Early complications following penetrating wounds of the brain

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✓ The experience of an evacuation hospital in Japan in treating 506 consecutive patients from Vietnam with penetrating wounds of the brain is reported with particular reference to early complications. Sixty-eight patients were operated on for still retained intracranial foreign bodies. Thirty-five of the 62 patients with retained intracranial bone fragments had positive microbial cultures of the fragment, which in 63% showed Staphylococcus epidermis. All of the metallic fragments cultured revealed microbial growth. Superficial infections were noted in 32 patients. Superficial plus deep infections were found in eight patients with no retained bone fragments. Eighteen patients had meningitis proven by culture, while an additional 12 patients with CSF sugars of less than 40 mg% were assumed to have meningitis. Twelve patients developed CSF leaks requiring surgery. Twenty-three patients (4.54%) died as a result of their wounds. The neurosurgical treatment recommended for these patients is described.

Abstract

✓ The experience of an evacuation hospital in Japan in treating 506 consecutive patients from Vietnam with penetrating wounds of the brain is reported with particular reference to early complications. Sixty-eight patients were operated on for still retained intracranial foreign bodies. Thirty-five of the 62 patients with retained intracranial bone fragments had positive microbial cultures of the fragment, which in 63% showed Staphylococcus epidermis. All of the metallic fragments cultured revealed microbial growth. Superficial infections were noted in 32 patients. Superficial plus deep infections were found in eight patients with no retained bone fragments. Eighteen patients had meningitis proven by culture, while an additional 12 patients with CSF sugars of less than 40 mg% were assumed to have meningitis. Twelve patients developed CSF leaks requiring surgery. Twenty-three patients (4.54%) died as a result of their wounds. The neurosurgical treatment recommended for these patients is described.

This paper reviews the early complications observed at the 106th General Hospital in Yokohama, Japan, in treating 506 patients from the Vietnamese War who were admitted with penetrating wounds of the brain from April 1, 1968, to November 30, 1969.

Results of Review
Location and Nature of Injury

Any compound injury of the skull with laceration of the dura, regardless of the extent of the underlying cerebral damage, was considered a penetrating wound. The majority of the injuries were due to missile fragments (Table 1). Frontal and right-sided wounds predominated (Table 2); 40 were bilateral.

TABLE 1

Mechanism of injury in 506 consecutive penetrating cranial wounds

Cause of WoundNo. of Cases
Related to hostile action:(481) 
 missiles: 
  MFW*85 
  mortar79 
  PFW69 
  booby traps64 
  rocket40 
  grenade26 
  mine21 
  “missile”6 
  artillery4 
 gunshot wounds66 
 “unknown”21 
Not related to hostile action:(25) 
 gunshot wounds7 
 vehicular accidents9 
 miscellaneous9 

MFW = multiple fragment wounds involving the head and other parts of the body presumed to be the result of booby traps or mortars.

PFW = penetrating fragment wound with the head wound the only wound, also presumed to be the result of booby trap, mortar, mine, or rocket.

TABLE 2

Location of skull fracture

Fracture LocationLeftRightBilat.
frontal7710830
frontotemporal79
frontoparietal814
frontotemporoparietal57
temporal2225
temporoparietal912
temporoparietooccipital24
temporosuboccipital23
parietal473010
parietooccipital910
occipital1318
suboccipital1111
occipitosuboccipital12

Neurological Deficits

On admission, neurological deficits were recorded in 349 (69%) of the patients (Table 3). Forty-seven patients with right hemiparesis or hemiplegia were dysphasic, while three had left hemiplegia and aphasia. Homonymous hemianopsia was present in 29 patients; inferior temporal quadrantanopsia occurred in three. Although these patients usually had multiple other fragment wounds, associated injuries were only included in Table 3 when they resulted in the single demonstrable deficit.

TABLE 3

Major neurological deficits noted at time of admission to 106th General Hospital in Japan

DeficitNo. of Cases
no significant defect detected157
left hemiplegia43
right hemiparesis40
left hemiparesis36
visual field defect31
right hemiplegia31
frontal lobe syndrome27
mixed dysphasia19
confusion, lethargy, disorientation17
paraparesis, triparesis, quadriparesis10
inappropriate affect8
monoparesis6
primary cerebellar findings5
diplopia with extraocular palsy5
decerebrate state5
Associated Injuries
eye39
decreased hearing10
facial nerve palsy (peripheral)8
major amputations4
peripheral nerve palsy3

Most of these patients had had a previous craniectomy in Vietnam. Four patients with penetrating wounds of the brain were not recognized in Vietnam, and the definitive surgery was performed in Japan; three of these had scalp lacerations sutured in Vietnam. The fourth patient had a facio-orbitocranial wound without intracranial exploration due to the severity of the other wounds; he developed a brain abscess around an intracranial metallic fragment, requiring surgery on his 16th post-injury day.

Infection
Cerebral Infection with Retained Fragments

Sixty-eight (13.4%) of our patients were operated on for retained intracranial fragments, 62 for retained bone fragments, and six for retained metallic fragments. Initially we made no effort to culture retained metallic fragments separately so that the number of these fragments actually contaminated by microorganisms is undoubtedly higher.

Thirty-five (56.4%) of the patients with retained bone fragments had positive bacteriologic cultures (Table 4). Staphylococcus epidermis was isolated in 63% of the positive cultures. In one patient, Staphylococcus epidermis was isolated from the retained bone fragment while Escherichia coli and Pseudomonas aeruginosa were cultured from a slightly deeper metallic fragment. Our preoperative use of antibiotics and failure to use anaerobic culture media routinely probably accounted for some “sterile” cultures.

TABLE 4

Organisms isolated from intracranial bone and metallic fragments

OrganismBoneMetalBoth
Staphylococcus epidermis2041
Bacillus species52
Klebsiella species4
Pseudomonas aeruginosa4
Aerobacter aerogenes2
Serratia marcescens2
Enterococci2
Paecilomyces species1
Pseudomonas aeruginosa11
Corynebacterium species1
Candida albicans1
Total3372

Superficial Infections

Superficial infections without deep wound contamination occurred in 32 cases. The infecting organism was usually Staphylococcus epidermis, Escherichia coli, Aerobacter aerogenes, or Pseudomonas aeruginosa.

