Anatomical cerebellar protection of contrecoup hematoma development. Analysis of the mechanism of 30 posterior fossa coup hematomas.

The aim of this paper is to present the topographical/anatomical conditions that protect the posterior fossa from posterior fossa hematoma (PFH) resulting from contrecoup mechanisms and to point out the value of neuroradiological findings in determining force direction and transition. The biomechanism of this clinical entity also plays an important role in correct forensic interpretation. Generally, PFH are rare. In our series, they occurred exclusively as a result of forces applied to the occipital region. However, their appearance as a result of contrecoup mechanisms is exceptional. Considering the particular anatomical traits that protect the posterior fossa from the force transition of fronto-occipital (F-O) direction we put forth seven hypotheses which should explain the low incidence of PFH. Between 1989 and 1998, we treated 523 patients with intracranial hematomas caused by blunt trauma. Among them were 30 patients with PFH. All of them sustained an occipital bone fracture, confirming the coup lesion. In conclusion, it is difficult to determine clinically whether forces in the F-O direction could produce PFH as a result of contrecoup mechanism. That could be only proven in vivo by neuroradiological findings.

Intracranial infection after missile brain wound: 15 war cases.

OBJECTIVES: 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. METHOD: 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). RESULTS: 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. CONCLUSIONS: 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.

Successful treatment of traumatic acute posterior fossa subdural hematoma: report of two cases.

BACKGROUND: Acute traumatic subdural hematoma of the posterior cranial fossa after a closed-head injury, excluding those in newborns, is a very rare clinical event. Generally, the outcome is poor and the overall mortality rate is high. METHODS: Acute posttraumatic subdural hematomas of the posterior fossa associated with acute hydrocephalus in two patients were removed by standard suboccipital approach. Preoperatively, one patient was in a coma and the Glasgow Coma Score was 9 in another. CT scans showed obliterated mesencephalic cisterns in both cases. In the former there was a complex posterior fossa lesion, i.e., combined subdural and intracerebellar hematoma. The surgical decompression was completed 3 and 11 hours after injury, respectively. Intraoperative tapping of the lateral ventricle through a burr hole in the occipital area was performed in the latter case. RESULTS: Both patients survived; one made a good recovery, (i.e., Glasgow Outcome Scale 4 in a patient who was comatose on admission), the other did not do as well (GOS 3). CONCLUSIONS: Our experience justifies the policy of mandatory early operation in cases of traumatic acute subdural hematoma of the posterior fossa associated with poor neurologic condition, even in patients of advanced age. In patients with obliterated mesencephalic cisterns and/or complex posterior fossa lesions the same approach must be followed. These clinical and CT features are not necessarily predictors of a poor outcome.

Physical and histologic properties of substitutes used for the anterior fossa region dural repair.

During the last 10 years, 41 patients with dural tear caused by anterior cranial fossa bone fracture were treated surgically. Those treated conservatively were not included in this series. The patients' mean age was 36 years. The average time of postoperative observation was 15 months. Traffic accidents, as well as wounds caused by missiles (shell fragments or bullets), blows, and falls were the mechanisms of injury. An autogenous graft, followed by homologous (lyodura) and most recently by heterologous (lyoplant; B. Braun Melsungen AG, Melsungen, Germany) implants, was used to repair the dural lacerations. Fibrin adhesive was used to seal the sutures inserted between graft and dural defect margins in a majority of cases. The following criteria are required for the best dural substitute: uncontaminated tissue, histologic similarity to the local dura mater, adaptability, quick rehidratation, waterproof closure and the dural margins fast healing, and tensile strength easily resisting cerebrospinal fluid pressurization in physiological and pathological conditions. To define the effects of different tissue that could meet the above-mentioned criteria, we have undertaken a mechanical testing of the dural substitutes' tensile strength followed by histologic examination, and comparison with the dura mater of the anterior fossa region. Finally, we have paid particular attention to the clinical results of these substitutes.

