- Department of Neurosurgery, Sher-i-Kashmir Institute of Medical, Sciences, Srinagar, Jammu and Kashmir, India
Correspondence Address:
Abrar Ahad Wani
Department of Neurosurgery, Sher-i-Kashmir Institute of Medical, Sciences, Srinagar, Jammu and Kashmir, India
DOI:10.4103/2152-7806.99930
Copyright: © 2012 Wani AA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Wani AA, Ramzan AU, Dar TI, Malik NK, Khan AQ, Wani MA, Alam S, Nizami FA. Management dilemma in penetrating head injuries in comatose patients: Scenario in underdeveloped countries. Surg Neurol Int 21-Aug-2012;3:89
How to cite this URL: Wani AA, Ramzan AU, Dar TI, Malik NK, Khan AQ, Wani MA, Alam S, Nizami FA. Management dilemma in penetrating head injuries in comatose patients: Scenario in underdeveloped countries. Surg Neurol Int 21-Aug-2012;3:89. Available from: http://sni.wpengine.com/surgicalint_articles/management-dilemma-in-penetrating-head-injuries-in-comatose-patients-scenario-in-underdeveloped-countries/
Abstract
Background:The optimal management of patients with minimal injury to brain has been a matter of controversy and this is especially intensified when the patient has a poor neurological status. This is important in the regions where neurosurgical services are limited and patient turnover is disproportionate to the available resources. We aimed to determine the effectiveness of aggressive management in coma patients after penetrating missile injuries of the brain.
Methods:All the patients of gunshots or blast injuries were included if they had a Glasgow Coma Scale score of less than 8 after initial resuscitation and had no other injury that could explain their poor neurological status. The indication for emergency surgery was evidence of a mass lesion causing a significant mass effect; otherwise, debridement was done in a delayed fashion. The patients who were not operated were those with irreversible shock or having small intracranial pellets with no significant scalp wounds. The patients who had a Glasgow outcome score of 1, 2, or 3 were classified as having an unfavorable outcome (UO) and those with scores 4 and 5 were classified as having a favorable outcome (FO).
Results:We operated 13 patients and the rest 13 were managed conservatively. The characteristics of the patients having a favorable outcome were young age (OR = 28, P = 0 .031), normal hemodynamic status (OR = 18, P = 0.08), presence of pupillary reaction (OR = 9.7, P = 0.1), and injury restricted to one hemisphere only (OR = 15, P = 0.07). All of the patients who were in shock after resuscitation died while 25% of the patients with a normal hemodynamic status had a favorable outcome.
Conclusions:In developing countries with limited resources, the patients who are in a comatose condition after sustaining penetrating missile injuries should not be managed aggressively if associated with bihemispheric damage, irreversible shock, or bilateral dilated nonreacting pupils. This is especially important in the event of receiving numerous patients with the same kind of injuries.
Keywords: Brain injury, comatose, missile, outcome
INTRODUCTION
Penetrating missile injuries due to bullets and bomb blasts are common in areas of conflict and are on an increasing trend.[
However, very few studies have focussed their attention on only those patients with a poor neurological status.[
MATERIALS AND METHODS
A total of 101 patients of penetrating missile injuries to brain were admitted to the Department of Neurosurgery over a period of 3 years. Out of them only 26 patients were included in our study as they had a Glasgow coma scale (GCS) score of less than 8. Patients who had multiple organ injuries or had a GCS score of 8 and above were excluded from the study. The age ranged from 8 to 60 years with a mean age of 29.92 years. The cause of injury was either bullet, or it was a splinter injury from bomb blasts. Most of the patients reached the hospital without any field resuscitation, and primary contact care was provided by us as we are the only neurocenter in the area with a population of nearly seven million. As soon as the patients were received in the Accident and Emergency Department, they were resuscitated using the standard protocol of airway, breathing, and circulation (ABC). In all of these patients, mannitol, 1 g/kg of body weight, was administered intravenously. All the patients were started on anticonvulsants (phenytoin) and broad-spectrum antibiotics (ceftriaxone and sulbactum 1.5 g, iv., every 12 h, and Amikacin 500 mg every 12 h. The patients were shifted for a CT scan and then surgery or medical management was planned. The most common CT finding consisted of the clear visualization of the missile tract in brain parenchyma along with disproportionate edema which was more so with bullet injuries as compared to the splinter injury. Surgery consisted of wound debridement. In the surgical group, a wide scalp flap was raised and craniectomy was done in all the cases. The bone fragments were removed along with necrotic brain and hematoma. We did not attempt to debride the whole of the missile tract. All the patients were shifted to neurointensive units and managed on anti-edema dugs, antibiotics, and anticonvulsants. The patients who were in irreversible shock despite resuscitation or those who had symptoms of brain death were not operated. Brain death was decided by the neurosurgeon and anesthesiologist together once patients were assessed in the emergency department. The outcome was assessed using the Glasgow outcome scale (GOS) with scores as follows: 1, death; 2, persistent vegetative state; 3, severely disabled; 4, moderately disabled (disabled but independent); 5, good recovery. Patients who had score 1, 2, or 3 were classified as having an unfavorable outcome (UO) and those with score 4 or 5 were classified as having a favorable outcome (FO). The follow-up ranged from 6 to 17 months (average 8.2 months). The data were analyzed by SPSS 11.5 software. The odds ratio was calculated to determine the likelihood association between various factors as the sample size was small. Than Fischer's exact test was used to determine the association between various variables and a P-value of <0.05 was taken as significant at a confidence interval of 95%.
