Penetrating Head Trauma Workup

  • Author: Federico C Vinas, MD; Chief Editor: Allen R Wyler, MD   more...
 
Updated: Jun 2, 2011
 

Laboratory Studies

  • The assessment of patients with penetrating brain injuries should include routine laboratory tests, electrolytes, and coagulation profile.
  • Many patients have lost a significant amount of blood before reaching the emergency department or might present with disseminated intravascular coagulation (DIC); consequently, determining the hemoglobin concentration and platelet count is important.
  • Type and cross match should always be obtained with the initial orders.
  • Obtaining a toxicology screen, including alcohol levels, is also appropriate.
Next

Imaging Studies

  • Radiological evaluation
    • The radiological methods of evaluation depend on the patient's condition.
    • In general, a lateral cervical spine and chest radiographs are obtained in the resuscitation room.
    • A CT scan of the head should be obtained as soon as the patient's cardiopulmonary condition has been stabilized to determine the extent of intracranial damage and the presence of intracranial metallic fragments. The study always should include bone windows to evaluate for fractures, especially when the skull base or orbits are compromised.
    • Some centers can perform computed tomographic angiography (CTA) for the evaluation of intracranial and extracranial vessels.
  • Cerebral angiography: If a vascular injury is suspected and the patient is stable, cerebral angiography often is used to diagnose injuries such as carotid and/or vertebral artery dissections, traumatic pseudoaneurysms, or arteriovenous fistulas.
  • Magnetic resonance imaging
  • In patients with penetrating injuries and intracranial metallic fragments, an MRI scan is contraindicated. If the presence of bullets or intracranial metallic fragments has been ruled out, an MRI scan of the brain provides valuable information on posterior fossa structures and the extent of sharing injuries.
  • A fluid-attenuated inversion recovery (FLAIR) sequence allows the evaluation of contusions or hemorrhages.
  • Diffusion or perfusion scan sequences are useful to evaluate areas of stroke or cerebral ischemia.
  • Magnetic resonance angiography (MRA) and magnetic resonance venogram (MRV) are useful if vascular or sinus injuries are suspected.
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Contributor Information and Disclosures
Author

Federico C Vinas, MD  Consulting Neurosurgeon, Department of Neurological Surgery, Halifax Medical Center

Federico C Vinas, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, American Medical Association, Congress of Neurological Surgeons, Florida Medical Association, and North American Spine Society

Disclosure: Nothing to disclose.

Coauthor(s)

Julie Pilitsis, MD  Staff Physician, Department of Surgery, Division of Neurosurgery, Wayne State University

Julie Pilitsis, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael G Nosko, MD, PhD  Associate Professor of Surgery, Chief, Division of Neurosurgery, Medical Director, Neuroscience Unit, Medical Director, Neurosurgical Intensive Care Unit, Director, Neurovascular Surgery, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School

Michael G Nosko, MD, PhD is a member of the following medical societies: Academy of Medicine of New Jersey, Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, Canadian Congress of Neurological Sciences, Congress of Neurological Surgeons, New York Academy of Sciences, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Ryszard M Pluta, MD, PhD  Associate Professor, Neurosurgical Department Medical Research Center, Polish Academy of Sciences at Warsaw, Poland; Clinical Staff Scientist, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH); Fishbein Fellow, JAMA, Chicago ,IL

Ryszard M Pluta, MD, PhD is a member of the following medical societies: Congress of Neurological Surgeons and Polish Society of Neurosurgeons

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Allen R Wyler, MD  Former Medical Director, Northstar Neuroscience, Inc

Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons

Disclosure: Nothing to disclose.

References

  1. Siccardi D, Cavaliere R, Pau A, et al. Penetrating craniocerebral missile injuries in civilians: a retrospective analysis of 314 cases. Surg Neurol. Jun 1991;35(6):455-60. [Medline].

