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Missiles and Fragments The descriptions in the preceding pages apply to blunt, nonpenetrating injuries of the skull and their effects on the brain The disorders included in this section are more the concern of the neurosurgeon than the neurologist In the past, the care of penetrating craniocerebral injuries was mainly the preoccupation of the military surgeon, but with the increasing amount of violent crime in society such cases have become commonplace on the emergency wards of general hospitals In civilian life, missile injuries are essentially caused by bullets red from ri es or handguns at high velocities Air is compressed in front of the bullet so that it has an explosive effect on entering tissue and causes damage for a considerable distance around the missile track Missile fragments, or shrapnel, are pieces of exploding shells, grenades, or bombs and are the usual causes of penetrating cranial injuries in wartime The cranial wounds that result from missiles and shrapnel have been classi ed by Purvis as tangential, with scalp lacerations, depressed skull fractures, and meningeal and cerebral lacerations; penetrating, with in-driven metal particles, hair, skin, and bone fragments; and through-andthrough wounds In most penetrating injuries from high-velocity missiles, the object (such as a bullet) causes a high-temperature coagulative lesion that is sterile and fortunately does not require surgery In these instances, the main considerations are the development of infection or CSF leaks or, in the long term, epilepsy or aneurysms in distal blood vessels The latter are considered to be the result of disruption of the vessel wall by the high-energy shock wave If the brain is penetrated at the lower levels of the brainstem, death is instantaneous because of respiratory and cardiac arrest Even through-and-through wounds at higher levels, as a result of energy dissipated in the brain tissue, may damage vital centers suf ciently to cause death immediately or within a few minutes in 80 percent of cases If vital centers are untouched, the immediate problem is intracranial bleeding and rising intracranial pressure from swelling of the traumatized brain tissue Once the initial complications are dealt with, the surgical problems, as outlined by Meirowsky, are reduced to three: prevention of infection by rapid and radical (de nitive) debridement, accompanied by the administration of broad-spectrum antibiotics; control of increased intracranial pressure and shift of midline structures by removal of clots of blood and the vigorous administration of mannitol or other dehydrating agents as well as dexamethasone; and the prevention of life-threatening systemic complications When rst seen, the majority of patients with penetrating cerebral lesions are comatose A small metal fragment may have penetrated the skull without causing concussion, but this is not true of high-velocity missiles In a series of 132 patients of the latter type analyzed by Frazier and Ingham, consciousness was lost in 120 The depth and duration of coma seemed to depend on the degree of cerebral necrosis, edema, and hemorrhage In the series of the.

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15

This condition is seen in the rst hours after injury and may prove rapidly fatal The CT scan shows enlargement of both hemispheres and compression of the basal cisterns and ventricles There is usually no papilledema in the early stages, during which the child hyperventilates, vomits, and shows extensor posturing The assumption has been that this represents a loss of regulation of cerebral blood ow and a massive increase in the blood volume of the brain The administration of excessive water in intravenous uids may contribute to the problem and should be avoided Inappropriate secretion of antidiuretic hormone (ADH) also exaggerates the swelling in some children We have not observed this complication in adults

002 400 005 0 1 0 430 0 1 5 520 0 2 0 600 025 550

.

This form of craniocerebral trauma in infants is well known in large emergency practices but can be missed if not speci cally considered As the name implies, the inciting trauma is typically violent shaking of the body or head of an infant, resulting in rapid acceleration and deceleration of the cranium combined with cervical whiplash The presence of this type of injury must often be inferred from the combination of lesions on imaging studies or autopsy examination, but precision in examination is paramount because of its forensic and legal implications The diagnosis is suspected from the combination of subdural hematomas and retinal hemorrhages, as summarized by Bonnier and colleagues Sometimes there are occult skull fractures, but more often, there is little or no direct cranial trauma Additional lesions may be evident on diffusion-

.

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