352 Traumatic and Penetrating Head

Injuries
Scott A. Wallace, R. Michael Meyer IV, Frederick L. Stephens, Rocco A.
Armonda, Bizhan Aarabi, and Randy S. Bell
Overview
• Penetrating brain injury (PBI) is a traumatic brain injury (TBI) caused by low-velocity sharp
objects (e.g., a knife) or high- velocity projectiles (shell fragment or bullets).
• Approximately 287,000 to 320,000 American soldiers sustained TBI since the year 2000
• Civilian gunshot wounds to the head (GSWHs) and battle-related head injuries, including
blast overpressure or PBI, differ significantly in pathophysiology, mortality, and neurological
outcomes

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Pathology
• Low-velocity objects penetrate the scalp, skull, and dura and lacerate the brain parenchyma,
including the cortex, subcortical white matter, basal ganglia, diencephalon, brainstem, and any
blood vessels in their paths
• The pathology with contact or near-contact injuries by civilian GSWHs is much more devastating
and may involve a significant thermal load
• The incidence of intracranial haematomas:
 Acute subdural haematoma 3-56 %,
 Intracerebral haematoma 4-37%,
 Intraventricular haematoma 1-56%
 Subarachnoid hemorrhage 9-78%

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Figure 1. Radiologic findings on penetrating head injury

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PRESENTATION AND DIAGNOSIS
• The initial history and physical examination is the cornerstone of medicine,
and its importance cannot be underestimated.
• Adherence to Advanced Trauma Life Support guidelines is critical and should
precede any imaging paradigm.

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Imaging Studies
COMPUTED TOMOGRAPHY
● General injury profile: three-dimensional reconstruction of the hea, defines
the entry site and trajectory, involvement of the paranasal sinuses, orbits, skull
base, and mastoids
● Vascular injury Profile: Direct or indirect evidence of vascular injury can
clearly be shown by cranial CT
● Involvement of Air Sinuses and Mastoid Air Cells: fragments penetrating the
paranasal air sinuses and mastoid air cells  susceptible to cerebrospinal fluid
(CSF) leak and deep intracranial infections

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• Retained Fragments: can cause delayed infections.

• Prognosticating tools: intraventricular hematoma, penetration of the

midsagittal and midcoronal planes, perforating injuries as opposed to
tangential injuries, and injuries involving multiple lobes  important predicors
of outcome
• Surgical Planning: especially in the case of missile head wounds with vascular
injuries, those in which the paranasal sinuses are involved, or there is massive
skin loss

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Figure 2. Non–contrast-enhanced CT view of a Figure 3. Radiologic assessment of penetrating
typical perforating civilian GSWH head injury

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Conventional Angiography
• Should be performed in patients who are at risk for intracranial vascular
injuries or cerebral vasospasm
• Limited by the metal spray artifact caused by retained metal frag- ments or
missiles.

Transcranial Doppler Ultrasound

• Traumatic vasospasm in TBI has been successfully diagnosed, treated, and
tracked by TCD
• Limited by the skill of the ultrasonographer

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Pupillometry
• Recent studies: automated pupillometers have better sensitivity,
reproducibility, and predictability of clinically significant change in ICP status
hours before other clinically significant symptoms manifest.

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Medical Management
• Intubation, oxygenation, ventilation, volume resuscitation is essential
• Prehospital management should focus on maneuvers that reduce ICP
• Guidelines for the “Management and Prognosis of Penetrating Brain Injury” 
broad-spectrum antibiotics and anticonvulsants should be used

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Management of Intracranial Pressure
● Brain Trauma Foundation: recommend intracranial and cerebral perfusion pressure–guided
treatment after severe TBI without change to their indications since 1996
● External ventricular drains are the gold standard for monitoring  may also be used for
targeted treatment
● Treatment typically is indicated for ICP > 20-25 mm Hg, with guideline goals of ICP less than
20 mm Hg and cerebral perfusion pressure (CPP) 50 - 70 mmHg
● Current opinion trends toward multiple modality monitoring
● The authors recommended that hypertonic saline (instead of mannitol) to be used in the
treatment algorithm for raised intracranial pressure.

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Surgical Management
Microbiology
• Military PBI: 28% to 78% of brain tracks were contaminated with gram-positive and gram-
negative organisms
• Retained foreign bodies are significant sources of delayed or recurrent infections leading to
reoperation in up to 95% of cases, 25% perioperative mortality, and morbidity in the form of
permanent neurological deficits in up to 72% of individuals
Deep infection
• Almost 25% of retained bone fragments were a nidus for deep infections such as abscesses.
• With the widespread use of antibiotics and proper debridement  chance of deep central
nervous system infection occurring has dropped precipitously
• Brain MRI is generally helpful for the evaluation of brain abscess, provided there is no
retained metal fragment.

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 Role of Débridement and Repair of the Scalp, Devitalized Brain,
Retained Fragments, and Antibiotic Prophylaxis
• Scalp lacerations from missile head wounds are usually contaminated and can be
difficult to repair  devitalized edges of up to a few millimeters that may require
resection.
• Patients with ventricular penetration are subject to CSF leakage from the skin
incision.
• High wound breakdown rates of the reverse question mark incision along the
posterior curve in patients requiring large craniotomies, and in soldiers with complex
scalp wounds  adoption of alternative scalp incisions, including the L. G. Kempe
incision
• In patients requiring bilateral decompression: a bicoronal incision is preferred
instead of a T-bar extension to the contralateral side.

