PenetratingBrainInjuriesPBI

(Civilianpopulation)

MohammadMaleki,MD,FRCSc
JudithMarcoux,MD,FRCSc
DivisionofNeurosurgery
MontrealGeneralHospital
McGillUniversityHealthCenter

outline

Definitionsofterms(missilesornonmissile,ballistics,etc.)
Epidemiology
DifferencesbetweenPBIandbluntTBI
Pathogenesis(anatomicalstructuresinvolved,velocityof
projectile,etc.)

Missilevs.NonmissilePBI
Casepresentations,medicalandsurgical
management
Outcome

Definition

Penetratingtrauma:aninjurythatoccurs
whenobjectpiercestheskin&entersa
tissueofbody,creatinganopenwound
Penetratingheadinjury
(oropenheadinjury):thereisabreachof
coveringsofbrain(meninges)withhigh
chanceofdamagingneurovasculartissues
AllTBIwhicharenottheresultofablunt
mechanismisclassifiedunderPBI

Definition

MissileV.SNonmissilePHI
speedmatters!

NonmissilePHI:speedofprojectile
<100m/sec,e.g.stabwound
MissilePHI:speedofprojectile>100m/sec
e.g.gunshot
Differencesinpathophysiologyintermsof
underlyingdamage
Differencesinprognosis majorityofnon
missilePBIsurvive,whilemajorityofmissile
PBIdie,orareleftwithsignificantdisabilities

Definitions

Ballistics=studyofdynamicsofprojectile
Ballisticsproperties:kineticenergy,mass,
velocity,shape,etc.
Woundballistics=isthestudyofprojectile's
actintissue,e.g.,inthebrain,shockwaves,
vacuumeffect,etc.

E= M(VIVR)

E =woundingEnergyofprojectile
M=projectilemass(weight)
VI=impactvelocity
VR=residualvelocity,iftheprojectilehasaperforatingmode

Note:SmallfirearmsincivilianGSWHsfollowconventionalballisticrulesof
woundingenergy,whenVelocityofprojectileislessthan700m/sec
(ifmorethanthat,thenformulawillchange)

Woundingenergy(ifV morethan700m/sec),dependsonpower,

P=MV
P=powerofprojectile
M=mass
V=velocity
Note:
Manyofthevictimsinthevicinityofcased,oranimprovised
explosivedevice(IED)willincurinjuriesbyfragmentswith
velocityofgreaterthan700m/secandlowballisticcoefficient

EpidemiologyofPBI

Injuryisthe4th leadingcauseofmortality,underage45
200400TBIadmission/100,000population(variesindifferentcountries)
Majority(over90%)arebluntheadtrauma
PenetratingBraininjuryfarlesscommonthanbluntTBI
Incertaindenselypopulatedcommunities(BaltimoreMaryland,Bronx
NY),uptoathirdofsevereTBIcouldbeduetoGSWinyoungmale,with
veryhighmortality
PBIcausedbynonmissileobjectsrepresentararepathologyamong
civilians&prognosisismuchbetterthanmissilePBI

EpidemiologyofPBI
Male>thanfemale,(speciallywithGSW)
Homicide,suicide,accidents,etc.
PBIcariesworseprognosis,esp.whenassociatedwithmissileinjury
PBIaremostlycausedbyhighvelocityobjectswhichresultsinmorecomplex
injury&highermortality
Morechanceofinfection,ascomparedtoclosedheadinjuries
Damagetobloodvesselcausingintracranialhemorrhage,ischemia,brain
swelling,highICP&itsconsequences

Penetratingobjects
manyvariety

Metals nails,knife,rods,gunshots
Organicmatters piecesofwood,pencil,etc

Factorsdeterminingtheextendofinjury

Lowvelocityprojectile,lowkineticenergy,
minimalshockwaves.E.g.knife(speed
<100m/sec)weakpointsofentryofskull
Highvelocityprojectile,highkineticenergy,high
shockwavese.g.Gun(anywhereontheskull)
Natureofprojectile
Pointofentry&angleofprojectile
Characteristicsofinterveningtissues
Anatomic&neurovascularstructureofthe
passage
(skull,muscle,mucosa,etc.)

PathophysiologyofhighvelocityprojectilePBI(GSW)
Primaryinjury:
DIRECT:1 softtissueinjury.
2 bonefracture comminuted.
3Cerebralinjuryinthepath..
Coup+countercoupfrommissileimpact
Shockwaves(sonic)
temporarycavityformation.
SecondaryInjury...HighICP

Shockwave&cavitationeffectwithGSW

Directblow,anddamagingwhateveritisonitspath
Shockwaves,temporaryvacuumeffect,stretching,cavitation,deformity
oftissue,furtherdamage

CavitationeffectwithGSW

Experimentwithgelatin.Longitudinalshockwaves,andtemporarycavity,
producedbytheprojectile,generatingpressurewavesasitentersacubeof
gelatin

Primaryinjury

Gunshotwoundtobrain,&shockwaveeffect
(damageisbeyondjustthebullettract!)

