. Infectious complications are common after open brain injury [33] and are associated with higher morbidity and mortality rates. In both military and civilian case series, the use of antibiotic drugs has been reported to decrease the infection rate following open brain injury [34,35], although the rate of intracranial infection after non-missile open brain injury has rarely been analysed. The intracranial infection rate in the present study
Non-missile open head trauma
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DOI: 10.3109/02699052.2015.1113565
(29.5%) was higher than that reported by McDonald [9] (17.4%) and Chibbaro and Tacconi [11] (22.2%) and may have contributed to the higher mortality rate (6.8%, 1.5% and 0%, respectively). Intracranial infections are due to the presence of hair, skin, foreign bodies and bone fragments. This study recommends: (1) the administration of broad-spectrum antibiotics as soon as possible after the patient reaches the emergency room, for at least 2 weeks; (2) surgery within 12 hours of the injury to decrease the risk of infectious complications [36,37]; and (3) attempts to remove all accessible bone fragments, except when deep-seated [38–40]. In the present study, there were no bone fragments lodged distantly from the entry site. All removed foreign bodies should be cultured for aerobic, anaerobic or fungal organisms and the administration of antibiotics guided by these cultures. Cultures from the wound or bone fragments have demonstrated that Staphylococcus aureus and Klebsiella pneumoniae are the predominant organisms [41].
Post-traumatic seizures Post-traumatic seizure is one of the most important complications in patients with PBI. In the present study, three patients developed post-traumatic seizures, one before surgery and two within 24 hours after surgery. These three patients received anti-seizure drugs and no other patients developed seizures during follow-up. Many factors, including extent of injury, retained bone fragments, focal neurological deficit or/ and intracranial haemorrhage may lead to the development of late seizures [42,43]. About 30–50% of patients with TBI develop seizures, 4–10% of those within the first week [44]. Anti-seizure medication in the first week after PBI is recommended to prevent early post-traumatic seizures [45], although prophylactic anticonvulsants do not seem to prevent the development of late post-traumatic epilepsy [45].
Hydrocephalus, CSF leak and brain abscess Post-traumatic hydrocephalus (PTH) is an important complication during post-acute rehabilitation of patients with severe TBI, with an incidence ranging between 0.7–86% [46–49]. During the observed 5-year period at this unit, three patients (6.8%) with GCS < 8 were treated for PTH with shunt implantation. Risk factors for PTH were reported to be duration of coma, age and decompressive craniectomy in one study [50] and age, decompressive craniectomy and subarachnoid haemorrhage in another [51]. Several studies have documented the development of brain abscesses in civilians after rare causes of injury, such as stabbing with pool or snooker cues, pencils or a tree branch, which may represent a different bacteriological or fungal risk [52–54]. However, five patients with an intracranial foreign body at admission did not develop a brain abscess, likely due to the routine use of prophylactic broad-spectrum antibiotics and adequate debridement. Thirteen patients had intracranial infection, but only one (2.3%) developed a brain abscess 6 months after TBI. Further studies are needed to analyse the relationship between brain abscesses and non-missile open head injury.
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The present study was limited by the small number of patients and by the lack of a comparator group. In addition, long-term follow-up outcomes are not yet available. The present study shows that treating non-missile open head injury with modern medical and surgical management techniques results in outcomes similar to those for closed head injury. The similarity in outcome between penetrating non-missile head injury in this study and non-penetrating head injury in previous studies may have been due to factors such as the rapid and efficient delivery of patients for treatment, early surgical intervention, optimized usage of antibiotics, good post-operative care and early rehabilitation. Furthermore, outcomes for non-missile head injury in this cohort were better than those reported elsewhere for missile-related open head injury.
Declaration of interest This work was supported by grants from the National Natural Science Foundation of China (No. 81070988, No. 81171166), and Science and Technology Committee of Shanghai (No. 0852nm04900, 11nm0503200). The authors report no conflicts of interest.