  2. Stuehmer C, Blum KS, Kokemueller H, Tavassol F, Bormann KH, Gellrich NC, et al. Influence of different types of guns, projectiles, and propellants on patterns of injury to the viscerocranium. J Oral Maxillofac Surg. Apr 2009;67(4):775-81. [Medline].

  3. Aarabi B. History of the management of craniocerebral wounds. In: Aarabi B, Kaufman HH, Dagi TF, George ED, Levy ML, eds. Missile Wounds of the Head and Neck. Vol 1. Park Ridge, Ill: American Association of Neurological Surgeons; 1999:281-292.

  4. De Villiers JC. Stab wounds of the brain and skull. In: Vinken PJ, Bruyn GW, eds. Handbook of clinical neurology. Vol 23. New York, NY: Elsevier Science Publishing; 1975:407-503.

  5. Hida K, Tsuda E, Sato H, et al. [Brain abscess discovered 38 years after head injury (author's transl)]. No Shinkei Geka. Aug 1978;6(8):811-3. [Medline].

  6. Grahm TW, Williams FC Jr, Harrington T, et al. Civilian gunshot wounds to the head: a prospective study. Neurosurgery. Nov 1990;27(5):696-700; discussion 700. [Medline].

  7. Levy ML, Masri LS, Lavine S, et al. Outcome prediction after penetrating craniocerebral injury in a civilian population: aggressive surgical management in patients with admission Glasgow Coma Scale scores of 3, 4, or 5. Neurosurgery. Jul 1994;35(1):77-84; discussion 84-5. [Medline].

  8. Ley EJ, Srour MK, Clond MA, et al. Diabetic patients with traumatic brain injury: insulin deficiency is associated with increased mortality. J Trauma. May 2011;70(5):1141-4. [Medline].

  9. Kaufman HH, Schwab K, Salazar AM. A national survey of neurosurgical care for penetrating head injury. Surg Neurol. Nov 1991;36(5):370-7. [Medline].

  10. Aarabi B. Causes of infections in penetrating head wounds in the Iran-Iraq War. Neurosurgery. Dec 1989;25(6):923-6. [Medline].

  11. Aarabi B. Surgical outcome in 435 patients who sustained missile head wounds during the Iran-Iraq War. Neurosurgery. Nov 1990;27(5):692-5; discussion 695. [Medline].

  12. Aarabi B. Traumatic aneurysms of brain due to high velocity missile head wounds. Neurosurgery. Jun 1988;22(6 Pt 1):1056-63. [Medline].

  13. American College of Surgeons. Advanced Trauma Life Support Guidelines. Advanced Trauma Life Support Course. American College of Surgeons. 1999.

  14. Annegers JF, Hauser WA, Coan SP, et al. A population-based study of seizures after traumatic brain injuries. N Engl J Med. Jan 1 1998;338(1):20-4. [Medline].

  15. Ardill W, Gidado S. Penetrating head wound: a remarkable case. Surg Neurol. Aug 2003;60(2):120-3; discussion 123. [Medline].

  16. Baker CC, Oppenheimer L, Stephens B, et al. Epidemiology of trauma deaths. Am J Surg. Jul 1980;140(1):144-50. [Medline].

  17. Bartholomew BJ, Poole C, Tayag EC. Unusual transoral penetrating injury of the foramen magnum: case report. Neurosurgery. Oct 2003;53(4):989-91; discussion 991. [Medline].

  18. Benzel EC, Day WT, Kesterson L, et al. Civilian craniocerebral gunshot wounds. Neurosurgery. Jul 1991;29(1):67-71; discussion 71-2. [Medline].

  19. Berjano R, Vinas FC, Dujovny M. A review of dural substitutes used in neurosurgery. Crit Rev Neurosurg. Jul 28 1999;9(4):217-222. [Medline].

  20. Breased JH. The Edwin Smith Surgical Papyrus. In: The Edwin Smith Surgical Papyrus. Vol 1. Chicago, Ill: University of Chicago Press; 1930:165-166.