Translationofkineticenergyintotissuedamage

Isbroughtaboutbythetremendousamountofcrushingpressureexerted
onthebrainparenchyma
Juxtamissilepressureaffectsthebraintissueimmediatelyinthepathofa
projectileandmaybeinthethousandsofatmospheres
Longitudinalstrongshockwavesstartimmediatelyafterimpactofthe
projectilewithbraintissue,andtravelinspheresaheadofprojectilewith
velocitiesinexcessof1460m/sec
Shockwavelastupto10secandmeasureupto80atm
Ordinarypressurewavesmeasuringupto2030atmaregeneratedasthe
projectiletransfersitskineticenergytothesurroundingbrain tissueand
producesatemporarycavity.Thenegativepressuregeneratedbythe
temporarycavitycansuckcontaminatedmaterialintothecavity
(inadditiontoinitialcrushingeffect)

Factorsimportantinterminalballistics

Penetration
Tissuedensity
Fragmentation
Detonation
Shapeofthecharge
Blastoverpressure
Combustion
Incendiaryeffect(firebombeffect)

ERmanagement

Primarysurvey&stabilization:Airway,Breathing(intubationperindication),
cervicalspine,Circulation,externalhemorrhage
Inspectionofwound,afterresuscitation:thoroughinspectionofscalp(powder
burn,CSFleak,brainmaterialexude!.Carefullyremovecollar,inspecttheneck,
allorificesshouldbechecked.
GCS shouldbenoted,aswellasclinicalindicationofraisedICP
Completeexaminationofotherorgansystems
Detailedmedicalhistoryfromthefamily&friends
Labs:CBC,electrolytes,ABG,coagulationprofile
Type,&crossmatch,
Alcohol&drugscreen
Transfertoradiologyforimaging,CT,CTA,angiography,ifindicated

ICU,orO.R.dependingonimaging

Antibioticcoverage
InfectionmorethanclosedTBI:entranceofforeignbodies,
hair,fragments,etc.
Importanceofmeticulousdebridement
MoreinfectionifParanasalsinusespenetrated,ifCSFleak,or
trajectorypassingventricles
Military,preantibioticera60%(withuseofAB,411%,&
civilian,15%)
Staph.Aureus,themostcommonbacteria,&Gramnegative
bacteria,etc.
Coverage:broadspectrum,cephalosporins,metronidazole,
vancomycin,57days(someuseupto2weeks)

Seizure
SeizuremorecommonwithPBIthanclosedTBI
3050%ofpatientsdevelopseizure
10%within1st week,80%during1st 2year
Upto18%maynothaveseizureuntilto5ormoreyearsafter
PBI)
BTFrecommendsseizureprophylaxisonlyforthe1st week,
unlesspatientsdevelopseizure,thenshouldbetreated
accordingly

Imaging
Plainskull&neckxray
CT
CTA(orcatheterangio),iftrajectorynear:
sylvienfissure,supraclinoidcarotid,cavernous
sinus,vertebrobasilarvessels,ormajordural
venoussinuses
Vascularinjuries:dissections,occlusion,delayed
pseudoaneurysms,CCF

SurgicalRx
MostofsurgicalRxshouldbedoneinOR
setting,(unlessforminorwoundclosureinER)

DonotattempttoremovevisibleforeignbodyinER!!
Surgicaldebridement&removalofdevitalizedtissueinOR
Removalofmasslesionsuchashematoma
Ifretainedfragmentsaredeepinvitalareaofbrain,wedonot attemptto
removethemall
Closefollowupforpossibleinfection

Casepresentations,
Gradualincreaseinspeed!!