Two patients with retained bone fragments had grossly infected extradural wounds treated in Japan without removal of the retained intracranial fragments. Repeated lumbar punctures were sterile in both patients. The first had an extradural abscess (150 cc) treated by irrigation, drainage, and continuous through-and-through irrigation of the wound with antibiotics for 10 days. The second patient had experienced massive hemorrhage from a laceration of a vertebral artery at the foramen magnum by a large metallic fragment; the artery was ligated and the grossly infected wound treated by the open method. After stabilization and improvement in their neurological status, both patients were evacuated to the United States for further evaluation.

When gross superficial infection was present but the dura intact, retained intracranial fragments were removed only when the risks of nonintervention were considered greater than the danger of surgical implantation of infected material within the brain. Eight patients in whom the dura was open had superficial infections combined with cerebritis or meningitis. Cottonoid sponges, used for hemostasis or retraction in Vietnam, were removed from three grossly infected brains at the time of reoperation in Japan.

Meningitis

Bacteriologically-proven meningitis was present in 18 patients. The organism grown from the cerebrospinal fluid (CSF) was not always the same as that isolated from the brain or intracranial fragments at surgery. There were 12 instances in which the CSF sugar was less than 40 mg%, and meningitis was assumed to be present despite the sterility of the CSF.

Seizures

Anticonvulsants, usually diphenylhydantoin, were started immediately after the patients were seen in Vietnam. Five patients had had seizures in Vietnam and an additional six in Japan.

Cerebrospinal Fluid Fistulas

Six patients without retained bone fragments required surgery for repair of CSF otorrhea or rhinorrhea. The majority of patients with CSF leaks responded to daily lumbar punctures or the insertion of a polyethylene catheter for continuous lumbar drainage for 7 to 10 days. Six patients without retained bone fragments needed closure of CSF-cutaneous fistulas with a dural graft. Two patients who had no evidence of CSF rhinorrhea in Japan subsequently developed this complication in the United States, which was then treated surgically.

Extradural Bone or Metallic Fragments

Seven patients had only extradural fragments, six bone and one metallic. Radiographically these fragments were considered to be possibly intradural. Six of the seven fragments were contaminated with staphylococci, enterococci, or Providence species.

Deaths

Twenty-three patients in this series died (Table 5). Thirteen of these had injuries of both hemispheres, nine had extensive involvement of one hemisphere only, while one had mainly a brain stem injury.

TABLE 5

Cause of 23 known deaths in this series

Cause of DeathNo. of Cases
Deaths in Japan:(19) 
 massive cerebral destruction6 
 pulmonary emboli5 
 cerebral infection5 
 intracranial hemorrhage2 
 brain stem injury, frontal lobe contusion, and secondary pneumonia1 
Deaths in United States:(4) 
 extensive brain damage2 
 recurrent CSF-cutaneous fistula1 
 intracranial hemorrhage after repair of CSF rhinorrhea1 

The only death occurring in a patient who was ambulatory on admission to our hospital resulted from bilateral pulmonary emboli. Only rarely did a patient who was in extremis in Vietnam or Japan survive long enough to be evacuated to the United States.

Discussion

Adequate facilities and personnel to accomplish early operation with removal of necrotic brain, foreign bodies, and hematomas appear to be the main factors in lowering the mortality rate with penetrating brain wounds.4,9,18,20,28,34,41

Early Management

There is no substitute for proper initial management. Preoperative skull x-rays are imperative to reduce unnecessary manipulations and may indicate the need of other procedures such as the removal of retained metallic fragments lodged subcortically on the side opposite to that of entrance, because of the frequent occurrence of intracranial hemorrhage near that site.4,30,31 However, it is pointless to obtain preoperative films showing multiple indriven bone fragments if they are not then removed. Digital palpation of the missile track by the original surgeon would have eliminated the need for many of the secondary craniectomies performed in Japan to remove bone fragments located at the bottom of the track or adherent to blood vessels just beneath the wall of the track. Postoperative films should be obtained to rule out their presence. A retained bone fragment constitutes prima facie evidence that the initial debridement of indriven debris, soft tissue, and necrotic brain was inadequate. The decision not to reoperate on a patient with a retained bone fragment because it is “small” ignores the results of studies demonstrating the high incidence of infection around a roentgenologically demonstrable bone fragment.3,5,8,12,13,19,23,29,39,42,44,50–52 The policy of secondary craniotomy whenever a retained bone fragment was found on postoperative x-rays, or a brain abscess suspected, helped reduce the incidence of meningiocerebral infection in Korean casualties from 41% initially to less than 1% ultimately34 and resulted in no brain abscesses being encountered among 51 British troops who received definitive care in Korea.27

Infection
Cerebral Infection with Retained Fragments

Various delayed manifestations of infection are now a more common problem than meningitis because of earlier surgery and routine use of antibiotics. Antimicrobial agents can arrest the invasion of certain bacteria but they are not as successful in a wound containing necrotic tissue, blood clot, or foreign material. A cerebral fungus will develop despite heavy doses of antibiotics when thorough and early radical debridement of a grossly contaminated wound is not accomplished.33,35 In our series, 56.4% of the patients with retained bone fragments showed positive cultures even though these patients had been on antibiotics preoperatively for an average of 2 weeks (range: 5 to 54 days). Some bacteria have been highly resistant to all the usual antibiotics; two of our fatalities occurred in patients infected with Serratia marcescens. Six of the eight fatalities in Wannamaker and Pulaski's series50 were due to organisms resistant to the antibiotics available for treatment of Korean battle casualties.

Orbito-facio-cranial Infections

Orbitofacio-cranial wounds are regarded as a greater potential source of infection than those entering the vault directly.30,39,44 They are also characterized by a high incidence of associated subdural and intracerebral clot formation.4,35 While it would be difficult to justify removal of all intracranial foreign bodies related to this type of injury, particularly those in the hypothalamic or third ventricular regions in asymptomatic patients, these cases should be observed carefully for prolonged periods.