  21. Camuscu H, Dujovny M, Abd el-Bary T, et al. Microanatomy of the perforators of the anterior communicating artery complex. Neurol Res. Dec 1997;19(6):577-87. [Medline].

  22. Centers for Disease Control. Traumatic brain injury--Colorado, Missouri, Oklahoma, and Utah, 1990-1993. MMWR Morb Mortal Wkly Rep. Jan 10 1997;46(1):8-11. [Medline].

  23. Chesnut RM, Marshall LF, Marshall SB. Medical management of intracranial pressure. In: Cooper PR, ed. Head Injury. 3rd ed. Baltimore, Md: Williams & Wilkins; 1993:225-246.

  24. Coplin WM, Cullen NK, Policherla PN, et al. Safety and feasibility of craniectomy with duraplasty as the initial surgical intervention for severe traumatic brain injury. J Trauma. Jun 2001;50(6):1050-9. [Medline].

  25. Cosar A, Gonul E, Kurt E, et al. Craniocerebral gunshot wounds: results of less aggressive surgery and complications. Minim Invasive Neurosurg. Apr 2005;48(2):113-8. [Medline].

  26. Cosar A, Gonul E, Kurt E, et al. Craniocerebral gunshot wounds: results of less aggressive surgery and complications. Minim Invasive Neurosurg. Apr 2005;48(2):113-8. [Medline].

  27. Cox MW, Whittaker DR, Martinez C, et al. Traumatic pseudoaneurysms of the head and neck: early endovascular intervention. J Vasc Surg. Dec 2007;46(6):1227-33. [Medline].

  28. Dagi TF, Meyer FB, Poletti CA. The incidence and prevention of meningitis after basilar skull fracture. Am J Emerg Med. Nov 1983;1(3):295-8. [Medline].

  29. Erdogan E, Izci Y, Gonul E, et al. Ventricular injury following cranial gunshot wounds: clinical study. Mil Med. Sep 2004;169(9):691-5. [Medline].

  30. Feldman Z, Narayan RK, Robertson CS. Secondary insults associated with severe closed head injury. Contemporary Neurosurgery. 1992;14:1-8.

  31. Giannotta SL, Gruen P. Vascular complications of head trauma. In: Barrow DL, ed. Complications and sequelae of head injury. Park Ridge, Ill: American Association of Neurological Surgeons; 1992:31-49.

  32. Goldstein M. Traumatic brain injury: a silent epidemic. Ann Neurol. Mar 1990;27(3):327. [Medline].

  33. Gonzalez-Cruz J, Cardenas R, Nanda A. Penetrating orbitocranial injury to the sella: case report and review of the literature. J La State Med Soc. Nov-Dec 2007;159(6):310, 312, 314. [Medline].

  34. Gray J, Molloy D, Jenkins MG. "Glass in a scalp laceration": an unusual case of penetrating head injury presenting to the emergency department. Eur J Emerg Med. Apr 2004;11(2):117-8. [Medline].

  35. Harris ME, Barrow D. Traumatic carotid-cavernous fistulas. In: Barrow DL, ed. Complications and sequelae of head injury. Park Ridge, Ill: American Association of Neurological Surgeons; 1992:13-30.

  36. Hoffmann B, Sepehrnia A. Taylored implants for alloplastic cranioplasty--clinical and surgical considerations. Acta Neurochir Suppl. 2005;93:127-9. [Medline].

  37. Izci Y, Kayali H, Daneyemez M, et al. Comparison of clinical outcomes between anteroposterior and lateral penetrating craniocerebral gunshot wounds. Emerg Med J. Jun 2005;22(6):409-10. [Medline].

  38. Izci Y, Kayali H, Daneyemez M, et al. The clinical, radiological and surgical characteristics of supratentorial penetrating craniocerebral injuries: a retrospective clinical study. Tohoku J Exp Med. Sep 2003;201(1):39-46. [Medline].