Organicmatter(wood)throughorbit
Sabwounds
Nailgunwounds
Gunshotwounds

Nonmissilepenetratingorbitocranialinjurieshasbeenreported
withvarietiesofdifferentobjects:metals,wood,syntheticmaterials,etc.etc.
Woodenpenetratingobjects,anuncommoninjury

Orbitocranialpenetratinginjury
Therehasbeenreportofvariouspenetratingobjectsintothe
cranialcavitythroughtheorbit
Thesemaybemetal,glass,syntheticmaterials,orpiecesof
wood
Wereporttwocasesofpenetratingwoodenobjectsintothe
cranialcavityenteringfromtheeye,tothesuperiororbital
fissure&cranium
Managementstrategiesisdiscussed
1st,areviewofanatomy

Vulnerableanatomicregionsofskullsusceptibleforpenetrating
injurywithlowvelocityprojectile

Orbitalroof(preferred,weakentranceforfrontallobotomyfor
P4Freeman1948)

Specialanatomicshapeoforbit
Temporalsquama
Cribriformplate

SpecialAnatomicstructuralcharacteristicsoforbit
Horizontalpyramidonaposteromedialaxis
Thisshapetendstodeflectobjectsenteringtoorbittowards
theapex,wherethesuperiororbitalfissure&opticforamen
mayprovideaneasypassageintotheintracranialspace

Case#1
Male,age20,falloffthebicycleonthecountryroad,penetratingwoundinto
innercantus,noteCSFleak.GCS12,agitated,wasintubated.Afferent
pupillarydefect,visioncouldnotbetested

Swollen,eyeproptosis.Lowdensity,?Airbobbleintosuperior
orbitalfissure(noteincidentalremoteheadinjurysequella)

Morerefinedcuts,withsagittalreconstruction,again,
tractofforeignbody?

Novascularinjury

Ptyrional,intra/extraduralapproachtoextractallthepiecesof
wood

Extractedpiecesofwoods(cutendofcanewoodonthesidesof
countryrood)&2monthsPO,CT,smallRtposteriororbitotomysite,
afterdrillingofclinoidprocess

Bamboolikegrasswood

3monthpostinjury

Rtopticatrophy,nolightperception
Rtconcentualpupilarylightreflexpresent
Ltlightreflexpresent
RtVInervepalsy

Case#2
17yearsoldautistic,falloffthebicycleinacountryroad.Smallwoundinto
superioreyelid,dilatedpupil,withproptoticcongestedeye,withlimitation
ofexrtaocularmovements.Itwasdifficulttoassesvision.Hehadtohave
lateralcanthotomytoreduceintraoccularpressure
Thisisday#5postinjury

IsthislooklikeOrbitalApexSyndrome?
Yes

Pain
Swelling,proptosis,congestion
Ophthalmoplegia
Decrease,orlossofvision
Symptomatologyrelatedtospecificethology

EthiologiesofOrbitalApexSyndrome(OAS)
Inflammatory:sarcoidosis,LupusE.,orbitalinflammatory
pseudotumor,thyroidorbitopathy,etc
Infectious:Fungus,bacteria,spirochetes,etc
Neoplastic:head&neckT.,neuronalT.Mets,hematologic
Iatrogenic(traumatic):sinonasalsurgery,orbitofacial
surgery
Accidental(traumatic):penetrating&nonpenetraiting
Vascular:Aneurysm,CCfistula,cavernousthrombosis,etc
Others mucocele
Re:S.Yeh,CurrentOpinionOphthal.2004

DDx:Cavernoussinussyndrome
Symptomatology:Ophthamoplegia,proptosis,chemosis,
HornerS.,V.nervesensorychanges
Etiology:Infectiousornoninfectiousinflammatoryprocess,
vascular,traumatic,neoplastic

Case#2CT,proptoticlefteye,withhypodensityin
superiororbitalfissure,

CTA,intimatepositionofforeignbodywiththeleftcavernous
sinus

MRA,leftcarotidintact

Shouldweattempttoremoveit,&how!?

Imagingcharacteristicofthisforeignbody
highlysuggestiveofwood(organicmatter)
Thereishighchanceofinfectionwithretained
wood
Transorbital!?Toorisky,withverycongested
eye
Transcranial!?

Explorationofsuperiororbitalfissure

FrontoTemporalexposure
dottedline,hiddenanteriorclinoid

Pterionalcraniotomy,extraduraldissection,retracting&
exposureofFrontoTemporalDuralFold(FTDF=a)

a=FTDFoverant.clinoid,b=SOF,c=greaterwing,d=lesserwingofspenoid

a=FTDF,b=SOF,c=greaterwing,d=lesserwing,e=posteriorperiorbita

AnteriorclinoidhiddenbehindFTDF(a)

SuperiorOrbitalFissure(SOF):acleftof3x22mmlyingbetweenthelesser&greaterwingofsphenoid,&
passageofcommunicationbetweentheorbitalapexandthecavernoussinus

Cadavericdissectionofcavernoussinus

E.Coscarella,NEUROSUEGERY 53:162167,2003

AnnulusofZinn,withextraoccularmuscleattachments,
&neurovascularstructurespassingthroughSOF

NeurovascularstructurepassingthroughSOF
1.
2.
3.
4.
5.
6.
7.
8.