Retained Metallic Fragments

Brain abscesses are less apt to form around a metallic than a bone fragment, devitalized brain, or other indriven debris. The size, velocity, and irregularity of a metallic fragment are related to the damage produced along its track and its ability to carry contaminants. Debris clinging to a metallic fragment is often sterilized by the heat of the metal.30 The missile and associated bone fragments do not necessarily follow the same track,29 and the track immediately behind a metallic fragment tends to seal off.30 Metal fragments usually pass deeper than infective debris and bone fragments and may be able to shed most of the contaminating material (of less momentum) which they drive in.3 However, every metallic fragment that we have cultured separately has been found to be contaminated by micro-organisms; they have been associated with brain abscesses in 10% to 33% of the cases,28,52,55 and even small fragments have caused infection.12,13,32

If a metallic fragment is readily accessible and removable without inflicting further functional damage, every effort should be made to remove it. Bullets and other large metallic fragments have a tendency to wander, causing further damage, and remain a potential source of infection for years. Early removal of large metallic fragments is usually easy due to the size of the necrotic track produced by the missile. The removal of metallic fragments within a ventricle is indicated because free migration may produce severe symptoms16 and because they can occlude the foramina, producing hydrocephalus,18 although surgery for removal is easier if the ventricle is dilated.21 Changes in position of the fragment in successive x-rays are suggestive of the development of a brain abscess around it, or intraventricular or subdural migration.29,55 Even if the foreign body is in an area usually considered inaccessible,47 stereotaxic removal may be feasible and safe, and may be indicated later anyway if complications such as infection or epilepsy develop. However, since epileptogenic foci tend to lie in the superficial part of a wound track and not in the area immediately surrounding the fragment, the presence of a metallic fragment per se does not materially influence the incidence of epilepsy.2,38

Superficial Infections

Simple linear and curvilinear incisions healed most satisfactorily. Most superficial infections resulted from mild necrosis or local dehiscence as a result of inadequate debridement, excessive tension, or overlapping skin edges. All tripod incisions were associated with poor healing and infection of the apex of the wound. Some of these problems were related to not using intradermal sutures at the tips of the three flaps to avoid devitalizing the ends of the flaps. Tripod incisions failed to heal per primum in 13 of 18 cases in Campbell's series.8 It is important to excise the wound of entrance and then to make up the scalp deficit, if necessary, by rotating a scalp flap over the site of the craniectomy and applying a split-thickness skin graft to the intact periosteum over the donor site.51 The recent Navy practice of performing a formal horseshoetype scalp flap with the missile entrance wound in the center has resulted in frequent early wound complications because the entrance wound usually has become necrotic and infected. The underlying devascularized bone flap, obtained by use of a craniotome, must then be discarded during the secondary debridement of the contaminated wound.

Dural Closure

The intact dura is, of course, a strong barrier to infection.3,38,45,48 Although the advisability or need for its closure at the time of debridement has been questioned,3,23,27 chemotherapy combined with thorough debridement has made tight closure of the dura and scalp possible in most cases.42 Reconstitution of the dura primarily or with fascial or pericranial grafts avoids further necrosis of the brain from herniation through the dural hole. Skin closure provides some mechanical protection from the stresses of herniation and bacterial contamination from without, but it does not prevent the development of a closed brain fungus with the resultant necrosis of brain not only in the fungus but also in the underlying white matter.7 Closure of the dura also lessens the risk of post-traumatic epilepsy by reducing adhesions between the brain and superficial tissues.17,30,32,34 Subsequent procedures such as cranioplasty can be performed more easily with an intact dura. Tight dural closure is particularly indicated in transventricular wounds43,49 and orbito-facio-cranial wounds.7

We saw no case in which a dural graft appeared to be harmful. Dural grafts helped confine superficial infections to the extracranial space in at least eight patients in whom the severe extradural infection necessitated leaving the skin open until the wound was clean enough to permit application of a skin graft or rotation of a scalp flap.

Antibiotic Therapy

Most of the organisms cultured at this hospital were sensitive to the combination of cephalothin and colistin, and these drugs have been administered preoperatively and postoperatively until sensitivity reports were available permitting the institution of more specific antibiotic therapy. Resistance of the infecting organisms to the drugs used earlier in Vietnam was common. Most gram-negative isolates were sensitive to colistin. When a gram-negative meningitis was present, we frequently used intrathecal polymyxin B. Amphotericin B was used intrathecally when indicated.

Brain Abscess

No encapsulated brain abscesses were encountered in this series; free pus within a missile track or areas of cerebritis with partially or poorly formed walls were the usual findings. Capsule formation was scanty or lacking due to the surrounding devitalized tissue39 and the nature of the infecting organism.1,8,29 This necessitated total removal rather than initial tapping of these abscesses. Even in the 27 patients with retained bone fragments who showed negative cultures, large areas of necrotic brain needed redebridement to reduce the incidence of subsequent complications.

Due to the devitalized tissue in their path, additional neurological deficit is rare during total removal of these abscesses. Neurological deficits were slightly increased in three patients while existing deficits improved fairly rapidly in at least six patients, possibly because the amount of edema-producing necrotic brain and hematoma were decreased and the size of the internal decompression increased.

Temporizing in the hope of capsule formation may prove fatal due to further brain destruction, meningitis, or rupture into the ventricular system.11,29 Walling off of a brain abscess depends primarily on the formation of fibrous tissue by fibroblasts formed from the meninges or the walls of blood vessels, both of which may be deficient at the site of contamination in a missile-penetrated brain. Collagenase produced by polymorphonuclear leukocytes may retard or prevent capsule formation. Gliosis, in general, is a poor barrier to the spread of infection. A heavy capsule may, however, form around a bone fragment located close to the meninges when the dura and pia mater participate in the formation of the capsule.

The fibrous connections and multilocular tendency of a chronic brain abscess may make it difficult to remove. An encapsulated abscess is not necessarily quiescent; within the cavity of the abscess virulent bacteria may be present which can result in death if permitted to escape into the meninges or ventricules. Following removal of the abscess, tight dural and scalp closure are usually possible.7,19,26

Brain abscesses due to retained intracranial fragments usually occur within 3 to 5 weeks,25,39 with an incidence of 13% to 16%.29,39,52 Infection has been reported to be 10 times more frequent around bone fragments than in their absence, and in one series 90% developed around a cluster of bone fragments.29

The development of a brain abscess around a retained intracranial fragment has been reported up to 38 years later.14,15,22,25 The late development of a brain abscess may be a tragic occurrence since the damage from the brain abscess is superimposed on an already damaged and scarred brain. Normal defense mechanisms are altered by changes in the cerebral architecture, and even though the patient survives, the functional loss is usually greater than in a primary abscess or wound at a similar site.14

