Paradigm Shift in Management Strategies of Craniocerebral Missile Injuries Improving Survival Rates and Functional Outcome Score

Abstract

Introduction With development of firearms, civilian violence, ethnic clashes, militancy, terrorist attack, and military operations there is a worldwide increase in incidence of craniocerebral missile injuries. The mortality of patients with craniocerebral missile injuries is high, and if the victim survives, functional outcome is poor. In spite of high mortality, no proper attention was given in last five decades in improving surgical techniques and resuscitation patterns of patients with craniocerebral missile injuries.

Problems Considered The problems are many, but the two problems highlighted are decreased survival because of the inadequate pre-op resuscitation and poor functional outcome due to aggressive surgery. Therefore, the study was performed to evaluate the outcome of early and less aggressive surgical strategy and aggressive preoperative resuscitation in patients with penetrating injuries and also to look for factors prognosticating outcome.

Methods A series of 96 patients with craniocerebral missile injuries to head were managed at a single center over a period of 3 years is presented. Aggressive resuscitation was done in all hemodynamically unstable patients and patients with coagulopathy either with blood products, hyperosmolar therapy or ionotropic support on protocols of damage control resuscitation. Blood product therapy consisted of packed red blood corpuscles, fresh frozen plasma (FFP) and platelets. Hypertonic saline was used for hyperosmolar resuscitation, and for ionotropic support dopamine, adrenalin, and vasopressin were used. Minimum debridement of the missile tract was done and maximum cortical tissue was preserved.

Results Neurosurgical procedures contemplated on 78 patients. Criteria for craniotomy were—Glasgow Coma Scale (GCS) of < 8 without hypotension and reacting pupils, GCS > 8 with intracranial bone fragments/significant clot, and raised intracranial pressure. Surgical approach were frontotemporal exposure (41%, n = 32/78), frontoparietal exposure (22%, n = 18/78), retrosigmoid exposure (2%, n = 2/78), combined middle and posterior fossa approach (2%, n = 2/78), and decompressive craniectomy (43%, n = 24/78). Procedures done were debridement of devitalized tissue (100%, n = 78/78), extraction of bone fragment (43%, n = 17/39), extraction of metallic pellet (62%, n = 42/67), lax duraplasty (100%, n = 78/789), debridement of missile tract (100%, n = 78/78). Overall, 36 patients were operated within 8 hours and 22 patients were operated within 14 hours. Median age group were 26 years, 81% were male, surgical mortality of 18%, and overall mortality was 33%.

Conclusion This study indicates the factors prognosticating outcomes and supports that less aggressive surgery and aggressive preoperative resuscitation has decreased surgical mortality rates and improved functional outcomes.

Keywords

craniocerebral missile injury - Glasgow Coma Scale - intracranial pressure - neurological deficit

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