Lacrimalnerve(branchofophthalmicN)
Frontalnerve(abranchofophthalmicnerve)
Superiorophthalmicvein
IVcranialnerve
SuperiordivisionofIIInerve
Nasociliarynerve(abranchofophthalmicnerve)
InferiordivisionoIIInerve
VInerve

Backto

Case#2 LeftFTcraniotomy,EVDtofacilitate
retraction

Case#2:Afterdrillingofgreaterwingofsphenoid,viaextradural
approach,&smallorbitotomy,objectisvisualizedsittinginthesuperior
orbitalfissure

Yellowishaccumulationaroundthewoodgrewmixedbacteria
F/U,Visionseemedtobeverylow,withrelativeafferentpupillarydefect,&
improvedEOMfewmonthlater

BevigilantwithPenetratingorbitalwounds
Woundssometimesmayappeardeceptivelyminer,or
superficial
Sometimespatientssymptomscouldbetrivial,orunder
estimatedbyparentsand/orcaregiver
Serioussequellaewillhappen,ifpenetratingobjectsare
underdiagnosed&undertreated

Inherentnatureofwoodaspenetratingagent
Porous,organicmaterialprovidesanaturalreservoirfor
microbialagents(bacteria,fungi,etc.)
Itissoft&canfragmentwithminimalforces
NoteasilydetectiblebyXray
OntheCT,lowdensity,sometimescouldbemistakenforS/C
emphysema,orpneumocephalus
Highrateofinfection(upto65%with25%mortality),ifnot
detected&extractedcompletelyearlyenough

Treatmentoforbitocranialpenetratinginjuries
Amultidisciplinaryapproachinvariousdisciplines
MedicalRx Antibioticcoverage
Surgicalextraction&repair(extraIntracranial),speciallyif
retainedwood,sincetherewouldbehighchanceofdelayed
infection
Whentheforeignbodytraversesorbit&intothecranium,
necessityoftranscranialexposure(extradural&intradural)

Summary
penetratingorbitocranialwoodinjury
Orbitocranialinjuryhadbeenreportedwithvariousnon
missileobjects
Thisinjuriesmaycausesignificantoccular&cranialdamage&
sequella
Peneraitinginjurywithwoodenobjectsisuncommon
Importanceofextractionofallthewoodparticlestoavoid
delayedinfection,foreignbodyreactivegranuloma,etc.

Knife,stabwounds

Case#3
Thismanwasstabbedwithknife,throughleftethmoidsinus,presentedwithCSFleak.
Neededcraniectomy,&eventualcranioplasty.Recovery,withverylittledeficit!!

Case#4
Thismanwasstabbedoverthesuperiorsagittalsinus,luckily,
ItwasremovedsafelyintheOR,aftercompletionofvascularstudies!.
F/UCTA,nodamage!Nosequellae

Case#5ThismanwasboughtintoER,withaknifeonhisskull.AbrilliantMDtried
toremoveitintheER!Itbroke!WehadtotakehimtoORtoremovetherestofthe
piece.Nobraindamage!

Case#645yearsoldman,8monthsafteranattack(withoutanymedical
consultation,initially)presentedwithseizure,andthiswasfoundinhisrightfrontal
lobe!!?

Surgicalplanning

Surgical
exposure

3monthsPO,doingwell(onantiseizuremedication)

Case#7Caseofbluntpenetratingtraumawithhammer
(unfaithful boyfriend !!?)verylittlesequellaaftersurgicalrepair!!

Case#8P4patient,selfinflictedPHIwithpowerdrill

Nailguns
Poweredbyexplosivecartridges
orcompressedair
Theyarepowerful(pressureashigh
as8.5Bar,whichcouldpenetrate
evenconcrete,withspeedashighas
427m/sec(likemissile)
Suicideattempt,oraccidental,
Lesslikelyhomicide

Case#9nailguninjury,GCS15
Whatshouldbe
donewiththisone!?

Becauseofcloseproximityofthenailwithimportantvascular
structures,onlyheadofnailwascutoff!!F/UCT,andclinicalstability

Case#10
Anothersuicidalattempt,&delayedremovalofnailoneyearlater!

