Missile injuries of the brain: results of less aggressive surgery

Sixty cases of missile injuries (59 males, average age 25 years) were studied over a period of one year. Forty-three patients had suffered splinter injuries, 12 had gunshot wounds and 5 had suffered injuries from improvised explosive devices. The Glasgow coma scale was <5 in 8 patients, 5-8 in 14, 8-12 in 30 and 13-15 in 8 patients. Extensive comminution of skull bones was found in 10 patients. Thirty-five patients had penetration of the skull and the rest had orbito-cranial or facio-cranial wounds. CT scan revealed small hemorrhagic contusion with in-driven bones without mass effect in 15, contusion with mass effect in 36 cases, cortical contusions without in-driven bones (tangential injuries) in 3, distant intracranial contusions in 4, intraventricular hemorrhages in 5, multilobar injuries in 14, and unilobar injury in 40. Fifty-two patients were operated upon at our center, of which 30 were operated within 24 hrs, 10 between 24 to 48 hrs, and 12 between 48 to 72 hrs. Six patients were treated conservatively and 2 underwent only a simple closure of scalp wound. Craniectomy was done in 10 and craniotomy in 42 patients. Two patients developed wound sepsis, one had aspiration pneumonia, one had septicemia and one had deep vein thrombosis while one had post-traumatic hydrocephalus. On follow-up at 6 months, the outcome as per the Glasgow outcome scale was as follows: Good outcome in 42, moderate disability in 7, severe disability in 6 and death of 5 patients. Retained bone fragments were found in 36.3 % on follow-up CT scan but no one had brain abscess.