Missile injuries to the brain treated by simple wound closure: results of a protocol during the Lebanese conflict

This is a prospective study of the treatment of penetrating missile injuries to the brain without intracranial surgery carried out at the American University of Beirut Medical Center between 1981 and 1988. Of 600 patients treated for missile injuries to the head, 32 satisfied the study criteria. There were 27 shrapnel and 5 bullet injuries. The mean patient age was 23 years (range, 3-51 years). Twenty patients had intracranial indriven bone fragments. Six patients had exposed brain tissue. The mean follow-up was 3.5 years (range, 1-7.5 years). The superficial entry wound was debrided and closed without drainage in the Emergency Room within a mean of 3 hours (range, 0.5-6 hours), and the patient received methicillin for 14 days. All patients survived and had no or improved neurological deficits. No leakage of the cerebrospinal fluid, infection, or seizures occurred in 31 patients. One patient with indriven bone fragments had leakage of the cerebrospinal fluid and developed seizures and a brain abscess 20 days after the injury. The management of penetrating missile injuries to the brain without intracranial surgery in a select patient population is a reasonable option. This treatment becomes important for a surgeon facing large numbers of casualties, or when operative personnel or resources are limited or unavailable.     

Compound elevated skull fracture: a forgotten type of skull fracture

BACKGROUND AND OBJECTIVE: We report 4 patients who presented with a rare type of vault fracture. This form of fracture has only been described in few instances in the literature. CASE DESCRIPTION: All the patients presented with elevation of free skull fracture fragments. The etiologies were assault (1 patient), domestic accident (1 patient), and road traffic accident (2 patients). All the fractures were compound as in previously reported cases. Delay in surgery resulted in cerebral abscess in 1 patient. Surgery was performed in all the patients: wound debrident, duroplasty, and reduction of fracture in 3 patients and craniotomy with excision of abscess in 1 patient. Two of the patients did well after surgery. The patients with abscess died 9 days after surgery. Another patient developed CSF fistula after surgery, and died of aspiration while waiting for the closure of the fistula. CONCLUSION: Elevated skull fractures in our series were all compound fractures. Both long, sharp objects as well as blunt objects can cause this injury. Delay in surgery could result in intracranial sepsis. We suggest that this fracture should be included in the classification of skull fractures.     

Free Latissimus Dorsi Flap for Reconstruction of the Anterior Base of the Skull

Defects resulting after resection of malignant tumors of the paranasal sinuses involving the anterior base of the skull need an adequate closure. In addition to such avital tissue as fascia lata, fat, or ceramics, in recent years we used free muscle flaps from the latissimus dorsi for reconstruction. We performed this reconstructive method in seven patients after radical tumor ##. The operation was performed in cooperation with the neurosurgeon. In three cases a transfrontal in combination with a transfacial approach was used and in four cases only a transfacial approach was chosen. The flap was tailored as a pure muscle transplant if only the base of the skull had to be repaired and the surgical cavity had to be obhiterated. In three cases a skin paddle was left on the muscle to perform a closure of the orbit and the hard palate. In four patients we performed primary reconstruction, in three cases secondary reconstruction, which was necessary because cerebrospinal fluid (CSF) leakage occurred after primary reconstruction with avital tissue in addition to insufficient pericranial flap. None of the patients with primary reconstruction developed CSF leakage. There was no free flap failure. The aim of this reconstruction is a safe closure of skull base defects to prevent infection, meningitis, brain abscess, and brain herniation.     

Endoscopic repair of large skull base defects after powered sinus surgery.