ImprovementofLtfacialparesthesia,sensibleimprovementofIIInervepalsy,
(Remainedwithresidualhemianopsia,andmemorychangesaspreop)

GunShots
I Small(light)arms(boresizelessthan20mm)
II Artillery(boresizemorethan20mm)

CivilianGunShotWounds
Usuallyarehandguns,withsmallcaliberlessthan
20mm,muzzlevelocity200400m/sec

Civildisorder
Crime
Suicide
Accident

MissilePHI
Lowvelocitybullet(upto300m/sec):damageismainlydue
tocrushingeffectofitspassagethroughtissue.Mostlynon
military(civilian,smallcaliber).Mostofcivilianhandguns
Highvelocitybullet(>300m/sec).Inadditiontocrushingthe
tissue,itwillsetupsecondaryshockwaves&cavitation that
resultsinrapidpressurepulses,causingdevastating
destruction distantformthemissiletrack.Highvelocitybullet
woundsseenofteninmilitary arena

Highvelocitymissiles
Injurycausedbylaceration&crushingof
underlyingtissues
Injurycausedby,rotation&shockwaves
causingstretchingoftissueleadingto
momentarycavitation&itsaftereffects
(damagingbloodbrainbarrier,swelling)

Pathophysiology
Primaryinjury:
DIRECT:1 softtissueinjury.
2 bonefracture comminuted.
3Cerebralinjuryinthepath..
Coup+countercoupfrommissileimpact
Shockwaves(sonic)
temporarycavityformation.
SecondaryInjury...HighICP

OutcomeofGSW
GCS atpresentationisthemajordeterminantforlong
termoutcome(349cases)
915GCS:
Goodoutcome43%
68GCS:
Goodoutcome32%
35GCS:
Goodoutcome0%
Gunshot wound to the Head.Contemp Neurosurgery 17:1-5 1995

GSW
Gunshotwoundaccountformajorityof
penetratingheadinjury.
Gunshotwoundarethemostlethaltype.
Twothirddieattheseen.
Halfofthesurvivorwilldiethefirstday.
Overallmortalityis90%.

Highmortalitywith

highvelocityGS
Multilobarinjury
Bihemisphericinjury
Ventricularbleed
LowGCSonarrival

Generally,majorityofbihemisphericGSWvictims
donotsurvive

GrimprognosisGunshotswounds
90%0fcivilianssustainingGSWdie
2/3dieatthescene
In2000,250peoplesustainedGSWinstateofMaryland,
222(89%)ofthemdiedatthescene,and45diedinER
Only10patientswerealiveinER,8/10underwentsurgery
Only6(2.4%)eventuallymadeafavorableoutcome

Re:Aarabi,YoumantextofNeurosurgery,2011

ManagementofGSW
Initialaseesandresus
ABC..
GCS+PupilsENTRY/EXITSITE
mustbeidentified.
TreatincreasingICP.
Anticonvulsant.
Antibiotics(staph/strept/E.Coli/Klebs/Entero)
tetanus

Surgery(ASAP)

Debridementofdevitalized.
Removalofanymasslesions.
RemovalofACCESSIBLEbonefragment.
Bulletfragment.
ObtainingHomeostasis.
Watertightduralclosure.
Adequateclosureofscalp

Post.op
ICUtreatmentofseverheadinjury
Coagulopathy.
Complications:
CSFLeakage
Infection
Vascularlesions
Cranioplasty.

Case#11
SevereTBI,GSW,entrance,LtPO,crossingtoRtsylvian,

Luckysurvivor,withGOS4/5(mildleftsidespasticity.Novisualfielddefect,very
littlecognitiveimpairment)

Itwasdecided
nottogoafter
thebullet!F/Uangio

MGH(19952006)
AR.Ajlan

48cases.(4cases/year)
Male:female44:4
12
10
8
6

4
2
0
15

25

35

45

55

65

MGH(19952006)
17outof48wassuicidalattempt.
All died
2outthe17females.
Mechanism:
65%fromtheside
27%throughoralcavity.

Mortality

Mortality36cases(75%)
11diedbeforearrival.(30%)
13diedsameday(ER/ICU) (30%)
9diedinthefirst14days
2survivefor3months.

Survivors

Only6/12survivorshadintracranialinvolvement.
Allofthemhadimmediatesurgery.
50%hadgoodoutcome.
Theother6extracranialinvolvementhadgood
recovery(5GCSoutcomescale)

Conclusion

PBIisfarlesscommonthancloseTBI
PBIincivilianpopulationiscausedbydifferentvarietiesofprojectiles
Degreeofdamagedependsonvarietyoffactors:velocityandimportance
ofneurovascularstructuresinvolvedinthepass,etc
Nonmissile,lowvelocityprojectileisanuncommoncauseofPBI,with
betterprognosisthanmissileinjuries
Missile,highvelocityprojectile(Gunshots)aremorecommonthannon
missileinjuriesandoftenarefatal
Amongsurvivors,infection&seizureismorecommonthancloseTBI

Thankyou