Outcome of extensive compound fractures associated with brain fungation

ABSTRACT

Head injury patients may present with extensive compound fractures associated with brain fungation. This type of injury may associated with craniofacial injuries, orbital injuries and skull base fractures. The management and outcome of those patients is still unclear. To evaluate the outcome of those patients who had this type of injuries and highlighted the methods of their management. During the last four years, 18 patients were admitted to department of neurosurgery in Al-Noor Specialist Hospital in Holy Makkaha, They were suffering from extensive compound fractures associated with brain fungation. Cause of injury included R.T.A in 11 patients, fall from height in 2 children, work injury in 2 patients, fall of heavy object in one patient, history of assault in one patient, and a kick by a horse in one child. Fourteen patients were males and 4 females. Mean age was 21 years [range from 4 to 37 years]. On admission, Fourteen patients had severe and 4 had moderate head injuries according to GCS. Eight patients had associated maxillofacial injuries, six had orbital injuries, two had nasal injuries and 11 had skull base fractures and 10 of them had CSF rhinorrhea. After resuscitation, CT Scan was done for the brain, orbit, facial bones and cervical spine. Urgent surgical repair was done for 18 patients by cleaning of the wound, control of bleeding, excision of lacerated brain, repair of the dura using fascia lata, reposition of skull bone fragments, and scalp repair. Optic nerve decompression was done in 2 patients to elevate compressing bone fragments. Open facial, nasal and orbital injuries were managed in the same time by concerned specialities. Closed maxillofacial fractures were managed after 10-14 days. All patients were managed initially in ICU by mechanical ventilation. Mean follow-up period was 22 months [range from 6- 42 months. Bilateral loss of vision occurred in one patient and unilateral blindness in 3 patients. CSF rhinorrhea stopped spontaneously within 10 days in seven patients and external lumber drainage for several days was done in 3 patients to control the condition. Postoperative meningitis developed in 3 [16.7%] out of 18 operated patients, two of them recovered and one died because of the infection after three months, another patient died due to severe brain injury and postoperative the patient became brain death and died after 24 hours. Outcome was evaluated according to Glasgow Outcome Scale, seven patients had Glasgow outcome score [GOS] of 4, another 6 patients had COS of 3, and 3 patients had GOS of 2. The mortality rate [2 patients 11%]. Urgent neurosurgical repair for extensive compound fractures associated with brain fungation would be associated with good outcome and had low mortality rate due to infection and severe injury. These results are better than that of closed head injury. However, traumatic unilateral or bilateral loss of vision may develop in one third of those patients. In future this study needs large number of patients to be involved and intracranial pressure monitoring during the initial course of treatment in intensive care unit