OBJECTIVES: To evaluate the management of patients with large skull base defects (> 2 cm) and intracranial injury caused by powered endoscopic sinus surgery.Study design and setting All patients treated for postendoscopic sinus surgery skull base injury over a 4-year period were reviewed. RESULTS: Three patients with skull base defects greater than 2 cm in size and associated intracranial injury from powered ESS were identified. All patients presented with active cerebrospinal fluid leaks. CT scans showed intracranial injury and pathology reports revealed brain tissue removal. Using image-guided endoscopic techniques, all defects were addressed with multilayer repair. Closure was achieved in all patients on the first attempt, with an average follow-up of 27 months. CONCLUSIONS: The use of powered instrumentation along the skull base can be dangerous and can result in extensive skull base defects with associated loss of dura and gray matter. Large ethmoid roof defects and significant intracranial injury, however, are not absolute contraindications to endoscopic repair.     

Free latissimus dorsi flap for reconstruction of the anterior base of the skull

Defects resulting after resection of malignant tumors of the paranasal sinuses involving the anterior base of the skull need an adequate closure. In addition to such avital tissue as fascia lata, fat, or ceramics, in recent years we used free muscle flaps from the latissimus dorsi for reconstruction. We performed this reconstructive method in seven patients after radical tumor ##. The operation was performed in cooperation with the neurosurgeon. In three cases a transfrontal in combination with a transfacial approach was used and in four cases only a transfacial approach was chosen. The flap was tailored as a pure muscle transplant if only the base of the skull had to be repaired and the surgical cavity had to be obhiterated. In three cases a skin paddle was left on the muscle to perform a closure of the orbit and the hard palate. In four patients we performed primary reconstruction, in three cases secondary reconstruction, which was necessary because cerebrospinal fluid (CSF) leakage occurred after primary reconstruction with avital tissue in addition to insufficient pericranial flap. None of the patients with primary reconstruction developed CSF leakage. There was no free flap failure. The aim of this reconstruction is a safe closure of skull base defects to prevent infection, meningitis, brain abscess, and brain herniation.     

The value of CT scan in gunshot injuries of the brain

Summary Fourteen cases of gunshot wounds of the brain, evaluated by CT scanning are presented. The results indicate that CT scanning is superior to other diagnostic tests in missile wounds of the brain. In individual patients it revealed gross injury to the skull, the location of the bullet or its fragments and indriven bone fragments, the track of the bullet, the gross injury suffered by the brain, the extent of oedema, the presence of any intracranial haematoma and late cerebral atrophy.Visualization of the missile track is of particular importance; this cannot be achieved by any other diagnostic method. It is essential for the planning of the surgical approach in these lesions.     

Computerized tomographic scan and gunshot wounds of the head: indications and radiographic findings.

The authors document their experience with the computerized tomographic (CT) scanner for evaluating gunshot wounds of the head. Only those patients who were considered to be operative candidates and who were neurologically stable were scanned. In the postoperative period, patients who were not scanned preoperatively and those whose condition did not improve were also scanned. In the preoperative period the CT scanner is useful for identifying and localizing missile tracks, bony and metallic fragments, intra- and extraparenchymal hematomas, intracranial air, and brain swelling. In the postoperative period the CT scanner may demonstrate retained bone fragments, edema, brain abscess, and intracranial air. The limitations of the CT scan in evaluating gunshot wounds include an inability to define vascular lesions suchas traumatic aneurysms and post-traumatic spasm. Metallic scatter from missile fragments may render certain CT cuts uninterpretable. In addition, the CT scan may appear minimally abnormal in spite of immediate and irreversible injury caused by a shock wave transmitted to brain stem structures. The CT scanner has superceded angiography as a diagnostic tool for evaluating gunshot wounds of the head because it is noninvasive and rapid, allows visualization of the entire head, can resolve very small lesions that produce little or no mass effect, can help to determine the nature of intracranial lesions and may quantitate the amount of hemorrhage and edema. Because it enables physicians to visualize intracranial structures in three dimensions, the CT scan may precisely define missile tracks and contiguous lesions in a manner not heretofore possible with other diagnostic modalities. Thus, it is invaluable for the rational planning of surgical therapy.     