RESULTS
A total of 26 patients were recruited for the study. We had grouped the patients into two groups of ≤18 years and >18 years of age. The number of patients in each group was 5 and 21, respectively. The likelihood of UO in patients >18 years of age was 28 times as compared to those ≤18 years and this yielded a P-value of 0.031 (CI = 1.77–379.4;
Regarding modes of injury, the patients had either bullet injury (n = 7) or splinter injury caused by bomb blasts (n = 19). None of the patients with bullet injuries survived (OR = 1.6) while we had two patients with FO in the splinter injury group (P > 0.05;
All the patients who had bihemispheric involvement died and the likelihood of having UO in patients with bihemispheric involvement was 15 times as compared to the unihemispheric involvement (OR = 15, P = 0.07;
Most of our patients reported to the hospital within 2 h (n = 20) and only six reached afterward (however, all had reported before 3.5 h). The likelihood of having FO was 3.8 times in patients reporting early; however, this did not prove to be a statistically significant factor (P = 0.41, CI 0.338–43.42).
A total of 18 patients were in shock (BP <90/60) at the time of admission (postresuscitation) and none of these patients survived. The likelihood of having UO in patients with shock was 12 times as compared to those with a normal hemodynamic status. However, due to the small sample size, the P-value was 0.08 [
A total of 17 patients were having pupils not reacting to light (FDP) and only 9 patients had reacting pupils (including anisocoria). All the patients who had dilated pupils had UO while we had two patients with FO in the other group, and so the chances of having UO was 9.7 times in patients with FDP as compared to those with reacting pupils [
There was an equal number of patients who were operated and managed conservatively. There was no difference in the outcome in the two groups (P = 1.000;
DISCUSSION
The incidence of missile injuries is on an ever-increasing trend due to the widespread increase in crimes and conflicts. Our state also being a disturbed area could not escape from this calamity. The initial significant work on the management of the patients is credited to none other than Harvey Cushing[
CONCLUSION
While analyzing the study, we conclude that in the places with limited resources that have to cater to a disproportionately large population, patients with missile injuries to brain and a GCS score of <8, having bilateral nonreacting pupils, or bihemispheric damage or irreversible shock should not be offered surgery. However, a larger study is required to answer the question of efficacy of surgery in this group.
References
1. Ansari SA, Panezai AM. Penetrating craniocerebral injuries: An escalating problem in Pakistan. Br J Neurosurg. 1998. 12: 340-3
2. Arabi B. Surgical outcome in 435 cases who sustained missile head wounds during the Iran-Iraq war. Neurosurgery. 1990. 27: 692-5
3. Benzel EC, Day WT, Kesteson L, Willis BK, Kessler CW, Modling D. Civilian carniocerebral gunshot wounds. Neurosurgery. 1991. 29: 67-71
4. Cavaliare R, Cavenago L, Siccardi D, Viale GL. Gunshot wounds of brain in civilians. Acta Neurochir (Wien). 1988. 94: 133-6
5. Cushing H. A study of series of wounds involving the brain and its enveloping structures. Br J Surg. 1918. 5: 558-684
6. Demetriades D, Kuncir E, Velmahos GC, Rhee P, Alo K, Chan LS. Chan. Outcome and prognostic factors in head injuries with an admission glasgow coma scale score of 3. Arch Surg. 2004. 139: 1066-8
7. Grahm TW, Williams FC, Harrington T, Spetzler RF. Civilian gunshot wounds to the head: A prospective study. Neurosurgery. 1990. 27: 696-700
8. Helling TS, McNabney WK, Whittaker CK, Schultz CC, Watkins M. Contusion, fragmentation, ventricular injury, and Glasgow Coma Score. The role of early surgical intervention in civilian gunshot wounds to the head. J Trauma. 1992. 32: 398-400
9. Jagger J, Dietz PE. Death and injury by firearms: Who cares?. JAMA. 1986. 255: 3143-4
10. Kaufman HH, Makela ME, Francis L, Haid RW, Gildenberg PL. Gunshot wounds to the head. A perspective. Neurosurgery. 1986. 18: 689-95
11. Levy ML, Masri LS, Lavine S, Appuzo ML. Outcome prediction after penetrating craniocerebral injury in a civilian population: Aggressive surgical management in patients with admission Glasgo Coma Scale scores of 3, 4, or 5 [clinical study]. Neurosurgery. 1994. 35: 77-85
12. Martins RS, Siqueira MG, Santos MT, Zanon-Collange N, Moraes OJ. Prognostic factors and treatment of penetrating gunshot wounds to the head Prognostic factors and treatment of penetrating gunshot wounds to the head. Surg Neurol. 2003. 60: 98-104
13. Nagib MG, Rockswold GL, Sherman RS, Lagaard MW. Civilian gunshot wounds to the brain: Prognosis and management. Neurosurgery. 1986. 18: 533-7
14. Sosin DM, Nelson DE, Sacks JJ. Head injury deaths: The enormity of firearms. JAMA. 1992. 268: 791-
15. Sosin DM, Sacks JJ, Smith SM. Head injury-associated deaths in the United States from 1979-1986. JAMA. 1989. 262: 2251-5
16. Splavski B, Vranković D, Saftić R, Muzević D, Kosuta M, Gmajnić R. Clinical predictors correlated to outcome of war missile penetrating brain injury. Acta Med Croatica. 2006. 60: 369-73
17. Suddaby L, Weir B, Forsyth C. The management of 0.22 caliber gunshot wounds of the brain: A review of 49 cases. Can J Neurol Sci. 1987. 14: 268-72
18. Webster DW, Champion HR, Gainer PS, Sykes L. Epidemiologic changes in gunshot wounds in Washington, DC: 1983-1990. Arch Surg. 1992. 127: 694-8