Wartime penetrating sellar/parasellar injuries: a novel classification and management based on trajectory

Penetrating brain injuries (PBIs) involving the sella region are rare, anatomically complex, and associated with high morbidity due to the proximity of critical neurovascular structures. Herein, the authors introduce a novel trajectory-based classification system derived from wartime injuries sustained during the conflict in Ukraine, aiming to improve the diagnostic framework, guide management strategies, and support prognostication in this unique population.

The authors conducted a retrospective analysis of all PBIs involving an anatomically defined critically important sellar injury zone (CRISIZ) treated at a tertiary care center over a 2.5-year period (February 2022-August 2024). Injuries were classified into 2 main categories based on projectile trajectory to the CRISIZ: transbasal (TB) and transcortical (TC). Each category was further subdivided into 4 anatomical subtypes. Clinical presentation, imaging characteristics, complications, treatment modalities, and outcomes were compared across subgroups. The primary outcome was the Glasgow Outcome Scale (GOS) score at 6 months.

A total of 29 patients with PBIs involving the CRISIZ were identified (mean patient age 38 years). TB injuries were more common than TC by a factor of 1.6 (18 vs 11; 62.1% vs 37.9%). TB subtypes included transnasal, transorbital, transmaxillary, and infratemporal trajectories; TC subtypes included transfrontal, transtemporal, transventricular, and transoccipital. TB injuries had a higher prevalence of multiple projectile fragments (88.9% vs 45.5%, p < 0.05) and CSF rhinorrhea (66.7% vs 18.2%, p < 0.05). TC injuries were associated with significantly higher rates of intracranial vascular injury (81.8% vs 22.2%, p < 0.01), subarachnoid hemorrhage, intraventricular hemorrhage, and coma on admission (54.5% vs 11.1%, p < 0.05). Overall, in-hospital mortality was 10.3%, and 75.9% of patients achieved favorable outcomes (GOS scores > 3) at 6 months.

Projectile trajectory is a critical determinant of injury pattern and clinical course in PBIs involving the CRISIZ. TC injuries are associated with a higher incidence of neurovascular complications, while TB injuries more commonly involve CSF leaks. Early identification and management of these complications are critical for optimizing outcomes. The proposed classification scheme provides a practical framework to guide evaluation and management in this high-risk patient population.