Frontal skull base surgery combined with endonasal endoscopic sinus surgery

BACKGROUND: Postoperative infection remains a serious complication after radical resection of anterior skull base lesions because intracranial, nasal, and paranasal cavities are opened during surgery. To prevent complications from postoperative infection, we combined endonasal endoscopic sinus surgery (ESS) with the frontal transbasal approach in patients with skull base lesions. METHODS: Patients (n = 16) with anterior skull base lesions extending to the paranasal or nasal cavity underwent surgical resection via the frontal transbasal approach. After removal of the lesion via the transcranial approach, enlargement of the ostium or sinusotomy was performed bilaterally using our endonasal ESS procedure. The main purpose of ESS is the establishment of a wide drainage route to avoid dead space and postoperative infection. Furthermore, we confirmed the absence of residual lesion and leakage of cerebrospinal fluid (CSF), endoscopically. RESULTS: The frontal transbasal approach combined with endonasal ESS was performed in 16 patients with frontal skull base lesions. There were 8 malignant tumors, 6 benign tumors, and 2 mucoceles. Although 11 patients had preoperative active paranasal sinusitis, most frequently at the ethmoid sinus, none experienced postoperative infection. There was no complication related to ESS procedure. Furthermore, leakage of CSF and extracranial residual tumor were not found. CONCLUSION: Endonasal ESS after frontal skull base surgery is a highly useful technique for preventing postoperative infection, especially for the cases with large skull base tumors extending into other regions involving the paranasal sinuses or nasal cavity and with active paranasal sinusitis.     

鼻内镜下脑脊液鼻漏修补及围手术期处理

目的 探讨鼻内镜下脑脊液鼻漏修补技巧及围手术期处理经验.方法 回顾性分析2005年4月～2011年1月脑脊液鼻漏26例,包括头部外伤12例,鼻息肉及筛窦囊肿手术误损伤颅底4例,鼻-颅底肿瘤切除6例,颅内手术颅底损伤3例,自发性1例.均在鼻内镜下用股外侧肌肌浆和阔筋膜修补,术后给予抗生素及降颅压等治疗.结果 随访6～24个月,平均10个月,23例一次修补成功,2例经二次修补成功,1例失败,总治愈率96％ (25/26).结论 鼻内镜下脑脊液鼻漏的修补手术应重视手术时机的选择以及围手术期管理和治疗,减少并发症发生,提高治愈率.     

The role of hair shaving in skull base surgery.

OBJECTIVE: We sought to evaluate surgical wound infection rates in patients undergoing skull base surgery without hair removal. METHODS: We undertook a retrospective study of 175 skull base operations performed without hair removal. Anterior operations were conducted via the subcranial approach (n = 120) and lateral or posterior procedures via various approaches (n = 55). Wounds were examined daily during hospitalization and at routine outpatient follow-up (8 to 45 months) and classified according to the Center for Disease Control and Prevention guidelines. RESULTS: The overall surgical wound infection rate was 1.1% (2 of 175): 0.8% (1 of 120) for anterior and 1.8% (1 of 55) for lateral or posterior procedures. It was similar for clean operations (lateral and posterior) and clean-contaminated (anterior) procedures and was less than or similar to the rates reported for skull base procedures with hair removal. No wound infection occurred among the infected (trauma, fungal infections, and brain abscess) patients. CONCLUSIONS: Skull base surgery without hair removal is safe and not associated with increased risk of wound infection. The method may prevent additional psychologic stress, promote restoration of the patient's self-image, and accelerate his or her return to normal life.     