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Surgical management and outcomes of nonmissile open head injury: Report of 44 cases from a single trauma centre Lei Chen, Yinghui Bao, Yumin Liang, Yong Wang & Jiyao Jiang To cite this article: Lei Chen, Yinghui Bao, Yumin Liang, Yong Wang & Jiyao Jiang (2016): Surgical management and outcomes of non-missile open head injury: Report of 44 cases from a single trauma centre, Brain Injury, DOI: 10.3109/02699052.2015.1113565 To link to this article: http://dx.doi.org/10.3109/02699052.2015.1113565
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Date: 22 February 2016, At: 23:35
http://tandfonline.com/ibij ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, 2016; 00(00): 1–6 © 2016 Taylor & Francis Group, LLC. DOI: 10.3109/02699052.2015.1113565
Surgical management and outcomes of non-missile open head injury: Report of 44 cases from a single trauma centre Lei Chen, Yinghui Bao, Yumin Liang, Yong Wang, & Jiyao Jiang
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Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P.R. China Abstract
Keywords
Objective: To retrospectively analyse the surgical management and outcomes of non-missile open head injuries (NMOHI). Methods: Forty-four patients who suffered from NMOHI were included. The Glasgow outcome score (GOS), computed tomography (CT), aetiology and outcomes and complications at discharge and during a 6-month follow-up were analysed. All patients underwent debridement. Intracranial haematoma evacuation, decompressive craniectomy (DC) or replacement were performed. Results: Motor vehicle accident and struck by/against were the most common causes (43.2% each). At admission, 33 patients had Glasgow coma scores (GCS) > 8 and 27 of them had a GCS score of > 13. Mean follow-up was 8.7 ± 4.3 months. All patients underwent debridement, 20 underwent bone fracture replacement and 27 underwent haematoma evacuation; 11 patients underwent haematoma evacuation and DC and one had bilateral DC. Twenty-seven patients showed good recovery; 11 patients had moderate disability; three patients had severe disability; and three patients died. After 6 months, 32 patients had good recovery and the morbidity of severe disability had decreased to 13.6%. Thirteen patients developed intracranial infection. Post-traumatic epilepsy and hydrocephalus was detected in three patients. Cerebrospinal fluid fistula was found in five patients. Only one patient developed a brain abscess after 6 months. Conclusions: NMOHI yielded satisfactory recovery and achieved good outcomes.
Non-missile, open head injury, surgical management, outcome
Introduction Open head injury is uncommon in civilian populations, but results in significant morbidity and mortality. Open head injuries mostly result from firearms, while non-missile causes include criminal assault, motor vehicle accident, struck by/against and falling. In the US, firearms are the leading cause of open head injury [1]. In China, motor vehicle-, motorcycle- and bicycle-related causes account for 80.14% of severe traumatic brain injuries, whereas firearms (which are forbidden) account for only 0.44% of cases [2]. The degree of primary injury to the brain is related to the ballistics (kinetic energy, mass, velocity, shape, etc.) of the projectile and any secondary projectiles such as bone or metallic fragments. The ability to penetrate the intracranial space is determined by the energy and shape of the object, the angle of approach and the characteristics of tissues (skull, muscle, mucosa, etc.). A high-velocity projectile, such as a bullet, will move deeply through brain tissue and produce heat associated with the high kinetic energy. The temporary cavity will rapidly collapse Correspondence: Yinghui Bao, Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, P.R. China. Email: [email protected]
History Received 21 May 2015 Revised 21 October 2015 Accepted 25 October 2015 Published online 27 January 2016
in a pulsatile manner and the retraction will suck bone fragments, skin and adjacent brain tissue into the cavity, resulting in extensive damage to brain tissues and vascular structures [3]. However, objects such as knives or bone fragments from skull fractures have a lower velocity and are more superficial and so cause direct disruption and laceration of superficial cerebral cortex. The remaining bone fragments may move around and injure brain tissue after the initial trauma. Most previous head trauma studies have examined outcomes of patients with firearm-related brain injuries and have shown consistently high mortality rates ranging from 51–92% [4–7]. However, open head injuries in civilians caused by non-missile, low-velocity trauma represent a different pathology, with better outcomes and widely variable mortality rates of 0–75% [8–11]. Despite the differences between firearm-related and non-missile open head injuries, both types may share surgical management approaches. The aim of the present study was to retrospectively analyse the surgical management and outcomes of nonmissile open head injuries in Shanghai, China.
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Methods Patients’ characteristics
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This was a retrospective analysis of patients with traumatic brain injury (TBI) admitted between April 2004 and March 2012 to the Neurosurgery department of the hospital affiliated to a university school of medicine. The study protocol was approved by the ethics committee of the hospital and all participants provided written informed consent. After admission, all patients were immediately transferred to the emergency room and diagnosed as non-missile open head injury based on the clinical presentation and computed tomography (CT). Inclusion criteria were: (1) aetiology of non-missile TBI; and (2) scalp laceration and a comminuted, depressed or linear skull fracture (> 1 cm) combined with dural penetration and epidural damage.
