- Department of Neurosurgery, Policlinico Riuniti Hospital, Foggia,
- Department of Neurosurgery, Giovanni XXIII Hospital, Bari,
- Department of Neurosurgery, University of Foggia, Foggia, Puglia, Italy.
Francesco Carbone, Department of Neurosurgery, University of Foggia, Foggia, Puglia, Italy.
DOI:10.25259/SNI_1134_2021Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Antonio Colamaria1, Maria Blagia2, Francesco Carbone3, Nicola Pio Fochi3. Blast-related traumatic brain injury: Report of a severe case and review of the literature. 15-Apr-2022;13:151
How to cite this URL: Antonio Colamaria1, Maria Blagia2, Francesco Carbone3, Nicola Pio Fochi3. Blast-related traumatic brain injury: Report of a severe case and review of the literature. 15-Apr-2022;13:151. Available from: https://surgicalneurologyint.com/surgicalint-articles/11532/
Background: Traumatic brain injury (TBI) is a well-known brain dysfunction commonly encountered in activities such as military combat or collision sports. The etiopathology can vary depending on the context and bomb explosions are becoming increasingly common in war zones, urban terrorist attacks, and civilian criminal feuds. Blast-related TBI may cause the full severity range of neurotrauma, from a mild concussion to severe, penetrating injury. Recent classifications of the pathophysiological mechanisms comprise five factors that reflect the gravity of the experienced trauma and suggest to the clinician different pathways of injury and consequent pathology caused by the explosion.
Case Description: In the present report, the authors describe a case of 26 years old presenting with blast-related severe TBI caused by the detonation of an explosive in an amusement arcade. Surgical decompression to control intracranial pressure and systemic antibiotic treatment to manage and prevent wound infections were the main options available in a civilian hospital.
Conclusion: While numerous studies examined the burden of blast-related brain injuries on service members, few papers have tackled this problem in a civilian setting, where hospitals are not sufficiently equipped, and physicians lack the necessary training. The present case demonstrates the urgent need for evidence-based diagnostic and therapeutic protocols in civilian hospitals that would improve the outcome of such patients.
Keywords: Blast, Civil population, Neurotrauma, Severe traumatic brain injury
Traumatic brain injury (TBI) is characterized by an acute brain injury that occurs as a result of external forces applied to the head. It is estimated that more than 5% of military personnel deployed to Iraq and Afghanistan have suffered from TBI and have exhibited long-term impairment of both cognitive and psychological functions.[
In the present report, a case of 26 years old with blast-related severe TBI presenting with a left frontoparietal fracture and multiple intraparenchymal foreign bodies is described. The management of such cases still poses various challenges, especially in nonmilitary hospitals, where physicians lack sufficient expertise and training.
A 26-year-old man was found unconscious in an amusement arcade following the detonation of an unspecified explosive. On his initial assessment, the emergency physician found a Glasgow Coma Scale (GCS) score of 3, a left frontoparietal lacerated and contused wound extending to the frontosphenoidal suture [
Preoperative CT scans of the head demonstrating (a) a right parietal fracture with underlying frontoparietal pneumocephalus and (b) bilateral multifragmentary burst fractures of the skull accompanied by the presence of intracerebral foreign bodies exhibiting metal density and causing interhemispheric and subarachnoid hemorrhage.
Following the first surgery, the patient developed signs of infection, and a control CT scan of the head showed (a) evidence of abscess formation and wound dehiscence and (b) obstructive hydrocephalus. (c) Subsequent surgical treatment consisted of an enlargement of the first craniotomy and positioning of a ventriculoperitoneal shunt.