The latency between the injury and the manifestation of a late abscess is difficult to explain.25 The abscess may develop slowly from an organism of low virulence left as an inoculant; or the area of injury, as a locus minoris resistentiae, may acquire the infection as the result of hematogenous spread. A low-grade infection may become activated by something upsetting the homeostatic mechanisms of the host, such as the removal of a foreign body from the skull or trauma to the head.7,25

Signs and Symptoms of Brain Abscess

The symptoms of a brain abscess following a penetrating wound are frequently atypical and insidious.37 Progressive neurological signs rarely occur because the lesion develops in previously traumatized cerebral tissue. The frequent lack of intracranial hypertension is probably due to the room for expansion provided by the internal decompression resulting from the wound. Irritability, mental sluggishness, increasing severity of headache, or sudden rise of temperature become quite significant.22,24 Recurrent headaches are usually unilateral and may awaken the patient from his sleep.8 Signs of intracranial hypertension are manifested by decreased pulsations of the scalp flap, bulging of the wound, increased CSF pressure on lumbar puncture, or mild papilledema. Focal fits may occur.35 A convulsion incident to rupture of the brain abscess into the ventricular system may be the initial symptom.37 Many small abscesses, operated on by us, consisted only of purulent collections found at the time of secondary debridement and, hence, were virtually asymptomatic at the time of surgery. Recurrent or worsening signs related to the injured part of the brain are suggestive of a brain abscess, thrombophlebitis, or delayed hemorrhage, but in deep wounds of the parietal region may follow the development of localized hydrocephalus due to obliteration of the body of the ventricle.

A rise in the CSF protein content or a low sugar may be a valuable sign of an early abscess.6 Pleocytosis is so common after penetrating wounds that it is of little value unless serial lumbar punctures have been performed and the white cell count starts to rise again or remains at a high level.

Sterile Abscess

A large number of abscesses are apparently sterile; however, the mortality rate associated with them may be as great as that with growth. The liquefaction of tissue in the formation of a brain abscess may result from the proteolytic enzymes released by disintegrating leukocytes, and the result may be an area of increased osmolarity that expands by attracting water, electrolytes, and small proteins from the adjacent tissues with its neovascularization.46 The mass may produce edema and increased intracranial pressure, and rupture into a ventricle or the subarachnoid space spontaneously or as the result of trauma or surgical intervention.11 Even if not infected, retained bone fragments may undergo chemical decomposition with time and form sterile abscesses.

Cerebral fungi have rarely developed in this conflict due to the rapid evacuation of patients with craniocerebral trauma to neurosurgical centers. When present, a closed cerebral fungus was treated by thorough debridement of the brain and dural closure with a pericranial or fascial graft as indicated. If satisfactory debridement of a brain abscess is accomplished, a drain will not be necessary; if not, the drain will not suffice.29,38 When fulminating cerebritis is present as a result of inadequately treated missile wounds of the brain, prolonged open therapy may lead to ultimate cure of an otherwise hopeless situation.35,52,53

Cerebrospinal Fluid Fistulas

CSF rhinorrhea and pneumocephalus may occur with wounds of the paranasal sinuses. In one case, extensive surgery was necessary to prevent the recurrence of a 250 cc bifrontal pneumocephalus associated with multiple anterior fossa fractures and bone fragments.

When it has been necessary to operate upon a patient with CSF otorrhea or rhinorrhea, the tears in the dura have usually been large and the fractures larger than they seemed on x-ray. In two patients with CSF rhinorrhea, the lateral ventricle on the involved side was widely open, and there was basically a fistula between the lateral ventrical and the ethmoid sinus on that side. The dural tears in these instances were closed with fascial or pericranial grafts.

Patients with recurrent collections of CSF in the subgaleal space responded well to lumbar CSF drainage after percutaneous tapping of the wound. When “minor” CSF-cutaneous fistulas were present, they were treated like subgaleal collections after prompt secondary closure of the wound and the institution of continuous lumbar CSF drainage. Juxtaposition of the scalp and the dura was enough to obliterate the hole in the dura when there was no underlying brain. Six patients came to operation shortly after admission due to the extent of their CSF-cutaneous fistulas or the poor condition of their wounds. In three patients, after debridement of the wound, it became necessary to use rotation scalp flaps in addition to dural grafts to obliterate the fistulas. Despite multiple procedures in Vietnam, Japan, and the United States, two patients with CSF-cutaneous fistulas and retained bone fragments died, probably due to the extent of brain damage.

CSF rhinorrhea may be confused with a watery discharge from the lacrimal gland, mucous membranes of the nose, or parotid gland.40 Of these, CSF is the only fluid containing sugar, and a chemical analysis for it distinguishes CSF from the other secretions. One patient had closure of a CSF rhinorrhea secondary to a fracture involving the left cribriform plate and 2 days later developed a clear nasal drainage again, which was now sugar-free and occurred only at mealtime. Subsequent workup revealed that the left parotid duct had been diverted into the left maxillary sinus at the time of his initial facial trauma or surgery. Preprandial atropine produced a marked reduction in nasal drainage; a transaural glossopharyngeal neurectomy was then performed to induce parotid atrophy, and the nasal drainage ceased.

Cranioplasty

Although the insertion of a tantalum cranioplasty was recommended in 1945 to control brain herniation,10 this is difficult to justify due to the incidence of infection associated with penetrating wounds and the danger of wound breakdown. Dural closure alone will prevent brain herniation without introducing a foreign body into the wound. Cranioplasty should be delayed for at least 6 months in all uncomplicated penetrating wounds, for 9 to 12 months in wounds of the paranasal sinuses, and for a year after clearance of infection in all infected cases.34,54 Secondary intervention for tantalum or acrylic plating in the presence of infection or immediately following wound healing cannot be justified on the basis of scattered successes.36 Complete coverage with good scalp is essential for a successful tantalum cranioplasty; thin, scarred, or inadequately vascularized scalp can be eroded easily by poorly fitted plates.

Certainly it is difficult to justify the use of a tantalum cranioplasty in the following patient, who sustained a penetrating wound extending down to the right lateral ventricle, which was entered at the initial surgery. The dura was not closed, and a tantalum cranioplasty was inserted immediately. Daily subgaleal taps were performed because of the rapid reaccumulation of CSF beneath the scalp flap. Postoperative films showed bone fragments (2 and 4 cm) present intracranially, and the referring physician felt that they were “so small that no further neurosurgical procedures are indicated.” We removed the tantalum plate and the bone fragments, and cultured Staphylococcus epidermis from all of them. The patient's subsequent hospital course was uncomplicated. Table 6 summarizes most of the early complications in this series.

