GUNSHOTINJURIES

OF THE BRAINBY DR

AMIN ALKAMALYMD NEUSURGERY

ASS.PROF.SANAA UNIVERSITY

YEMEN

INTRODUCTION Gunshot injuries of the brain has been

changed from one uniquely military to broadly civilian concern in Yemen firearms considered part of the personality of men, So it is present in hands of most of population ,it used for many purposes as parties ,social conflicts ,protecting farms

and for entertainments .

INTRODUCTION(CON.)Traumatic brain injury (TBI) is the fourth

leading cause of death in the United States and is the leading cause of death in persons aged 1-44 years. Approximately 2 million traumatic brain injuries occur each year, and an approximate 50% of all trauma deaths are secondary to TBI, and gunshot wounds to the head caused 35% of these mortalities.

INTRODUCTION(CON.)Harvey Cushing was the first who

recommended early and definitive surgical interference for these injuries. during the Vietnam war aggressive initial debridement of missile track was advocated to reduced the rate of infections, abscess formation and decrease mortality rate.The reducing of the rate of mortality Arabia,1987 was due to the early surgical management.

Material and Methods

during the period (1998-2004) 200patient with brain injuries by gun shots (189) male (11) females – age ranged (2-65) years.

Material and Methods (con.)PATIENTS TIME GROUP

80 1 to 24 hours 1

45 24 to 48 hours 2

47 48 to 72 hours 3

28 More than 3 days

4

Material and Methods (con.)Initial resuscitation, clinical evolution according

to Glasgow coma scale, (less than-8=90, 8-12=82 and 13-15=18), laboratory and radiological evolution by plain

X.RAYS.CT SCAN and M.RI in some cases. All cases received anti epileptic drugs –antibiotic dexamethasone and dehydrating medications 162 Patients operated upon

Results

01020304050607080

1 2 3 4

Good outcomeMild disabilityMortalitySever disability

Result (con.)Radiological investigation revealed :53 with

small heamorrhagis contusion with driven bones 15 with cortical contusion without in driven bone, contusion 105, with large hematoma

And mass effect, 14 with distant contusion, 43 with intraventricular hemorrhage, 48

DiscussionBrandvold et al 1971 concluded

Limiting surgical goals to removal of grass contamination and any hematomas with minml manipulation of cerebral tissue, with no attempt to remove fragments that are not readly accessible produced a discharge mortality rate of 13%, an infection rate of 8%, and correlation between retained bone and epilepsy (22%). The variable most highly correlated with intracranial infection is the presence of an acute or delayed CSF leak.

Discussion (con)Gonul et al 1997

The variable most highly correlated with intracranial infection is the presence of an acute or delayed CSF leak.

Lillard 1987 Found that limited debridment approach produced no

increase in incidence of infection (4%) .Singh P 2003

Also has the same conclusion, therefore the argument for aggressive debridement no longer appears to be supported .

Discussion (con)Helling et all 1992

Found that early surgical intervention seemed to result in better survival but was unable to statistically control for the various prognostic variables.

Arendall and Meirowsky 1983Found that high mortality associated with penetrating wound of air

sinuses can be reduced by prompt and radical depridment.Sigh P 2003

Found that antibiotics are no substitute for early surgical depridment. And from our result i has been suggested that a lower mortality rate

reflects early triage and survivability decisions as much as treatment effectiveness .

Result (con.)

24 died just after admission before operation 13 of them due to delayed early management in spite of their mild to moderate initial injury,

14 patients treated conservatively by just suturing and cleaning of the wound.

9 patients complains of brain abscess,15With wound sepsis, 19 with hydrocephalus

Anti epileptics cannot be stopped in 44 patients .

ConclusionI can conclude that in addition to well

known factors affecting morbidity and mortality early management with less aggressive meticulous neurosurgical technique can significantly reduce mortality and morbidity after gun shot injury of the brain.