Top

World Journal of Surgery

Published in:

Open Access 01-06-2015 | Surgical Symposium Contribution

Current Concepts in Penetrating and Blast Injury to the Central Nervous System

Authors: Jeffrey V. Rosenfeld, Randy S. Bell, Rocco Armonda

Published in: World Journal of Surgery | Issue 6/2015

Abstract

Aim

To review the current management, prognostic factors and outcomes of penetrating and blast injuries to the central nervous system and highlight the differences between gunshot wound, blast injury and stabbing.

Methods

A review of the current literature was performed.

Results

Of patients with craniocerebral GSW, 66–90 % die before reaching hospital. Of those who are admitted to hospital, up to 51 % survive. The patient age, GCS, pupil size and reaction, ballistics and CT features are important factors in the decision to operate and in prognostication. Blast injury to the brain is a component of multisystem polytrauma and has become a common injury encountered in war zones and following urban terrorist events. GSW to the spine account for 13–17 % of all gunshot injuries.

Conclusions

Urgent resuscitation, correction of coagulopathy and early surgery with wide cranial decompression may improve the outcome in selected patients with severe craniocerebral GSW. More limited surgery is undertaken for focal brain injury due to GSW. A non-operative approach may be taken if the clinical status is very poor (GCS 3, fixed dilated pupils) or GCS 4–5 with adverse CT findings or where there is a high likelihood of death or poor outcome. Civilian spinal GSWs are usually stable neurologically and biomechanically and do not require exploration. The indications for exploration are as follows: (1) compressive lesions with partial spinal cord or cauda equina injury, (2) mechanical instability and (3) complications. The principles of management of blast injury to the head and spine are the same as for GSW. Multidisciplinary specialist management is required for these complex injuries.

Parks SE, Johnson LL, McDaniel DD et al (2014) Surveillance for violent deaths—national violent death reporting system, 16 states, 2010. MMWR Surveill Summ 63:1–33PubMed

Kaufman HH, Levy ML, Stone JL et al (1995) Patients with Glasgow Coma Scale scores 3, 4, 5 after gunshot wounds to the brain. Neurosurg Clin N Am 6:701–714PubMed

Joseph B, Aziz H, Pandit V et al (2014) Improving survival rates after civilian gunshot wounds to the brain. J Am Coll Surg 218:58–65CrossRefPubMed

Sidhu GS, Ghag A, Prokuski V et al (2013) Civilian gunshot injuries of the spinal cord: a systematic review of the current literature. Clin Orthop Relat Res 471:3945–3955CrossRefPubMedCentralPubMed

Aarabi B, Tofighi B, Kufera JA et al (2014) Predictors of outcome in civilian gunshot wounds to the head. J Neurosurg 120:1138–1146CrossRefPubMed

Gressot LV, Chamoun RB, Patel AJ et al (2014) Predictors of outcome in civilians with gunshot wounds to the head upon presentation. J Neurosurg 121:645–652

Jandial R, Reichwage B, Levy M et al (2008) Ballistics for the neurosurgeon. Neurosurgery 62:472–480CrossRefPubMed

Powers DB, Delo RI (2013) Characteristics of ballistic and blast injuries. Atlas Oral Maxillofac Surg Clin North Am 21:15–24CrossRefPubMed

McCully SP, Schreiber MA (2013) Traumatic brain injury and its effect on coagulopathy. Semin Thromb Hemost 39:896–901CrossRefPubMed

10.

Halpern CH, Reilly PM, Turtz AR et al (2008) Traumatic coagulopathy: the effect of brain injury. J Neurotrauma 25:997–1001CrossRefPubMed

11.

Mitra B, O’Reilly G, Cameron PA et al (2013) Effectiveness of massive transfusion protocols on mortality in trauma: a systematic review and meta-analysis. ANZ J Surg 83:918–923CrossRefPubMed

12.

Baraniuk S, Tilley BC, Del Junco DJ et al (2014) Pragmatic randomized optimal platelet and plasma ratios (PROPPR) trial: design, rationale and implementation. Injury 45:1287–1295CrossRefPubMed

13.

Smith CE BA, Pivalizza EG, Tanaka K, Boral L, Shander A, Waters JH (2014) Massive transfusion protocol for hemorrhagic shock. American Society of Anesthesiologists, Schaumburg, IL

14.

Epstein DS, Mitra B, Cameron PA et al (2014) Acute traumatic coagulopathy in the setting of isolated traumatic brain injury: definition, incidence and outcomes. Brit J Neurosurg 25:1–5

15.

Talving P, Benfield R, Hadjizacharia P et al (2009) Coagulopathy in severe traumatic brain injury: a prospective study. J Trauma 66:55–61CrossRefPubMed

16.