  39. Jandial R, Reichwage B, Levy M, et al. Ballistics for the neurosurgeon. Neurosurgery. Feb 2008;62(2):472-80; discussion 480. [Medline].

  40. Kaufman HH, Timberlake G, Voelker J, et al. Medical complications of head injury. Med Clin North Am. Jan 1993;77(1):43-60. [Medline].

  41. Knightly JJ, Pulliam MW. Military head injuries. In: Narayan R, Wilberger J, Povlishock J, eds. Neurotrauma. New York, NY: McGraw Hill; 1996.

  42. Koçak A, OZer MH. Intracranial migrating bullet. Am J Forensic Med Pathol. Sep 2004;25(3):246-50. [Medline].

  43. Kriet JD, Stanley RB Jr, Grady MS. Self-inflicted submental and transoral gunshot wounds that produce nonfatal brain injuries: management and prognosis. J Neurosurg. Jun 2005;102(6):1029-32. [Medline].

  44. Martin EM, Lu WC, Helmick K, et al. Traumatic brain injuries sustained in the Afghanistan and Iraq wars. Am J Nurs. Apr 2008;108(4):40-7; quiz 47-8. [Medline].

  45. Muizelaar JP, Marmarou A, Ward JD, et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg. Nov 1991;75(5):731-9. [Medline].

  46. Murano T, Mohr AM, Lavery RF, et al. Civilian craniocerebral gunshot wounds: an update in predicting outcomes. Am Surg. Dec 2005;71(12):1009-14. [Medline].

  47. Nelson TJ, Wall DB, Stedje-Larsen ET, et al. Predictors of mortality in close proximity blast injuries during Operation Iraqi Freedom. J Am Coll Surg. Mar 2006;202(3):418-22. [Medline].

  48. Nicol A. Gunshot wounds. S Afr J Surg. Nov 2005;43(4):150, 152. [Medline].

  49. Pepe PE, Dutton RP, Fowler RL. Preoperative resuscitation of the trauma patient. Curr Opin Anaesthesiol. Apr 2008;21(2):216-21. [Medline].

  50. Perez-Arjona E, Dujovny M, Vinas F, et al. CNS child abuse: epidemiology and prevention. Neurol Res. Jan 2002;24(1):29-40. [Medline].

  51. Phillips ED. Greek Medicine. London, UK: Thames & Hudsen; 1973.

  52. Price DJ, Sleigh JD. Control of infection due to Klebsiella aerogenes in a neurosurgical unit by withdrawal of all antibiotics. Lancet. Dec 12 1970;2(7685):1213-5. [Medline].

  53. Ratiu P, Talos IF, Haker S, et al. The tale of Phineas Gage, digitally remastered. J Neurotrauma. May 2004;21(5):637-43. [Medline].

  54. Rezai AR, Lee M, Kite C, et al. Traumatic posterior cerebral artery aneurysm secondary to an intracranial nail: case report. Surg Neurol. Oct 1994;42(4):312-5. [Medline].

  55. Rosenberg WS, Harsh GR. Penetraing wounds of the head. In: Wilkins RH, Rengachary SS, eds. Neurosurgery. Vol 2. New York, NY: McGraw Hill; 1996:2813-2820.

  56. Rosenwasser RH, Andrews DW, Jimenez DF. Penetrating craniocerebral trauma. Surg Clin North Am. Apr 1991;71(2):305-16. [Medline].

  57. Rosselli D. [Phineas Gage, 'Tan' and the importance of case reports]. Rev Neurol. Jan 16-31 2005;40(2):122-4. [Medline].

  58. Salar G, Costella GB, Mottaran R, et al. Multiple craniocerebral injuries from penetrating nails. Case illustration. J Neurosurg. May 2004;100(5):963. [Medline].