TABLE 6

Summary of early complications in 506 patients

ComplicationNo. of Cases% of Series
neurological deficits37273.5 
retained intracranial bone fragments6212.25 
superficial infections326.32 
deaths234.54 
meningitis (proven by culture)183.56 
meningitis (not proven by culture)122.37 
seizures112.15 
superficial plus deep infection (no retained bone fragments)81.58 
retained metallic fragments61.19 
CSF-cutaneous fistula (no retained bone fragments)61.19 
CSF rhinorrhea40.79 
CSF otorrhea20.39 

Conclusions

The operating neurosurgeon can reduce the final neurological deficit and other complications by early and thorough definitive care. We suggest the following routine steps in the surgical management of penetrating wounds of the brain:

  1. Stabilization of the patient and establishment of the order of priority in treatment of associated injuries and those of the head

  2. Utilization of satisfactory x-ray films preoperatively and during surgery if necessary

  3. Radical debridement of the scalp and periosteum at the site of penetration

  4. Craniectomy with resection of all depressed and comminuted bone fragments

  5. Excision of the dural edges at the site of penetration, if indicated, and enlargement of the dural opening to permit adequate visualization of the underlying damage

  6. Resection of all questionably viable brain tissue surrounding the entrance to the missile track

  7. Removal of all pulped brain tissue from the missile track

  8. Removal of all indriven bone fragments and accessible metallic fragments

  9. Watertight dural closure and primary closure of the scalp, and rotation of a scalp flap if necessary

  10. Routine use of pre- and postoperative antibiotics

  11. Postoperative x-ray check for retained foreign bodies, and reoperation when indicated

Acknowledgments

The author wishes to acknowledge the encouragement from Brigadier General George J. Hayes, Commanding General of the United States Army Medical Command, Japan, to write this paper. Major William P. McCann helped care for some of these patients while stationed at this hospital.

References

  • 1.

    Alpers BJ: Abscess of the brain: relation of the histologic to the clinical features. Arch Otolaryng (Chicago) 29:1992221939Alpers BJ: Abscess of the brain: relation of the histologic to the clinical features. Arch Otolaryng (Chicago) 29:

  • 2.

    Ascroft PB: Traumatic epilepsy after gunshot wounds of the head. Brit Med J 1:7397441941Ascroft PB: Traumatic epilepsy after gunshot wounds of the head. Brit Med J 1:

  • 3.

    Ascroft PB: Treatment of head wounds due to missiles: analysis of 500 cases. Lancet 2:2112181943Ascroft PB: Treatment of head wounds due to missiles: analysis of 500 cases. Lancet 2:

  • 4.

    Barnett JCMeirowsky AM: Intracranial hematomas associated with penetrating wounds of the brain. J Neurosurg 12:34381955J Neurosurg 12:

  • 5.

    Botterell EH: Brain injuries and complicationsCarling ERRoss JP (eds): British Surgical Practice2. LondonButterworth & Co1948349384British Surgical Practice

  • 6.

    Cairns H: Neurosurgery in British Army 1939–1945. Brit J Surg (War Surg Suppl no 1) : 9251947Cairns H: Neurosurgery in British Army 1939–1945. Brit J Surg (War Surg Suppl no 1):

  • 7.

    Cairns HCalvert CADaniel Pet al: Complications of head wounds, with especial reference to infection. Brit J Surg (War Surg Suppl no 1) : 1982431947Brit J Surg (War Surg Suppl no 1):

  • 8.

    Campbell EH Jr: Compound comminuted skull fractures produced by missiles: report based on 100 cases. Ann Surg 122:3753971945Campbell EH Jr: Compound comminuted skull fractures produced by missiles: report based on 100 cases. Ann Surg 122:

  • 9.

    Campbell EMKuhlenbeck H: Mortal brain wounds: a pathologic study. J Neuropath Exp Neurol 9:1391491950J Neuropath Exp Neurol 9:

  • 10.

    Carmichael FA Jr: The reduction of hernia cerebri by tantalum cranioplasty: a preliminary report. J Neurosurg 2:3793831945Carmichael FA Jr: The reduction of hernia cerebri by tantalum cranioplasty: a preliminary report. J Neurosurg 2:

  • 11.

    Carmichael FA JrKernohan JWAdson AW: Histopathogenesis of cerebral abscess. Arch Neurol Psychiat (Chicago) 42:100110291939Arch Neurol Psychiat (Chicago) 42:

  • 12.

    Cushing H: A study of a series of wounds involving the brain and its enveloping structures. Brit J Surg 5:5586841918Cushing H: A study of a series of wounds involving the brain and its enveloping structures. Brit J Surg 5:

  • 13.

    Cushing H: Notes on penetrating wounds of the brain. Brit Med J 1:2212261918Cushing H: Notes on penetrating wounds of the brain. Brit Med J 1:

  • 14.

    Drew JHFager CA: Delayed brain abscess in relation to retained intracranial foreign bodies. J Neurosurg 11:3863931954J Neurosurg 11:

  • 15.

    Dzenitis AJKalsbeck JE: Chronic brain abscess discovered 31 years after intracerebral injury by missile: report of a case. J Neurosurg 22:1691711965J Neurosurg 22:

  • 16.

    Furlow LTBender MBTueber L: Movable foreign body within the cerebral ventricle: a case report. J Neurosurg 4:3803861947J Neurosurg 4:

  • 17.

    Grant FC: Post-traumatic brain abscess. Posttraumatic meningitisBrock S (ed): BaltimoreWilliams & Wilkins Co1960ed 4187202

  • 18.

    Hammon W: Neurosurgery in Vietnam. USARV Medical BulletinNov–Dec 1969Hammon W: Neurosurgery in Vietnam. USARV Medical Bulletin

  • 19.

    Harsh GR: Infection complicating penetrating craniocerebral traumaCoates JB Jr (ed): Neurological Surgery of Trauma. Washington D COffice of the Surgeon General, Department of the Army1965135142Neurological Surgery of Trauma

  • 20.