Dermal sinus and dermoid cyst revealed by abscess formation in posterior fossa. Report of 2 pediatric cases and review of the litterature

Cranial dermal sinus, usually associated with dermoid cyst, is the persistance of an abnormal embryonal communication between the skin and the central nervous system. It may be the source of intracranial infection, most often a meningitis and rarely an abscess formation. Two cases of little girls (18 months and 2 years) having dermal sinus with dermoid cyst revealed by cerebellar abscess formations are reported. In the first case there were multiple cerebellar abscesses with hydrocephalus leading to a raised intracranial pressure. In the second case there was an abscess formation adjacent to the dermoid cyst. CT scan showed cysts and abscesses but MRI, achieved in the second case, was useful in demonstrating the sinus tract as well as the associated cyst and abscess. The two patients underwent a posterior fossa surgery with antibiotic therapy. In the first case abscess drainage and ventricular external drainage were necessary before sinus and cyst excision. Two months after surgery the two patients were neurologically intact and developping well. Surgery with total excision of dermal sinus and dermoid cyst, even sometimes difficult, must be preferred to the simple abscess drainage and antibiotic therapy.     

Extending the traditional resection limits of squamous cell carcinoma of the anterior skull base

OBJECTIVES: Preliminary report to evaluate the efficacy of resection of squamous cell carcinomas that demonstrate intracranial invasion. METHODS: A retrospective review of all cases of extracranial squamous cell carcinomas that extend intracranially treated by a single surgeon. RESULTS: A total of 21 cases were reviewed. In 6 cases, there was noted to be overt brain invasion. Complete resection of the intracranial disease was achieved in each of the remaining 15 cases. There were no instances of CSF leak, meningitis, brain abscess, stroke, or other intracranial complication noted either acutely or secondarily. In follow-ups that ranged from 10 months (single patient died of disease at 10 months) to 6 years (average, 3.8 years), there were no instances of intracranial recurrence. There was a disease-free control rate of 67.7% at an average follow-up of 4.1 years. CONCLUSIONS: Extending the resection of squamous cell carcinoma into the intracranial vault judiciously as outlined appears to be associated with acceptable outcomes in the treatment of advanced squamous cell carcinoma of the skull base.     

Intracranial infection after missile injuries to the brain: report of 30 cases from the Lebanese conflict.

This study reviews the features of 30 intracranial infections complicating 600 penetrating head injuries from missiles in patients treated at the American University of Beirut Medical Center between 1981 and 1988. The follow-up period ranged from 1 month to 7 years (mean, 2.5 years). Sixteen patients had a brain abscess, 9 had cerebritis, 2 had an infected intracerebral hematoma, and 5 had meningitis. Infection developed 4 days to 7 years after the initial debridement. The infecting organisms were Gram positive in 11 patients (36%), Gram negative in 12 (40%), and a combination of Gram positive and Gram negative in 2 (7%). Twenty-four patients (80%) had wound dehiscence or cerebrospinal fluid leakage at the time the infection appeared. There was a 76% correlation between the organisms cultured from the dehiscent scalp wound and the brain. Twenty-three patients had intracranial retention of bone. Infection developed in 16 of the 30 patients (70%) around bone fragments, in 4 around a metallic fragment, in 2 around absorbable gelatin sponge, and in 3 along the missile tract; 2 had an infected intracerebral hematoma, and 3 had meningitis. At least one of the following risk factors was present in each patient: extensive brain injury, coma, trajectory through an air sinus, cerebrospinal fluid fistula, inadequate initial debridement, or incomplete dural closure. The incidence of intracranial infection in patients with postoperative retention of bone was 4% in the absence of scalp wound dehiscence, compared with 84.6% when wound dehiscence was present. Ten patients (43%) still retained a bone fragment measuring less than 1 cm after excision of a brain abscess or treatment of cerebritis or meningitis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cloverleaf skull syndrome with occipital bone cristae. Report of two cases