  59. Salazar AM, Aarabi B, Levi L. Postraumatic epilepsy following craniocerebral missile wounds in recent armed conflicts. In: Aarabi B, Kaufman HH, Dagi TF, George ED, Levy ML, eds. Missile Wounds of the Head and Neck. Vol 2. Park Ridge, Ill: American Association of Neurological Surgeons; 1999:281-292.

  60. Schulz C, Woerner U, Luelsdorf P. Image-guided neurosurgery for secondary operative removal of projectiles after missile injury of the brain. Surg Neurol. Apr 2008;69(4):364-8; discussion 368. [Medline].

  61. Sinha P, Conrad GR, Williams BL. Visualization of bullet track and bullet by radionuclide brain scintigraphy. Clin Nucl Med. Apr 2005;30(4):249-52. [Medline].

  62. Sosin DM, Sacks JJ, Smith SM. Head injury-associated deaths in the United States from 1979 to 1986. JAMA. Oct 27 1989;262(16):2251-5. [Medline].

  63. Sosin DM, Sniezek JE, Waxweiler RJ. Trends in death associated with traumatic brain injury, 1979 through 1992. Success and failure. JAMA. Jun 14 1995;273(22):1778-80. [Medline].

  64. Stack BC Jr, Farrior JB. Missile injuries to the temporal bone. South Med J. Jan 1995;88(1):72-8. [Medline].

  65. Steinsvag S. [Penetrating injuries in the head and neck region]. Tidsskr Nor Laegeforen. Sep 8 2005;125(17):2369. [Medline].

  66. Stiernberg CM, Jahrsdoerfer RA, Gillenwater A, et al. Gunshot wounds to the head and neck. Arch Otolaryngol Head Neck Surg. Jun 1992;118(6):592-7. [Medline].

  67. Temkin NR, Dikmen SS, Wilensky AJ, et al. A randomized, double-blind study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med. Aug 23 1990;323(8):497-502. [Medline].

  68. Torner JC, Choi S, Barnes TY. Epidemiology of head injuries. In: Marion DW, ed. Traumatic Brain Injury. New York, NY: Thieme; 1999:9-25.

  69. Trask TW, Narayan RK. Civilian Penetrating Head Injury. In: Narayan R, Wilberger J, Povlishock, J, eds. Neurotrauma. New York, NY: McGraw Hill; 1996:868-889.

  70. Tsuei YS, Sun MH, Lee HD, et al. Civilian gunshot wounds to the brain. J Chin Med Assoc. Mar 2005;68(3):126-30. [Medline].

  71. Tudor M, Tudor L, Tudor KI. Complications of missile craniocerebral injuries during the Croatian Homeland War. Mil Med. May 2005;170(5):422-6. [Medline].

  72. Verweij BH, Muizelaar JP, Vinas FC. Hyperacute measurement of intracranial pressure, cerebral perfusion pressure, jugular venous oxygen saturation, and laser Doppler flowmetry, before and during removal of traumatic acute subdural hematoma. J Neurosurg. Oct 2001;95(4):569-72. [Medline].

  73. Verweij BH, Muizelaar JP, Vinas FC, et al. Mitochondrial dysfunction after experimental and human brain injury and its possible reversal with a selective N-type calcium channel antagonist (SNX-111). Neurol Res. Jun 1997;19(3):334-9. [Medline].

  74. Vetter H, Kolloch R, Appenheimer M, et al. [Effect of a chronic alpha adrenergic receptor blockade on basal secretion of renin in essential hypertension]. Schweiz Med Wochenschr. Dec 9 1978;108(49):1978-81. [Medline].

  75. Vinas FC. Bedside invasive monitoring techniques in severe brain-injured patients. Neurol Res. Mar-Apr 2001;23(2-3):157-66. [Medline].

  76. Vinas FC. Clinical Uses of Laser Doppler in the Intensive care Unit. Critical Reviews in Neurosurgery. 1999;9:28-33.

  77. Vinas FC, Fandino R, Dujovny M, et al. Microsurgical anatomy of the supratentorial arachnoidal trabecular membranes and cisterns. Neurol Res. Dec 1994;16(6):417-24. [Medline].