Radiological study Patients with unstable blood pressure or signs of cerebral hernia at admission were administered appropriate fluids (crystalloid, colloid, blood products or mannitol) before CT. If necessary, patients were intubated and received mechanical ventilation. The aim of the initial CT scan was to assess the site of penetration, the extent of skull and brain injury and the presence of any large foreign bodies, intracranial haematoma and intracranial air. The development of substantial and otherwise unexplained subarachnoid haemorrhage or delayed haematoma hinted toward a vascular injury and angiography was performed [12].
Medical and surgical management Medical management of non-missile open head injuries includes: (1) control of intracranial hypertension; (2) maintenance of adequate cerebral circulation and oxygenation; and (3) prevention of secondary complications. This study followed the guidelines for the surgical management of penetrating brain injury (PBI): (1) treatment of extensive wounds with debridement of non-viable scalp, bone and dura before primary closure or grafting to secure a watertight wound; (2) in patients with significant fragmentation of the skull, debridement of the cranial wound with either craniectomy or craniotomy; (3) in the presence of a significant mass effect, debridement of necrotic brain tissue and safely accessible bone fragments; (4) evacuation of intracranial haematomas with a significant mass effect; and (5) repair of an open-air sinus injury with watertight closure of the dura. For stab injuries, which obviously differ from firearm-related injuries, this study ensured that movements of the protruding objects during withdrawal were minimized, to avoid further damage to the brain, and these objects were withdrawn in a direct reverse path [13]. The indications for bone fragment replacement were: (1) open (compound) cranial fractures depressed greater than the thickness of the cranium were treated surgically to prevent infection; and (2) open (compound) depressed cranial fractures were treated non-surgically if there was no clinical or
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radiographic evidence of dural penetration, significant intracranial haematoma, depression > 1 cm, frontal sinus involvement, gross cosmetic deformity, wound infection, pneumocephalus or gross wound contamination [14]. Indications for decompressive craniectomy (DC) were: (1) the appearance of unilateral massive cerebral contusion and/or swelling with a midline shift of > 1.0 cm on CT scan, with correlating clinical deterioration; (2) unilateral or bilateral papillary dilation with lack of response to light before operation; (3) an initial Glasgow coma score (GCS) of 4–8; (4) age 15–70 years; and (5) vital signs, including blood pressure and respiration, within the normal range [15]. If the patients met the following additional conditions, a bilateral decompressive craniectomy (BDC) was performed: (1) intracranial pressure (ICP) increased to > 30 mmHg for more than 15 minutes and failure to respond to maximal conservative medical treatment [16]; and (2) CT scan showing bilateral diffuse brain swelling (compressed or obliterated ventricle and basal cisterns) along with clinical deterioration or a decline in Glasgow outcome score (GOS) [17]. Patients who experienced increased ICP were implanted with ICP probes, according to the Guidelines for the Management of Severe Head Injury and revision [16,18]. Treatment protocol Patients were treated according to the principles described in the AANS guidelines for the management of severe head injury [16]. The cerebral perfusion pressure was maintained above 70 mmHg at all times by keeping the mean arterial pressure at 90–120 mmHg and the ICP at < 25 mmHg. Pressors were used as needed to maintain normal blood pressure. Bolus intravenous infusions of mannitol (25–50 g every 6–12 hours) and furosemide (20–40 mg every 6–12 hours) were given to reduce intracranial hypertension. Corticosteroids were not used. Body temperature, respiratory rate, heart rate, blood pressure, cardiac rhythm and oxygen saturation were monitored continuously. Serum glucose, blood gases and serum electrolyte values were measured regularly and kept within the respective normal ranges. This study used a broad-spectrum antibiotic regimen before surgery and for at least 7–14 days [19]. Assessment of neurological outcome Neurological outcomes were evaluated using the GOS: (1) death; (2) vegetative state; (3) severe disability; (4) moderate disability; or (5) good recovery. Statistical analysis Only descriptive statistics were used. Continuous variables are presented as mean ± standard deviation (SD). Categorical variables are presented as numbers and proportions.
Results Participants Between April 2004 and March 2012, 2172 patients with TBI were admitted to the neurosurgery department. Among these,
Non-missile open head trauma
DOI: 10.3109/02699052.2015.1113565
112 patients (5.2%) had non-missile open head injury. Sixtyeight of these 112 patients were excluded due to absence of dural penetration and epidural damage; therefore, 44 patients were included in the analysis.