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Figure 4. The layout and reflection of the L.G. Kempe incision

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Figure 5. The final dissection of a bifrontal decompressive craniotomy

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• The skin edges are debrided and approximated in two layers.
• Simple scalp debridement and meticulous closure: precipitously dropped the rate
of deep wound infections without antibiotics.
• Carey et al: increased risk for deep infections are found with minimally debrided
missile head wounds.
• Retained bone fragments are always a source of worry after a missile head
wound with or without previous debridement.
• After the introduction of antibiotic therapy, incidence of specific lesions such as
brain abscesses decreased from 8.5% to 1.6% to 3.1%.
• MSSA was the most common organism; the most common prophylaxis was a
third-generation cephalosporin

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Management strategies for military PBI currently focus on:
 Early, aggressive cranial decompression,
 Repair of lacerated dura if possible,
 Aggressive CSF diversion
 Watertight skin closure.

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Three variables associated with posttraumatic intracranial infection which could
potentially be useful prospectively predictive factors (Jimenez et al):
(1) Projectile trajectory through potentially contaminating orifices (oral cavity or
the paranasal)
(2) The presence of osseous or metallic intracranial fragments persisting after
surgery, according to CT scan
(3) Poor neurological condition at hospital admission (GCS score <8)

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Craniectomy versus Craniotomy
• Present recommendation for civilian PBI management: craniotomy and
debridement of the skull with replacement of the bone to avoid the future need
for cranioplasty.

• Military PBI: early decompressive craniectomy is favored to protect the patient

from the delayed swelling during long overseas transport to higher levels of care.

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On the basis of experiences in Iraq and Afghanistan, current recommendation for
military PBI:
• Large craniectomies (greater than 14 cm anteroposteriorly)
• Adequate brainstem decompression
• Dural onlay substitutes for dural closure (when supplies or personnel are limited)

With these specifications: 84% of patients with initial average GCS scores of 7.7 and
undergoing decompressive craniectomies achieved a GOS score >3 at 1 - 2 years

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• Bell et al: for frontotemporoparietal
craniotomy, recommended
craniotomy decompression size is 14
cm (anteroposterior) by 12 cm
(superoinferior)

• DECRA trial: Craniectomy in blunt TBI

may be less useful than in penetrating
head injury

Figure 6. Recommended fronto-

temporoparietal decompressive
craniotomy

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Débridement and Watertight Closure of the Dura Mater

Figure 7. CT scan and its schematic representation of a Civilian GSWH

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Débridement and Watertight Closure of the Dura Mater

Figure 8. Schematic representation of adequate débridement and watertight closure

of the dura and scalp

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Repair of the Skull Base
Disruption of lateral skull base  risk for CSF leaks and loss of anatomic continuity
between the anterior cranial fossa, orbits, maxilla, and infratemporal fossa
Management strategies:
• Early skull base repair with split cortical bone graft, local pericranium, fat,
temporalis fascia, and muscle
• Can be followed by more extensive skull base reconstruction

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Complications
Vascular Injuries with Civilian or Wartime Penetrating Brain Injury
• The timing of angiography may be an important factor in detecting aneurysms
• Current guidelines: recommend angiography for patients with PBI who are at risk
for TICA
• Risk factors:
 Orbitofaciocraniocerebral Injuries
 Injuries Near The Pterion
 Patients Harboring Intracranial Hematomas
• If 1 risk factors (+)  recommended to undergo either CT angiography or
conventional angiography to rule out TICA

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• Malignant cerebral edema can occur rapidly in individuals exposed to blast TBI 
can be as fast as 1 hour
• Cerebral vasospasm occurred in almost 50% in severe blast injured patients 
lasted as long as 30 days after injury (much longer than the 14-day window reported
for closed head injury).

Posttraumatic Epilepsy
• PBI: major risk factors for posttraumatic epilepsy
• 34% to 50% of victims of PBI become epileptic when monitored for 2 to 15 years
• Higher incidence in PBI than in victims of closed head injury

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Risk Factors of posttraumatic epilepsy (Temkan et al):
 Evacuation of subdural hematoma
 Surgery for intracerebral hematoma
 Severe head injury
 Early seizures
 A depressed skull fracture that was not elevated
 Dural penetration by injury
 At least one nonreactive pupil
 Parietal lesions on CT

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• Prophylactic antiseizure: Phenytoin, carbamazepine, and valproate
• They are effective in preventing early posttraumatic seizures, but do not prevent
long-term epileptic seizures.
• “Management and Prognosis of Penetrating Brain Injury” guidelines: recommend
prophylactic antiseizure medications for the first week after PBI, but not beyond
that

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Prognosis
• Combat deaths attributed to brain wounds: 35% to 40%
• 91% overall mortality in civilian patients with GSWHs (Arabi et al, 2014)
• Long-term effects: increased rates of dementia or chronic cognitive impairment,
except in the young and those with repetitive injury
• The major link between mild TBI and poor physical performance seems to center
on PTSD

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Cranioplasty
Indications for calvarial reconstruction:
• Defects larger than 6 cm2
• The need for rigid brain protection
• Deformity correction
• Treatment of the syndrome of the trephined

Figure 4. Algorithm for consideration of the factors relevant to

guiding the selection of cranioplasty technique

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Cranioplasty
Patient selection criteria :
(1) Excellent soft-tissue coverage of the graft site
(2) No clinical evidence of infection,
(3) No biochemical evidence of infection (erythrocyte sedimentation rate, C-reactive
protein, leukocytosis),
(4) No radiographic evidence of infection
(5) 6 months’ demonstrated survivorship

With these patient selection criteria, Kumar and et al reported success rates of 95%
using alloplastic materials for cranioplasty

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• Overall complication rates are moderate: 73% are complication free
• Most common complications:
 Need for further contouring procedures (18%)
 Hematoma or hygroma formation (7%)
 Required implant removal due to infection (5%)
 Postoperative seizures (3%)
• Following cranioplasty, complete re-expansion observed in almost all patients
(92%)

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THANK YOU

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