Intracranial infection after missile brain wound: 15 war cases

The present study describes 15 cases of intracranial infections developed in a group of in patients with missile brain wound (MBW), during the war in Croatia in the region of East Slavonia.

The retrospective study included 88 MBW casualties. There were 11 females and 77 males aged 2-80 years. The projectile penetration of the cranial dura was confirmed and the presence of intracranially retained foreign bodies was evaluated with computerized tomography (CT) in all the patients. The wounded were treated according to the modern recommendations of neurotrauma care. However, we extracted only accessible bone/metallic fragments during intracranial debridement. All intracranial infections were documented by cultures, CT, surgery or autopsy. The mean follow-up period of wounded with intracranial infections was 2.4 years (range, 10 days to 7 years).

Intracranial infection developed in 14 patients (17%) as "early intracranial infections". Among 14/15 cases, infection developed within the first 8 weeks, and in 1 case 5 months after wounding. We recorded 4 cases of isolated bacterial meningitis, whereas in 9 cases brain abscess had developed. In 6 cases brain abscess was associated with concomitant meningitis and epidural empyema. Local cerebritis developed in one case, as well as subdural empyema with the concomitant meningitis in one case. There were 8 deaths in total of 15 cases. Glasgow Outcome Score 3 was observed in 2 and good outcome in 5/15 cases. The infectious organisms were isolated in 8 cases. Gram-positive bacteria were found in 12 different specimens. Gram-negative bacteria were found in 9 specimens. The most frequently isolated organism was Staphylococcus aureus. beta-hemolytic streptococcal and clostridial infections were not observed. Among the 15 patients with intracranial infection, just one did not have intracranially retained bone and/or metallic fragments. However, among the 73 head injuries without intracranial infections only 10 did not have retained fragments. CSF fistula and/or dehiscence developed in 13/15 patients with intracranial infection. In 67/73 wounded without intracranial infections, wound complications were not registered.

The liberal use of post-contrast CT of the brain within the first 2 months after injury, especially if performed early in the clinical course, can lead to a prompt diagnosis of most of "early intracranial infections". The surgical procedures in order to prevent wound CSF fistula/dehiscence development are absolutely necessary. The immediate scalp and dural wound repair in case of wound complications are absolutely indicated and if needed, the procedures can be repeated. However, it seems that retained fragments are not responsible for an increased rate of intracranial infection.