  78. Vinas FC, Ferris D, Kupsky WJ, et al. Evaluation of expanded polytetrafluoroethylene (ePTFE) versus polydioxanone (PDS) for the repair of dura mater defects. Neurol Res. Apr 1999;21(3):262-8. [Medline].

  79. Vinas FC, Verweij B, Muizelaar P. Invasive monitoring of cerebral oxygenation. Critical Reviews in Neurosurgery. 1998;8:31-40.

  80. Vinas FJ, Dujovny M, Barrionuevo PJ. [The craniocerebral injury. Experience on 3,443 cases in the police health department]. Rev Fac Cienc Med Cordoba. Oct-Dec 1966;24(4):441-57. [Medline].

  81. Wald SL. Advances in the early management of patients with head injury. Surg Clin North Am. Apr 1995;75(2):225-42. [Medline].

  82. Waxweiler RJ, Thurman D, Sniezek J, et al. Monitoring the impact of traumatic brain injury: a review and update. J Neurotrauma. Aug 1995;12(4):509-16. [Medline].

  83. Weigelt JA. Resuscitation and initial management. Crit Care Clin. Oct 1993;9(4):657-71. [Medline].

  84. West CG. A short history of the management of penetrating missile injuries of the head. Surg Neurol. Aug 1981;16(2):145-9. [Medline].

  85. Winder MJ, Monteith SJ, Lightfoot N, et al. Penetrating head injury from nailguns: a case series from New Zealand. J Clin Neurosci. Jan 2008;15(1):18-25. [Medline].

  86. Yorks ML. More on Phineas Gage. N Engl J Med. Mar 3 2005;352(9):944; author reply 944. [Medline].

  87. Zhang J, Yoganandan N, Pintar FA, et al. Temporal cavity and pressure distribution in a brain simulant following ballistic penetration. J Neurotrauma. Nov 2005;22(11):1335-47. [Medline].

 
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A young man arrived in the emergency department after experiencing a gunshot wound to the brain. The entrance was on the left occipital region. A CT scan shows the skull fracture and a large underlying cerebral contusion. The patient was taken to the operating room for debridement of the wound and skull fracture, with repair of the dura mater. He was discharged in good neurological condition, with a significant visual field defect.
Lateral skull radiograph of a young female who presented to the emergency department with a stab wound to the head produced by a large knife.
A CT scan of a young female who presented to the emergency department with a stab wound to the head produced by a large knife shows the extent of intracranial damage, which affects midline structures.
Lateral skull x-ray film of a patient who presented with a severe intracranial injury produced by a golf club.
The patient presented to the emergency department with a golf club in his head. The club was removed in the operating room.
A 65-year-old man experienced a gunshot wound to the right frontoparietal region. A CT scan shows that the bullet crossed the midline, lacerated the superior longitudinal sinus, and produced a large midline subdural hematoma. The patient presented with a Glasgow Coma Scale (GCS) score of 4 and died.
Intraoperative view of a middle-aged male with an open depressed skull fracture.
Intraoperative view the surgical reconstruction repair of a complex skull fracture.
A 57-year-old male who suffered a motorcycle accident. He was not wearing a helmet. He suffered a severe abrasion with tissue loss through skin, temporalis muscle, temporal bone, and dura. Note brain tissue exposed through his wound. He was taken urgently to surgery for debridement and reconstruction using a rotational flap.
Table. Glasgow Coma Scale
PointsEye OpeningBest VerbalBest Motor
6……Follows commands
5…AppropriateLocalizes pain
4SpontaneousInappropriateWithdraws to pain
3In response to voiceMoaningFlexion (decorticate)
2In response to painIncomprehensibleExtension (decerebrate)
1NoneNoneNone
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