Kim KA, Wang MY, McNatt SA et al (2005) Vector analysis correlating bullet trajectory to outcome after civilian through-and-through gunshot wound to the head: using imaging cues to predict fatal outcome. J Neurosurg 57:737–747CrossRef

17.

Lin DJ, Lam FC, Siracuse JJ et al (2012) “Time is brain” the Gifford factor—or: why do some civilian gunshot wounds to the head do unexpectedly well? A case series with outcomes analysis and a management guide. Surg Neurol Int 3:98CrossRefPubMedCentralPubMed

18.

Part 1: guidelines for the management of penetrating brain injury. Introduction and methodology. J Trauma 51:S3–S6 (2001)

19.

United States Army Institute of Surgical Research Joint Theater Trauma System Clinical Practice Guideline (Neurosurgical management), United States Army, 2012

20.

Kazim SF, Shamim MS, Tahir MZ et al (2011) Management of penetrating brain injury. J Emerg Trauma Shock 4:395–402CrossRefPubMedCentralPubMed

21.

Ragel BT, Klimo P Jr, Martin JE et al (2010) Wartime decompressive craniectomy: technique and lessons learned. Neurosurgery 28:E2

22.

Aarabi B, Taghipour M, Alibaii E et al (1998) Central nervous system infections after military missile head wounds. J Neurosurg 42:500–509CrossRef

23.

Antibiotic prophylaxis for penetrating brain injury. J Trauma 51:S34–S40 (2001)

24.

Management of cerebrospinal fluid leaks. J Trauma 51:S29–S33 (2001)

25.

Bayston R, de Louvois J, Brown EM et al (2000) Use of antibiotics in penetrating craniocerebral injuries. “Infection in Neurosurgery” Working Party of British Society for Antimicrobial Chemotherapy. Lancet 355:1813–1817CrossRefPubMed

26.

United States Army Institute of Surgical Research Joint Theater Trauma System Clinical Practice Guideline (Management of patients with Severe Head Trauma), 2012

27.

Rosenfeld JV (2002) Gunshot injury to the head and spine. J Clin Neurosci 9:9–16CrossRefPubMed

28.

Armonda RA, Bell RS, Vo AH et al (2006) Wartime traumatic cerebral vasospasm: recent review of combat casualties. Neurosurgery 59:1215–1225CrossRefPubMed

29.

Armonda R, Tigno T, Hochheimer S et al (2011) Specific clinical applications of transcranial doppler ultrasound for patients with wartime traumatic brain injury. J Neurotrauma 28:A5

30.

Bell RS, Vo AH, Roberts R et al (2010) Wartime traumatic aneurysms: acute presentation, diagnosis, and multimodal treatment of 64 craniocervical arterial injuries. Neurosurgery 66:66–79CrossRefPubMed

31.

Elserry T, Anwer H, Esene IN (2013) Image guided surgery in the management of craniocerebral gunshot injuries. Surg Neurol Int 4:S448–S454CrossRefPubMedCentralPubMed

32.

Glapa M, Zorio M, Snyckers FD et al (2009) Gunshot wounds to the head in civilian practice. Am Surg 75:223–226PubMed

33.

Rosenfeld JV, McFarlane AC, Bragge P et al (2013) Blast-related traumatic brain injury. Lancet Neurol 12:882–893CrossRefPubMed

34.

Bell RS, Mossop CM, Dirks MS et al (2010) Early decompressive craniectomy for severe penetrating and closed head injury during wartime. Neurosurgery 28:E1

35.

Weisbrod AB, Rodriguez C, Bell R et al (2012) Long-term outcomes of combat casualties sustaining penetrating traumatic brain injury. J Trauma Acute Care Surg 73:1523–1528CrossRef

36.

Ecker RD, Mulligan LP, Dirks M et al (2011) Outcomes of 33 patients from the wars in Iraq and Afghanistan undergoing bilateral or bicompartmental craniectomy. J Neurosurg 115:124–129CrossRefPubMed

37.

DuBose JJ, Barmparas G, Inaba K et al (2011) Isolated severe traumatic brain injuries sustained during combat operations: demographics, mortality outcomes, and lessons to be learned from contrasts to civilian counterparts. J Trauma 70:11–18CrossRefPubMed

38.

Enicker B, Madiba TE (2014) Cranial injuries secondary to assault with a machete. Injury 45:1355–1358CrossRefPubMed

39.

Schoenfeld AJ, Lehman RA Jr, Hsu JR (2012) Evaluation and management of combat-related spinal injuries: a review based on recent experiences. Spine J 12:817–823CrossRefPubMed

40.

Jaiswal M, Mittal RS (2013) Concept of gunshot wound spine. Asian Spine J 7:359–364CrossRefPubMedCentralPubMed

41.

Bono CM, Heary RF (2004) Gunshot wounds to the spine. Spine J 4:230–240CrossRefPubMed

42.