    Hayes GJ: Medical aspects of the Vietnamese campaign. Clin Neurosurg 14:3803851967Hayes GJ: Medical aspects of the Vietnamese campaign. Clin Neurosurg 14:

  • 21.

    Haynes WG: Penetrating brain wounds: analysis of 342 cases. J Neurosurg 2:3653781945Haynes WG: Penetrating brain wounds: analysis of 342 cases. J Neurosurg 2:

  • 22.

    Horner FABerry RGFrantz M: Broken pencil points as a cause of brain abscess. New Eng J Med 271:3423451964New Eng J Med 271:

  • 23.

    Jefferson G: Head wounds and infection in 2 wars. Brit J Surg (War Surg Suppl no 1) : 381947Jefferson G: Head wounds and infection in 2 wars. Brit J Surg (War Surg Suppl no 1):

  • 24.

    Johnson RT: Missile wounds of the head in the Burma campaign, with special reference to meningitis and ventriculitis due to virulent strains of Escherichia coli. Brit J Surg (War Surg Suppl no 1) : 1721771947Escherichia coli.Brit J Surg (War Surg Suppl no 1):

  • 25.

    King JE: Brain abscess of traumatic origin. Am J Surg 47:3483661940King JE: Brain abscess of traumatic origin. Am J Surg 47:

  • 26.

    LeBeau J: Radical surgery and penicillin in brain abscess: a method of treatment in one stage with special reference to the cure of three thoracogenic cases. J Neurosurg 3:3593741946LeBeau J: Radical surgery and penicillin in brain abscess: a method of treatment in one stage with special reference to the cure of three thoracogenic cases. J Neurosurg 3:

  • 27.

    Lewin WGibson RM: Missile head wounds in the Korean campaign: a survey of British casualties. Brit J Surg 43:6286321956Brit J Surg 43:

  • 28.

    Maltby GL: Penetrating craniocerebral injuries: evaluation of the late results in a group of 200 penetrating cranial war wounds. J Neurosurg 3:2392491946Maltby GL: Penetrating craniocerebral injuries: evaluation of the late results in a group of 200 penetrating cranial war wounds. J Neurosurg 3:

  • 29.

    Martin JCampbell EH Jr: Early complications following penetrating wounds of the skull. J Neurosurg 3:58731946J Neurosurg 3:

  • 30.

    Matson DD: The Treatment of Acute Craniocerebral Injuries Due to Missiles. Springfield, IllinoisCharles C Thomas1948Matson DD: The Treatment of Acute Craniocerebral Injuries Due to Missiles

  • 31.

    Matson DDWolkin J: Hematomas associated with penetrating wounds of the brain. J Neurosurg 3:46531946J Neurosurg 3:

  • 32.

    Meirowsky AM: Penetrating craniocerebral trauma. Clin Neurosurg 12:2532651966Meirowsky AM: Penetrating craniocerebral trauma. Clin Neurosurg 12:

  • 33.

    Meirowsky AM: Penetrating craniocerebral trauma. JAMA 154:6666691954Meirowsky AM: Penetrating craniocerebral trauma. JAMA 154:

  • 34.

    Meirowsky AM: Penetrating wounds of the brainCoates JB Jr (ed): Neurological Surgery of Trauma. Washington D COffice of the Surgeon General, Department of the Army1965103130Neurological Surgery of Trauma

  • 35.

    Meirowsky AMHarsh GR: The surgical management of cerebritis complicating penetrating wounds of the brain. J Neurosurg 10:3733791953J Neurosurg 10:

  • 36.

    Reeves DL: Repair of cranial defectsCoates JB Jr (ed): Neurological Surgery of Trauma. Washington D COffice of the Surgeon General, Department of the Army1965233256Neurological Surgery of Trauma

  • 37.

    Robinson EFMoiel RHGol A: Brain abscess 36 years after head injury: case report. J Neurosurg 28:1661681968J Neurosurg 28:

  • 38.

    Rowbotham GF: BaltimoreWilliams & Wilkins1964296352Rowbotham GF:

  • 39.

    Rowe SNTurner OA: Observations on infection in penetrating wounds of the head. J Neurosurg 2:3914011945J Neurosurg 2:

  • 40.

    Scheibert CD: Cerebrospinal fluid fistulaCoates JB Jr (ed): Neurological Surgery of Trauma. Washington D COffice of the Surgeon General, Department of the Army1965213220Neurological Surgery of Trauma

  • 41.

    Schorstein J: Intracranial hematoma in missile wounds. Brit J Surg (War Surg Suppl no 1) : 961111947Schorstein J: Intracranial hematoma in missile wounds. Brit J Surg (War Surg Suppl no 1):

  • 42.

    Schwartz HGRoulhac GE: Craniocerebral war wounds: observations on delayed treatment. Ann Surg 121:1291511945Ann Surg 121:

  • 43.

    Schwartz HGRoulhac GE: Penetrating wounds of the cerebral ventricles. Ann Surg 127:58741948Ann Surg 127:

  • 44.

    Small JMTurner EA: A surgical experience of 1200 cases of penetrating brain wounds in battle, N. W. Europe, 1944–45. Brit J Surg (War Surg Suppl no 1) : 62741947Brit J Surg (War Surg Suppl no 1):

  • 45.

    Spatz EL: Central nervous system infections of surgical importance. Am J Surg 107:6786821964Spatz EL: Central nervous system infections of surgical importance. Am J Surg 107:

  • 46.

    Sperl MPMacCarty CSWellman WE: Observations on current therapy of abscess of the brain. Arch Neurol Psychiat 81:4394411959Arch Neurol Psychiat 81:

  • 47.

    Sugita KDoi TSato Oet al: Successful removal of intracranial air-gun bullet with stereotaxic apparatus: case report. J Neurosurg 30:1771811969J Neurosurg 30:

  • 48.

    Wallace PBMeirowsky AM: The repair of dural defects by graft: an analysis of 540 penetrating wounds of the brain incurred in the Korean War. Ann Surg 151:1741801960Ann Surg 151:

  • 49.

    Wannamaker GT: Transventricular wounds of the brainCoates JB Jr (ed): Neurological Surgery of Trauma. Washington D COffice of the Surgeon General, Department of the Army1965165180Neurological Surgery of Trauma

  • 50.