Self-inflicted gunshot wounds to the head during the war and post-war period.

Thirty-five patients with self-inflicted gunshot brain injury were admitted to our hospital during 1991-96. War conditions and availability of firearms influenced the increase in these injuries, nearly six times greater than in the previous 6-year peace time period (1985-90). Our management protocol consisted of radical debridement of the missile track and evacuation of haematomata. For in-driven bone fragments we followed a less radical approach, but, if a post-operative computed tomogram (CT) showed a cluster of retained bone fragments, we operated on this. Attention was paid to the development of intracranial infection performing in such cases a contrast enhanced brain computed tomography. Ten patients died early and 29 were managed operatively. Twelve survived, and were followed-up for up to 60 months. No case of suicide recidivism was noted. We conclude that patients with a Glasgow Coma score of 3 should not be considered for operation. Per-operatively ultrasonography was very helpful in localizing and extracting in-driven bone fragments. Post-operatively, a CT scan is needed to demonstrate retained bone fragments.

Computed tomography of the spine as an important diagnostic tool in the management of war missile spinal trauma.

Twenty-two patients with spinal injury were evaluated by plain radiography immediately after hospital admission. In 14 patients whose condition was stable, we performed computed tomography (CT) scanning through the involved segments. To provide better planning before neurosurgical management, we divided the vertebral column in thirds. According to this division, we concluded that these injuries are mostly extensive, severely damaging all three thirds of the vertebral column and accompanying neural structures in the majority of cases. The information acquired by Ct concerning bony fragments, bone destruction, dural tear, spinal cord and nerve root compression, and neural damage directly influenced the surgical management. All patients except one underwent surgery while associated injuries of other organs were given priority in management. Injuries of the thoracic and the lumbar spine were the most common ones, frequently found in association with lesions of nearby organs. Penetrating injuries with a dural lesion were present in the majority of cases, while spinal cord injury was obvious in some. They were all well visualized using spinal CT scanning. Our view is that the role of CT is essential in guiding surgical management of war missile injuries to the spine.

Early management of war missile spine and spinal cord injuries: experience with 21 cases.

Between 1991 and 1994, 21 patients with war missile injuries of the spine and spinal cord were treated; there were 17 men and four women, with a mean age 30.7 years; 52.4 per cent were civilians. The wounds were caused by shells (54.6 per cent) and bullets (45.4 per cent). The thoracic and lumbar spines were most commonly injured, and the injuries were frequently associated with lesions of other organs (47.6 per cent). There was extensive initial neurological deficit (tetraplegia, paraplegia) in 47.6 per cent of cases in whom there was no postoperative neurological recovery. All patients were treated operatively and associated injuries of other organs received priority management. A decompressive laminectomy was performed in 80.9 per cent of patients. Penetrating injuries of the dura were recorded in 61.9 per cent, while the spinal cord was injured in 28.5 per cent of patients. The dural defect was reconstructed in these patients. There was a low incidence of postoperative complications (14.5 per cent) which emphasizes the importance of early surgery.

Spinal stability after war missile injuries of the spine.

OBJECTIVE: Spinal stability after surgery for war missile wound to the spine is addressed in this study. DESIGNS: A retrospective 4-year analysis of 21 patients. MATERIAL AND METHODS: The most common injuries were of the thoracic and lumbar spine. The injuries were frequently associated with the lesions of other organs. We registered extensive initial neurologic deficit in 47.6% of cases. All the patients were treated surgically. MEASUREMENTS AND MAIN RESULTS: A decompressive laminectomy was performed in 80.9% of cases. Internal stabilization after laminectomy was performed in only one patient in our series. None had clinical signs of instability. There were no radiologic signs of postoperative spinal instability found on mean follow-ups of 15 months. CONCLUSIONS: Wound debridement with or without removal of bony and foreign body fragments from the spinal canal was performed. A laminectomy is considered a method of choice. The spine was not stabilized in most patients because the facet joints were left intact.