Two cases of cloverleaf skull syndrome are reported. The patients were born with trilobed deformity of the skull associated with synostosis of the lambdoidal, coronal, and sagittal sutures in Case 1 and of the lambdoidal suture in Case 2. Both patients had hydrocephalus, low-set ears, and ocular hypertelorism. Ventriculoperitoneal shunting had been performed for hydrocephalus in both cases in early infancy. Thereafter, the skull anomaly caused mental and physical retardation and elevated intracranial pressure. In both cases, surgery was successful in terms of cosmetic and neurological improvement. Both cases involved prominent midline crista formation of the skull over the posterior fossa, which steadily progressed during the first year of life and produced hydrocephalus, apparently by compressing or obstructing the aqueduct and/or the ostia of the fourth ventricle. Twenty-four cases of surgery for cloverleaf skull syndrome have been reported to date. Only Partington's types II and III were treated surgically, and patients with type III had more favorable outcomes than those with type II. However, these reports provide no clear-cut data that surgery significantly influences the outcome. The experience with the two cases reported here suggests the benefits of early shunting followed later by radical surgery.     

Delayed brain abscess after penetrating transorbital injury

We report a case of brain abscess caused by a penetrating head injury that occurred 9 years earlier. A 14-year-old girl presenting with fever, headache, and stiff neck was admitted to our hospital. She was diagnosed with aseptic meningitis and treated conservatively. Seven days after admission she became stuporous and showed left hemiparesis. Computed tomography (CT) revealed two ring-enhancing masses with perifocal edema in the right frontal lobe. We diagnosed brain abscess and performed right fronto-temporal decompressive craniectomy and stereotactic aspiration, followed by systemic antibiotic therapy. Post-surgery bone window CT revealed a well-defined, low-density foreign body passing from the left orbita to the right frontal lobe through the ethmoid sinus. We learned that the patient had been struck with a plastic chopstick in the left medial eyelid at the age of 5 years. No particular symptoms developed during the following 9 years. After the cerebral edema had diminished over the next 10 days, a second surgery was performed to remove the residual chopstick, repair the fistula at the base of the skull, and perform cranioplasty. The patient was discharged with only slight hyposmia after a 4-week course of antibiotics. This case showed that it is necessary to remove a residual foreign body and to close the dural fistula if there is a possibility of recurrent central nervous system infection. When a child presents with brain abscess, previous penetrating head injury should be considered.     

Salmonella enteritidis causing brain abscess and coxitis following intracranial surgery

We report the case of a 46-year-old woman who underwent surgery for an adamantinous craniopharyngeoma (WHO grade I). The postoperative course, during which the patient received 16 mg/day of dexamethasone, was initially uneventful. After a fortnight the patient developed infectious signs and an intracranial abscess at the operation site with simultaneous purulent coxitis. Both the intracranial abscess and the coxitis were evacuated and drained. In tissue samples and pus obtained during re-craniotomy and during surgery on the hip, Salmonella enteritidis was detected by cultivation. Salmonella enteritidis was also isolated from several stool specimens. There was no known salmonellosis in the patient's medical history. She recovered as a result of antibiotic treatment with ciprofloxacin and chloramphenicol. The intracranial abscess healed without leaving any neurological deficit. Unfortunately the left hip subsequently required further surgery, culminating in removal of the entire femoral head. Prosthetic replacement could not yet be performed due to the recurrent septic course of the hip. Our case illustrates a serious complication with presumed haematogenous spread of the infection from a pre-existing asymptomatic and unknown colon infection. The immunosuppressive effect of corticosteroids in the treatment of the brain neoplasm might have been a contributing factor to the sudden exacerbation of the latent infection.     

Microsurgical total removal of olfactory groove meningiomas and reconstruction of the invaded skull bases

In order to study the microsurgical techniques of olfactory groove meningiomas invading the skull base and the reconstruction of the skull base, clinical materials of 17 patients with olfactory groove meningiomas were analyzed retrospectively. Simpson Grade I resection was achieved in all cases. No death, cerebrospinal fluid rhinorrhea, or intracranial infection occurred postoperatively, and no tumor recurrence was observed after a 1- to 9-year follow-up. For olfactory groove meningiomas invading the skull bases, microsurgical total removal of the lesions as well as the complete reconstruction of the skull bases is essential in order to achieve total tumor resection and impede tumor recurrence without serious complication.     