    Wannamaker GTPulaski EJ: Pyogenic neurosurgical infections in Korean battle casualties. J Neurosurg 15:5125181958J Neurosurg 15:

  • 51.

    Weaver TA JrFrishman AJ: A report on the treatment of craniocerebral wounds in an evacuation hospital. J Neurosurg 3:1481561946J Neurosurg 3:

  • 52.

    Webster JESchneider RCLofstrom JE: Observations on early type of brain abscess following penetrating wounds of the brain. J Neurosurg 3:7141946J Neurosurg 3:

  • 53.

    Whitaker R: Gunshot wounds of the cranium; with a special reference to those of the brain. Brit J Surg 3:7087351916Whitaker R: Gunshot wounds of the cranium; with a special reference to those of the brain. Brit J Surg 3:

  • 54.

    White JC: Late complications following cranioplasty with alloplastic plates. Ann Surg 128:7437551948White JC: Late complications following cranioplasty with alloplastic plates. Ann Surg 128:

  • 55.

    Wood EH: The diagnostic significance of change in position of metallic foreign bodies in brain abscess. Amer J Roentg 59:52581948Wood EH: The diagnostic significance of change in position of metallic foreign bodies in brain abscess. Amer J Roentg 59:

An abstract of this paper was presented at the Breakfast Seminar on Combat Neurosurgery, April 22, 1970, during the Annual Meeting, American Association of Neurological Surgeons, Washington, D.C.

Article Information

Address reprint requests to: Ralph E. Hagan, M.D., Suite 100, 1717 Bellevue Avenue, Richmond, Virginia 23227.

© AANS, except where prohibited by US copyright law.

Headings

References

1.

Alpers BJ: Abscess of the brain: relation of the histologic to the clinical features. Arch Otolaryng (Chicago) 29:1992221939Alpers BJ: Abscess of the brain: relation of the histologic to the clinical features. Arch Otolaryng (Chicago) 29:

2.

Ascroft PB: Traumatic epilepsy after gunshot wounds of the head. Brit Med J 1:7397441941Ascroft PB: Traumatic epilepsy after gunshot wounds of the head. Brit Med J 1:

3.

Ascroft PB: Treatment of head wounds due to missiles: analysis of 500 cases. Lancet 2:2112181943Ascroft PB: Treatment of head wounds due to missiles: analysis of 500 cases. Lancet 2:

4.

Barnett JCMeirowsky AM: Intracranial hematomas associated with penetrating wounds of the brain. J Neurosurg 12:34381955J Neurosurg 12:

5.

Botterell EH: Brain injuries and complicationsCarling ERRoss JP (eds): British Surgical Practice2. LondonButterworth & Co1948349384British Surgical Practice

6.

Cairns H: Neurosurgery in British Army 1939–1945. Brit J Surg (War Surg Suppl no 1) : 9251947Cairns H: Neurosurgery in British Army 1939–1945. Brit J Surg (War Surg Suppl no 1):

7.

Cairns HCalvert CADaniel Pet al: Complications of head wounds, with especial reference to infection. Brit J Surg (War Surg Suppl no 1) : 1982431947Brit J Surg (War Surg Suppl no 1):

8.

Campbell EH Jr: Compound comminuted skull fractures produced by missiles: report based on 100 cases. Ann Surg 122:3753971945Campbell EH Jr: Compound comminuted skull fractures produced by missiles: report based on 100 cases. Ann Surg 122:

9.

Campbell EMKuhlenbeck H: Mortal brain wounds: a pathologic study. J Neuropath Exp Neurol 9:1391491950J Neuropath Exp Neurol 9:

10.

Carmichael FA Jr: The reduction of hernia cerebri by tantalum cranioplasty: a preliminary report. J Neurosurg 2:3793831945Carmichael FA Jr: The reduction of hernia cerebri by tantalum cranioplasty: a preliminary report. J Neurosurg 2:

11.

Carmichael FA JrKernohan JWAdson AW: Histopathogenesis of cerebral abscess. Arch Neurol Psychiat (Chicago) 42:100110291939Arch Neurol Psychiat (Chicago) 42:

12.

Cushing H: A study of a series of wounds involving the brain and its enveloping structures. Brit J Surg 5:5586841918Cushing H: A study of a series of wounds involving the brain and its enveloping structures. Brit J Surg 5:

13.

Cushing H: Notes on penetrating wounds of the brain. Brit Med J 1:2212261918Cushing H: Notes on penetrating wounds of the brain. Brit Med J 1:

14.

Drew JHFager CA: Delayed brain abscess in relation to retained intracranial foreign bodies. J Neurosurg 11:3863931954J Neurosurg 11:

15.

Dzenitis AJKalsbeck JE: Chronic brain abscess discovered 31 years after intracerebral injury by missile: report of a case. J Neurosurg 22:1691711965J Neurosurg 22:

16.

Furlow LTBender MBTueber L: Movable foreign body within the cerebral ventricle: a case report. J Neurosurg 4:3803861947J Neurosurg 4:

17.

Grant FC: Post-traumatic brain abscess. Posttraumatic meningitisBrock S (ed): BaltimoreWilliams & Wilkins Co1960ed 4187202

18.

Hammon W: Neurosurgery in Vietnam. USARV Medical BulletinNov–Dec 1969Hammon W: Neurosurgery in Vietnam. USARV Medical Bulletin

19.

Harsh GR: Infection complicating penetrating craniocerebral traumaCoates JB Jr (ed): Neurological Surgery of Trauma. Washington D COffice of the Surgeon General, Department of the Army1965135142Neurological Surgery of Trauma

20.

Hayes GJ: Medical aspects of the Vietnamese campaign. Clin Neurosurg 14:3803851967Hayes GJ: Medical aspects of the Vietnamese campaign. Clin Neurosurg 14:

21.

Haynes WG: Penetrating brain wounds: analysis of 342 cases. J Neurosurg 2:3653781945Haynes WG: Penetrating brain wounds: analysis of 342 cases. J Neurosurg 2:

22.

Horner FABerry RGFrantz M: Broken pencil points as a cause of brain abscess. New Eng J Med 271:3423451964New Eng J Med 271:

23.

Jefferson G: Head wounds and infection in 2 wars. Brit J Surg (War Surg Suppl no 1) : 381947Jefferson G: Head wounds and infection in 2 wars. Brit J Surg (War Surg Suppl no 1):

24.