Definition of a complex entity
TBI is a physical and psychological injury that has been considered a major public health concern for decades, largely associated with motor vehicle crashes, accidental falls, and sports collisions.[
Extent of the burden
In a recent article, Phipps et al.[
Pathophysiology and clinical aspects of blast-related TBI
Recent classifications of blast-related TBI comprise five factors that reflect the gravity of the experienced trauma and suggest to the clinician various mechanisms of injury and consequent pathology caused by the explosion. The majority of deceases are not to be associated with the explosion’s blast wave alone, which most frequently causes ear damage, pulmonary trauma, and concussions. For instance, penetrating injuries are associated with 70% of moderate-to-severe blast-induced TBIs and are extensively more invalidating, as a consequence of the wide variety of fragments propelled by the detonation that can lead to fatal outcomes. Further analysis reveals also tertiary mechanisms that comprise bone fractures, traumatic amputations, and collapsing of buildings that result in crushing of the body. Moreover, quaternary injuries may result from burns, asphyxia, and exposure to toxic inhalants usually contained within the explosive.[
Blast-related mTBI is reported to be associated with impairments in sensory and neurocognitive functions, which tend to be most prominent immediately after the injury and usually diminish 3 months after the accident.[
Blast-related severe TBI
Clinical management of blast-related severe TBI includes the assessment of the airway, breathing, and circulation and the GCS scores. The patient should undergo a CT scan as soon as possible to evaluate possible brain injuries, such as skull fractures, intracranial hemorrhage, or cerebral edema.
Attention to secondary brain injuries, being SBP < 90 mmHg or SpO2 < 92%, should be paid during prehospital management, as they both appear to increase mortality. Along with these, preintubation in patients with a GCS score <9 is not recommended, as it may result in excessive overventilation, consequent to transient hypoxia.[
Adequate oxygenation in the hospital setting, functional cerebral perfusion, and control of ICP are vital to avoid further damage, given that intracranial hypertension is a common finding in severe TBI.
Blood in the basilar cisterns might suggest a higher severity of the lesion, whereas a subarachnoid hemorrhage, revealed with the CT scan, usually leads to hyperemia and severe edema in the acute period.[
Vascular damage, unexplained variations of the neurological status, or sudden alteration observed by ICU monitoring imply the need for angiography or transcranial Doppler, due to the high risk of pseudoaneurysms formation and cerebral vasospasm.[
Early decompressive craniotomy has been a major factor in the improvement of survival and outcomes for patients with these severe injuries. Extensive unilateral or bilateral decompressive craniotomies are often needed to treat gross brain swelling and increased ICP. Cranioplasty could represent a viable option after the craniotomy; however, a latency of 3 months is recommended following evidence of infection. Ventriculostomy or lumbar drain can be performed if there is evidence of concomitant CSF leaks. Besides surgical treatment, hypertonic saline solutions and mild hypothermia (34–36°C) seem to have a beneficial effect on delayed intracranial hypertension.[
Summary of the present case
In the present report, a case of a 26-year-old male with blast-related severe TBI that occurred in a civilian setting is described. On his initial assessment, the patient presented in a comatose state with a left frontoparietal lacerated and contused wound, hypotension, and tachycardia. A head CT scan revealed multifragmentary burst fractures of the skull bilaterally accompanied by the presence of intracerebral foreign bodies, indicating that both primary and secondary explosion-related mechanisms had concurred in the damage. Emergency surgical treatment consisted of a left frontotemporal decompressive craniotomy with ligation and transection of the anterior third of the superior sagittal sinus and microscopic resection of intraparenchymal foreign bodies. Subsequent reoperation was needed as the patient soon exhibited signs of infection and obstructive hydrocephalus, and intravenous and intrathecal antibiotic treatment was initiated. Unfortunately, the patient showed progressive worsening of the neurological condition and died 1 month after the accident.
Blast-related TBI has come to represent a serious concern in both the military and the civilian settings. The effects of a bomb blast on the human brain depend on many factors, such as blast energy, distance from the blast, and body position at the moment of explosion, therefore, resulting in damage of variable gravity. Management of this kind of trauma may be challenging, especially for severe TBI occurring in the civilian setting. In the present report, the authors describe the case of a 26-year-old patient presenting in a comatose state with a left frontoparietal lacerated and contused wound, hypotension, and tachycardia. Notwithstanding surgical and antibiotic emergency treatment, the patient died 1 month after the accident. Therefore, it appears clear that early neurosurgical and pharmacological treatment is crucial to favor the outcome of these patients, although evidence-based treatment algorithms are still needed.
Patient’s consent not required as patients identity is not disclosed or compromised.
There are no conflicts of interest.
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