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Patients’ characteristics The clinical characteristics of the patients are presented in Table I. Motor vehicle accident and struck by/against each accounted for 43.2% of causes. Mean age was 41.4 ± 16.6 years (range = 18–83 years). Thirty-two patients were male (72.7%). GCS scores ranged from 3–14, including 11 patients with a GCS score of 3–8 (27.3%) and 33 patients with a GCS score of 9–14 (75%). Six patients had unilaterally fixed and dilated pupils with a lack of response to light and three patients had bilaterally fixed and dilated pupils at admission. Among all patients, 93.2% arrived at the emergency room less than 48 hours after trauma. Three patients were sent to the emergency room 3–5 days after head injury, due to mild headache; initial CT scans demonstrated depressed skull fracture; two had no intracranial haemorrhage and one had a subdural haematoma. All patients were sent to the operating room within 6 hours after their initial CT scan. Two patients were in shock at admission, and three had brain tissue exposed to air. An intra-parenchymal or intra-ventricular ICP probe was implanted into the right frontal lobe or lateral ventricle of 11 patients after admission. As listed in Table II, 32 patients (72.7%) had comminuted and depressed skull fracture shown by initial CT and 11 patients (25%) had linear skull fracture. Basilar fracture was seen in 10 patients (22.7%). Five patients (11.4%) had an Table I. Clinical characteristics of 44 patients with non-missile open head injury. Variable Mean age (years), mean ± SD Male gender, n (%) Cause Motor vehicle accident Struck by/against Falling Penetrating Admission GCS score 3–5 6–8 9–12 13–15 Pupillary size and light response Normal Unilateral Bilateral Time interval from to admission < 48 hours 2–7 days Clinical presentation Coma Shock at admission Brain tissue outflow Follow up (months), mean ± SD GCS, Glasgow coma score.
Value 41.4 ± 16.6 32 (72.7%) 19 19 2 4
(43.2%) (43.2%) (4.5%) (9.1%)
5 (11.4%) 6 (13.6%) 6 (13.6%) 27 (61.4%) 35 (79.5%) 6 (13.6%) 3 (6.8%) 41 (93.2%) 3 (6.8%) 12 (27.3%) 2 (4.5%) 3 (6.8%) 10.7 ± 4.3
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Table II. CT findings in 44 cases with open head injury at admission. CT findings Comminuted and depressed skull fracture Linear fracture Basilar fracture Intracranial foreign body Contusion Intracranial haematoma Epidural haematoma Subdural haematoma Intraparenchymal haematoma Intraventricular haematoma tSAH Pneumocephalus
n (%) 32 (72.7%) 11 (25%) 10 (22.7%) 5 (11.4%) 10 (22.7%) 21 (47.7%) 11 (25%) 8 (18.2%) 6 (13.6%) 1 (2.3%) 20 (45.5%) 10 (22.7%)
tSAH, traumatic subarachnoid haemorrhage.
intracranial foreign body. Initial CT also showed contusion (22.7%), intracranial haematoma (47.7%), traumatic subarachnoid haemorrhage (tSAH) (45.5%) and pneumocephalus (22.7%). One patient had intraventricular haemorrhage after surgical management and angiography showed arteriovenous malformation (AVM) beside the right ventricle. Medical and surgical management Two patients had low blood pressure and received appropriate fluids and/or blood products to ensure a normal circulating blood volume and pressure. Two patients had decreased GCS and brain hernia before CT scan; they received 1 g kg–1 mannitol on the way to the operating room. Intravenous antibiotics were started and empiric antibiotic coverage was appropriate. Cultures from the wound and foreign body were performed to guide subsequent antibiotic therapy. Only one patient developed early post-traumatic epilepsy and anticonvulsants were given before surgery. All 44 patients underwent debridement of non-viable scalp, bone, dura or necrotic brain tissue. Intracranial haematomas or contusions with a significant mass effect were evacuated in 27 patients. Eleven patients underwent haematoma evacuation and DC and one had bilateral DC. Twenty patients with comminuted and depressed skull fracture underwent replacement. Clinical outcomes Twenty-seven patients (61.4%) showed good recovery; 11 (25%) had moderate disability; three (6.8%) had severe disability; and three (6.8%) died. No patients suffered from a sustained vegetative state. Mean follow-up was 10.7 ± 4.3 months. Thirty-two patients (72.7%) had good recovery, two (4.5%) remained with severe disability and six (13.6%) had moderate disability (Table III). Complications of non-missile open head injury The most common complications of non-missile open head injury were intracranial infections (Table IV). Thirty-one patients (70.5%) developed intracranial infection, detected as
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Table III. Clinical outcomes of non-missile open head injury at discharge and at 6 months. Outcomes Death (GOS 1) Vegetative state (GOS 2) Severe disability (GOS 3) Moderate disability (GOS 4) Good recovery (GOS 5)
Discharge, n (%) 3 0 3 11 27
6 months, n (%)
(6.8%) (0%) (6.8%) (25%) (61.4%)
3 (6.8%) 0 (0%) 2 (4.5%) 6 (13.6%) 32 (72.7%)
GOS, Glasgow outcome score.