Heary RFMA (2010) Gunshot injuries to the thoracolumbar spine. Semin Spine Surg 22:73–77CrossRef

43.

Klimo P Jr, Ragel BT, Rosner M et al (2010) Can surgery improve neurological function in penetrating spinal injury? A review of the military and civilian literature and treatment recommendations for military neurosurgeons. Neurosurgery 28:E4

44.

Shen FH, Samartzis D (2013) Operative management of a sacral gunshot injury via minimally invasive techniques and instrumentation. Asian Spine J 7:44–49CrossRefPubMedCentralPubMed

45.

Aryan HE, Amar AP, Ozgur BM et al (2005) Gunshot wounds to the spine in adolescents. Neurosurgery 57:748–752CrossRefPubMed

46.

Schoenfeld AJ, Goodman GP, Belmont PJ Jr (2012) Characterization of combat-related spinal injuries sustained by a US Army Brigade Combat Team during Operation Iraqi Freedom. Spine J 12:771–776CrossRefPubMed

47.

Schoenfeld AJ, Laughlin MD, McCriskin BJ et al (2013) Spinal injuries in United States military personnel deployed to Iraq and Afghanistan: an epidemiological investigation involving 7877 combat casualties from 2005 to 2009. Spine 38:1770–1778CrossRefPubMed

48.

Schoenfeld AJ, Dunn JC, Belmont PJ (2013) Pelvic, spinal and extremity wounds among combat-specific personnel serving in Iraq and Afghanistan (2003–2011): a new paradigm in military musculoskeletal medicine. Injury 44:1866–1870CrossRefPubMed

49.

Ramasamy A, Midwinter M, Mahoney P et al (2009) Learning the lessons from conflict: pre-hospital cervical spine stabilisation following ballistic neck trauma. Injury 40:1342–1345CrossRefPubMed

50.

Patzkowski JC, Blair JA, Schoenfeld AJ et al (2012) Multiple associated injuries are common with spine fractures during war. Spine J 12:791–797CrossRefPubMed

51.

Blair JA, Possley DR, Petfield JL et al (2012) Military penetrating spine injuries compared with blunt. Spine J 12:762–768CrossRefPubMed

52.

Medzon R, Rothenhaus T, Bono CM et al (2005) Stability of cervical spine fractures after gunshot wounds to the head and neck. Spine 30:2274–2279CrossRefPubMed

53.

Trahan J, Serban D, Tender GC (2013) Gunshot wounds to the spine in post-Katrina New Orleans. Injury 44:1601–1606CrossRefPubMed

54.

Syre P 3rd, Rodriguez-Cruz L, Desai R et al (2013) Civilian gunshot wounds to the atlantoaxial spine: a report of 10 cases treated using a multidisciplinary approach. J Neurosurg Spine 19:759–766CrossRefPubMed

55.

Shahlaie K, Chang DJ, Anderson JT (2006) Nonmissile penetrating spinal injury. Case report and review of the literature. J Neurosurg Spine 4:400–408CrossRefPubMed

56.

Levy ML (2000) Outcome prediction following penetrating craniocerebral injury in a civilian population: aggressive surgical management in patients with admission Glasgow Coma Scale scores of 6 to 15. Neurosurgery 8:e2

57.

Polin RS, Shaffrey ME, Phillips CD et al (1995) Multivariate analysis and prediction of outcome following penetrating head injury. Neurosurg Clin N Am 6:689–699PubMed

Title: Current Concepts in Penetrating and Blast Injury to the Central Nervous System
Authors: Jeffrey V. Rosenfeld
Randy S. Bell
Rocco Armonda
Publication date: 01-06-2015
Publisher: Springer International Publishing
Published in: World Journal of Surgery / Issue 6/2015
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI: https://doi.org/10.1007/s00268-014-2874-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Current Concepts in Penetrating and Blast Injury to the Central Nervous System

Abstract

Aim

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Aim

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 6/2015

Repeat Cytoreductive Surgery and HIPEC for Peritoneal Surface Malignancy and Peritoneal Carcinomatosis

Macrometastasis, Micrometastasis, and Isolated Tumor Cells in Sentinel Lymph Nodes of Early Breast Cancers: A 10-Year Histopathological and Survival Analysis of 537 Asian Patients

Surgery for Undiagnosed Ground Glass Pulmonary Nodules: Decision Making Using Serial Computed Tomography

The EPOS-CC Score: An Integration of Independent, Tumor- and Patient-Associated Risk Factors to Predict 5-years Overall Survival Following Colorectal Cancer Surgery

CUP Syndrome in Neuroendocrine Neoplasia: Analysis of Risk Factors and Impact of Surgical Intervention

Effects of Intra-abdominally Instilled Isotonic Saline on Pain, Recovery, and Health-Related Quality-of-Life Following Laparoscopic Cholecystectomy: A Randomized Prospective Double-Blind Controlled Study