Skull base reconstruction in cases of intracranial teratoma extending into the extracranial structures.

Recently experienced were two cases of postnatally diagnosed intracranial teratoma, one a mature teratoma and the other an immature teratoma, both extending into the extracranial structures. In each case, tumor resection was performed in which a barrier was created between the intracranial and extracranial spaces with a temporalis muscle flap. The technical aspect of skull base reconstruction is described, and previously reported cases of intracranial teratoma involving the skull base are reviewed.     

Cranioplasty following decompressive craniectomy--analysis of 300 cases (author's transl)

Three hundred cases of cranioplasty, following large decompressive craniectomy for various diseases, were analyzed. 1. Neurological status was evaluated before and after cranioplasty in 52 patients with remaining neurological deficit. There observed no changes in 13 patients with skin flap of full or bulging type. However, 4 (10%) among 39 patients with skin flap of sinking or flat type showed unquestionable objective improvement within a few days following cranioplasty, after stationary period of more than 2 and half months. In these situation, placement of acrylic plate has presumably corrected deformity of underlying brain tissue secondary to pressure gradient between extra- and intracranial spaces, which might have unidentifiably caused unfavorable eflects on neural function. 2. Seven children underwent procedure within 24 months of age and all of them had troublesome bluging of skin flap. This deformity was extreme in 5, in whom the dura mater was not repaired in the previous surgery. Those children had various intracranial problems as causes of bulging skin flap-hydrocephaly in 2, porencephaly in 1, CSF collection under the skin flap in 4, brain migration in 2, enlarged subarachnoid space over the bulging brain surface in 2, deformity of the skull resembling growing skull fracture in 5; and as complications of cranioplasty in 3 and infection in 2. 3. Fracture of the cranioplasty was seen in 7 (2%) among 300 cases and 6 of them were under the age of 7. In one case, there occurred 3 episodes of fracture. 4. Infected cranioplasty, in all as epidural empyema, was seen in 10 (3%) of 300 cases. One of the most important factors related to infection, was the time interval after the primary surgery; all infected cases were operated on within 3 months.     

Positive predictive values of selected clinical signs associated with skull base fractures

BACKGROUND: The goal of this study was to determinate the positive predictive values of selected clinical signs for skull base fractures and associated intracranial lesions. METHODS: EXPERIMENTAL DESIGN: Clinical and radiological data were collected prospectively for all patients with selected clinical signs of skull base fractures, and their admission criteria were: 1) recent head injury story; 2) presence of one or more of following clinical signs: unilateral or bilateral blepharohaematoma, bloody otorrhea, and Battle's sign. SETTING: Emergency service of a institutional hospital. PATIENTS: One hundred forty two patients with the selected clinical signs for skull base fracture. RESULTS: Frontal bone fractures were the most frequent in patients with selected clinical signs. Battle's sign (100%) and unilateral blepharohaematoma (90%) were the signs with higher positive predictive values for skull base fractures; bilateral blepharohaematoma (70%) and bloody otorrhea (70%) were those with less values. The positive predictive values of the selected signs for intracranial lesions (acute extradural haematoma, pneumocephalus, brain contusion, brain sweLling, and acute subdural haematoma) were: unilateral and bilateral blepharohaematoma with positive predictive values of 85% and 68%, respectively; Battle's sign was 66%; and bloody otorrhea was 46%. For patients at admission on the 13-15 Glasgow Coma Scale only, the positive predictive values for that intracranial lesions were: blepharohaematoma=78%; Battle's sign=66%; and bloody otorrhea=41%. CONCLUSIONS: Our data demonstrated that the selected signs of skull base fractures have high positive predictive values for the presence of skull fracture and intracranial lesions, even in those patients classified in the Glasgow Coma Scale between 13 and 15. This indicates that all patients with the selected clinical signs should be submitted to computerized tomography of skull and with bone window, with the aim to detect associated lesions.