Table IV. Complications of non-missile open head injury.
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Complications Intracranial infection Post-traumatic epilepsy CSF fistula Hydrocephalus Brain abscess
n (%) 13 3 5 3 1
(29.5%) (6.8%) (11.4%) (6.8%) (2.3%)
CSF, cerebrospinal fluid.
increased white blood cells in CSF puncture. Post-traumatic epilepsy occurred in three patients (6.8%): before surgery in one and during the 24-hour period after surgery in two. Three patients (6.8%) developed hydrocephalus (diagnosed by CT) and were treated with a ventriculoperitoneal shunt (V-P shunt). One patient (2.3%) had a CSF fistula 2 weeks after operation and underwent dural repair. One patient (2.3%) was identified during follow-up as having an abscess in the wounded brain lobe and good recovery was achieved after surgical management.
Discussion The aim of the present study was to retrospectively analyse the surgical management and outcomes of patients with nonmissile open head injuries in Shanghai, China. Non-missile open brain injury accounted for 5.2% of all patients with TBI in Shanghai and 39.3% of these patients needed surgery. Motor vehicle accident and struck by/against were the main causes of non-missile open head injury. More than 90% of patients survived and 32 (72.7%) showed a satisfactory recovery 6 months after surgical management. These results suggest that non-missile open head injury may achieve good outcomes. Although advances in acute emergency care and increased awareness of protective measures have contributed to a significant decrease in the number of deaths associated with motor vehicle brain injuries, the improvements in mortality and morbidity associated with penetrating head injuries have been less promising. Studies have documented consistently high mortality and morbidity rates from firearm-related brain injuries [4,5]. In the US, incidents involving firearms accounted for 44% of all deaths due to TBI in 1992, while motor vehicle accidents accounted for 34% [20]. In China, vehicle-related causes account for 80.14% of all severe cases of TBI [2]. Accordingly, in this series, motor vehicle accident and struck by/against each accounted for 43.2% of open brain injury cases.
The mortality of penetrating brain injuries is higher for firearm injuries than for other causes due to the high kinetic energy of bullets [21–23]. In this study, > 90% of patients survived following surgical management and only three patients with GCS ≤ 8 died from refractory intracranial hypertension. These results suggest that non-missile open head injuries lead to outcomes that are very different to those after gun TBI. The few studies of non-missile open head injury have suggested that the outcomes may be expected to be good. McDonaldl [9] reported that 20 of 23 patients with non-missile open head injury had surprisingly good recovery following surgical management. Miller et al. [8] reported a mortality rate of 25% in 28 cases with intracranial wooden pieces, whereas Nathoo et al. [24] reported that 23.5% of 17 patients with transcranial brainstem stab injuries survived. More surprisingly, Chibbaro and Tacconi [11] reported no deaths in 18 patients after orbito-cranial injuries caused by penetrating non-missile foreign bodies. In the present study, only four patients had cerebral hernia at admission and 75% of patients had a GCS > 8. The most common injury site is the frontoparietal region [25]. Temporal wounds are more likely to lead to neurological deficits due to the thinness of the temporal bone and the short distance to deeper, vital brain and vascular structures. Breaking of the skull exposes the delicate tissues of the brain to further harm from infections or additional injury during subsequent blows. Stab injury to the carotid artery may lead to carotid cavernous fistula, false aneurysm of the artery and injury to the cavernous sinus [26]. In addition, an open head injury can lead to more severe side-effects such as seizures, dementia or even paralysis. Specific aspects of management Intravenous prophylactic broad-spectrum antibiotic therapy is recommended in all cases [27]. Haines [28,29] showed a significant reduction in post-operative infections with the use of pre-operative antibiotic prophylaxis. The aim of surgery is to remove any mass lesions, debride the wound tract and necrotic brain tissue, remove bone fragments and close any dural openings. The removal of bone fragments or foreign bodies lodged distantly from the entry site is not recommended; although this may decrease the risk of post-traumatic epilepsy and infection and formation of abscesses, it has been documented to correlate with worse outcomes and higher morbidity [30–33]. Complications Infections Most enrolled patients (35/44) underwent surgical treatment within 6 hours of admission to hospital. Infectious complications are common after open brain injury [33] and are associated with higher morbidity and mortality rates. In both military and civilian case series, the use of antibiotic drugs has been reported to decrease the infection rate following open brain injury [34,35], although the rate of intracranial infection after non-missile open brain injury has rarely been analysed. The intracranial infection rate in the present study