Johnson RT: Missile wounds of the head in the Burma campaign, with special reference to meningitis and ventriculitis due to virulent strains of Escherichia coli. Brit J Surg (War Surg Suppl no 1) : 1721771947Escherichia coli.Brit J Surg (War Surg Suppl no 1):

25.

King JE: Brain abscess of traumatic origin. Am J Surg 47:3483661940King JE: Brain abscess of traumatic origin. Am J Surg 47:

26.

LeBeau J: Radical surgery and penicillin in brain abscess: a method of treatment in one stage with special reference to the cure of three thoracogenic cases. J Neurosurg 3:3593741946LeBeau J: Radical surgery and penicillin in brain abscess: a method of treatment in one stage with special reference to the cure of three thoracogenic cases. J Neurosurg 3:

27.

Lewin WGibson RM: Missile head wounds in the Korean campaign: a survey of British casualties. Brit J Surg 43:6286321956Brit J Surg 43:

28.

Maltby GL: Penetrating craniocerebral injuries: evaluation of the late results in a group of 200 penetrating cranial war wounds. J Neurosurg 3:2392491946Maltby GL: Penetrating craniocerebral injuries: evaluation of the late results in a group of 200 penetrating cranial war wounds. J Neurosurg 3:

29.

Martin JCampbell EH Jr: Early complications following penetrating wounds of the skull. J Neurosurg 3:58731946J Neurosurg 3:

30.

Matson DD: The Treatment of Acute Craniocerebral Injuries Due to Missiles. Springfield, IllinoisCharles C Thomas1948Matson DD: The Treatment of Acute Craniocerebral Injuries Due to Missiles

31.

Matson DDWolkin J: Hematomas associated with penetrating wounds of the brain. J Neurosurg 3:46531946J Neurosurg 3:

32.

Meirowsky AM: Penetrating craniocerebral trauma. Clin Neurosurg 12:2532651966Meirowsky AM: Penetrating craniocerebral trauma. Clin Neurosurg 12:

33.

Meirowsky AM: Penetrating craniocerebral trauma. JAMA 154:6666691954Meirowsky AM: Penetrating craniocerebral trauma. JAMA 154:

34.

Meirowsky AM: Penetrating wounds of the brainCoates JB Jr (ed): Neurological Surgery of Trauma. Washington D COffice of the Surgeon General, Department of the Army1965103130Neurological Surgery of Trauma

35.

Meirowsky AMHarsh GR: The surgical management of cerebritis complicating penetrating wounds of the brain. J Neurosurg 10:3733791953J Neurosurg 10:

36.

Reeves DL: Repair of cranial defectsCoates JB Jr (ed): Neurological Surgery of Trauma. Washington D COffice of the Surgeon General, Department of the Army1965233256Neurological Surgery of Trauma

37.

Robinson EFMoiel RHGol A: Brain abscess 36 years after head injury: case report. J Neurosurg 28:1661681968J Neurosurg 28:

38.

Rowbotham GF: BaltimoreWilliams & Wilkins1964296352Rowbotham GF:

39.

Rowe SNTurner OA: Observations on infection in penetrating wounds of the head. J Neurosurg 2:3914011945J Neurosurg 2:

40.

Scheibert CD: Cerebrospinal fluid fistulaCoates JB Jr (ed): Neurological Surgery of Trauma. Washington D COffice of the Surgeon General, Department of the Army1965213220Neurological Surgery of Trauma

41.

Schorstein J: Intracranial hematoma in missile wounds. Brit J Surg (War Surg Suppl no 1) : 961111947Schorstein J: Intracranial hematoma in missile wounds. Brit J Surg (War Surg Suppl no 1):

42.

Schwartz HGRoulhac GE: Craniocerebral war wounds: observations on delayed treatment. Ann Surg 121:1291511945Ann Surg 121:

43.

Schwartz HGRoulhac GE: Penetrating wounds of the cerebral ventricles. Ann Surg 127:58741948Ann Surg 127:

44.

Small JMTurner EA: A surgical experience of 1200 cases of penetrating brain wounds in battle, N. W. Europe, 1944–45. Brit J Surg (War Surg Suppl no 1) : 62741947Brit J Surg (War Surg Suppl no 1):

45.

Spatz EL: Central nervous system infections of surgical importance. Am J Surg 107:6786821964Spatz EL: Central nervous system infections of surgical importance. Am J Surg 107:

46.

Sperl MPMacCarty CSWellman WE: Observations on current therapy of abscess of the brain. Arch Neurol Psychiat 81:4394411959Arch Neurol Psychiat 81:

47.

Sugita KDoi TSato Oet al: Successful removal of intracranial air-gun bullet with stereotaxic apparatus: case report. J Neurosurg 30:1771811969J Neurosurg 30:

48.

Wallace PBMeirowsky AM: The repair of dural defects by graft: an analysis of 540 penetrating wounds of the brain incurred in the Korean War. Ann Surg 151:1741801960Ann Surg 151:

49.

Wannamaker GT: Transventricular wounds of the brainCoates JB Jr (ed): Neurological Surgery of Trauma. Washington D COffice of the Surgeon General, Department of the Army1965165180Neurological Surgery of Trauma

50.

Wannamaker GTPulaski EJ: Pyogenic neurosurgical infections in Korean battle casualties. J Neurosurg 15:5125181958J Neurosurg 15:

51.

Weaver TA JrFrishman AJ: A report on the treatment of craniocerebral wounds in an evacuation hospital. J Neurosurg 3:1481561946J Neurosurg 3:

52.

Webster JESchneider RCLofstrom JE: Observations on early type of brain abscess following penetrating wounds of the brain. J Neurosurg 3:7141946J Neurosurg 3:

53.

Whitaker R: Gunshot wounds of the cranium; with a special reference to those of the brain. Brit J Surg 3:7087351916Whitaker R: Gunshot wounds of the cranium; with a special reference to those of the brain. Brit J Surg 3:

54.

White JC: Late complications following cranioplasty with alloplastic plates. Ann Surg 128:7437551948White JC: Late complications following cranioplasty with alloplastic plates. Ann Surg 128:

55.

Wood EH: The diagnostic significance of change in position of metallic foreign bodies in brain abscess. Amer J Roentg 59:52581948Wood EH: The diagnostic significance of change in position of metallic foreign bodies in brain abscess. Amer J Roentg 59:

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