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(29.5%) was higher than that reported by McDonald [9] (17.4%) and Chibbaro and Tacconi [11] (22.2%) and may have contributed to the higher mortality rate (6.8%, 1.5% and 0%, respectively). Intracranial infections are due to the presence of hair, skin, foreign bodies and bone fragments. This study recommends: (1) the administration of broad-spectrum antibiotics as soon as possible after the patient reaches the emergency room, for at least 2 weeks; (2) surgery within 12 hours of the injury to decrease the risk of infectious complications [36,37]; and (3) attempts to remove all accessible bone fragments, except when deep-seated [38–40]. In the present study, there were no bone fragments lodged distantly from the entry site. All removed foreign bodies should be cultured for aerobic, anaerobic or fungal organisms and the administration of antibiotics guided by these cultures. Cultures from the wound or bone fragments have demonstrated that Staphylococcus aureus and Klebsiella pneumoniae are the predominant organisms [41].
Post-traumatic seizures Post-traumatic seizure is one of the most important complications in patients with PBI. In the present study, three patients developed post-traumatic seizures, one before surgery and two within 24 hours after surgery. These three patients received anti-seizure drugs and no other patients developed seizures during follow-up. Many factors, including extent of injury, retained bone fragments, focal neurological deficit or/ and intracranial haemorrhage may lead to the development of late seizures [42,43]. About 30–50% of patients with TBI develop seizures, 4–10% of those within the first week [44]. Anti-seizure medication in the first week after PBI is recommended to prevent early post-traumatic seizures [45], although prophylactic anticonvulsants do not seem to prevent the development of late post-traumatic epilepsy [45].
Hydrocephalus, CSF leak and brain abscess Post-traumatic hydrocephalus (PTH) is an important complication during post-acute rehabilitation of patients with severe TBI, with an incidence ranging between 0.7–86% [46–49]. During the observed 5-year period at this unit, three patients (6.8%) with GCS < 8 were treated for PTH with shunt implantation. Risk factors for PTH were reported to be duration of coma, age and decompressive craniectomy in one study [50] and age, decompressive craniectomy and subarachnoid haemorrhage in another [51]. Several studies have documented the development of brain abscesses in civilians after rare causes of injury, such as stabbing with pool or snooker cues, pencils or a tree branch, which may represent a different bacteriological or fungal risk [52–54]. However, five patients with an intracranial foreign body at admission did not develop a brain abscess, likely due to the routine use of prophylactic broad-spectrum antibiotics and adequate debridement. Thirteen patients had intracranial infection, but only one (2.3%) developed a brain abscess 6 months after TBI. Further studies are needed to analyse the relationship between brain abscesses and non-missile open head injury.
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The present study was limited by the small number of patients and by the lack of a comparator group. In addition, long-term follow-up outcomes are not yet available. The present study shows that treating non-missile open head injury with modern medical and surgical management techniques results in outcomes similar to those for closed head injury. The similarity in outcome between penetrating non-missile head injury in this study and non-penetrating head injury in previous studies may have been due to factors such as the rapid and efficient delivery of patients for treatment, early surgical intervention, optimized usage of antibiotics, good post-operative care and early rehabilitation. Furthermore, outcomes for non-missile head injury in this cohort were better than those reported elsewhere for missile-related open head injury.
Declaration of interest This work was supported by grants from the National Natural Science Foundation of China (No. 81070988, No. 81171166), and Science and Technology Committee of Shanghai (No. 0852nm04900, 11nm0503200). The authors report no conflicts of interest.
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