Missile Injuries of the Anterior Skull Base

Missile injuries of the anterior skull base usually occur during war or warlike situations. These injuries may be isolated or associated with multiple traumatic injuries. We report 23 such cases managed during military conflicts and peacekeeping operations. All were adult males. Four of these patients sustained bullet injuries; the rest were injured from shrapnel. Eighteen patients had injury to the visual apparatus with permanent blindness. Proptosis was seen in 16, cerebrospinal fluid (CSF) leak from the wound in seven, and CSF orbitorrhea in three patients. Sixteen had irreparable injury to the eye necessitating evisceration/enucleation, and two had retrobulbar optic nerve injury. Three patients were comatose [Glasgow Coma Scale (GCS) 3/15], and 14 had altered sensorium. Six patients were fully conscious. All were investigated by computed tomography (CT), which revealed injury to the eyeball and skull base, orbital fracture, frontal hematoma, contusion, and pneumocephalus. Seventeen patients underwent emergency surgery, and six patients were initially managed conservatively. Neurosurgical management consisted of making bifrontal flaps, craniotomy/craniectomy, debridement, and repair of the base with fascia lata. Reconstruction of the orbital rim was required in three cases. All were managed postoperatively with cerebral decongestants and antibiotics in antimeningitic dosages. There was one death in the postoperative period; outcome was good in 16 and moderate in four patients. Twelve patients had retained intracranial splinters; three of these developed recurrent suppurative meningitis. Of the six patients initially managed conservatively, three were subsequently operated for CSF rhinorrhea. Gross communition, dural loss, and injury to the frontal scalp often preclude the use of pericranial repair of the skull base. Fascia lata is extremely useful for reconstruction and repair. Anterior cranial fossa injury probably carries a better prognosis; however, there is increased risk of suppurative complications due to breach of air-filled sinuses by the missile and contamination of the intradural compartment, as compared with supratentorial vault injuries not involving the orbit or paranasal sinuses. Three patients who underwent no operative procedure and remain asymptomatic are under follow-up.

KEYWORDS

Brain abscess - gunshot wound - head injury - meningitis - missile injury - orbitocranial injury

REFERENCES

• 1 Jankovic S, Buca A, Busic Z, Zuljan I, Primorac D. Orbitocranial injuries: report of 14 cases.  Mil Med. 1998;  163 490-493
• 2 Betz P, Stiefel D, Hausmann R, Eisenmenger W. Fractures at the base of the skull in gunshots to the head.  Forensic Sci Int. 1997;  86 155-161
• 3 Swan K G, Swan R C. Principles of ballistics applicable to the treatment of gunshot wounds.  Surg Clin North Am. 1991;  71 221-238
• 4 Dillon Jr J D, Meirowsky A M. Facio-orbito-cranial missile wounds.  Surg Neurol. 1975;  4 515-518
• 5 Aarabi B, Taghipour M, Alibii E, Kamgarpour A. Central nervous system infections after military missile wounds.  Neurosurgery. 1998;  42 500-509
• 6 Shoung H M, Sichez J P, Pertuiset B. The early prognosis of craniocerebral gunshot wounds in civilian practice as an aid to the choice of treatment: a series of 56 cases studied by computed tomography.  Acta Neurochir (Wien). 1985;  74 27-30
• 7 Kaufman H H, Makela M E, Lee K F et al.. Gunshot wounds to the head: a perspective.  Neurosurgery. 1986;  18 689-695
• 8 Cooper P R. Gunshot wounds of the brain. In: Cooper PR Head Injury. 3rd ed. Baltimore; Williams & Wilkins 1993: 355-371
• 9 Levy M. Outcome prediction following penetrating craniocerebral injury in a civilian population: aggressive surgical management in patients with admission Glasgow Coma Scale scores of 6 to 15. Neurosurg Focus 2000 8: Article 2
• 10 Grahm T, Williams F C, Harrington T et al.. Civilian gunshot wounds to the head: a prospective study.  Neurosurgery. 1990;  27 696-700
• 11 Kennedy F, Gonzalez P, Dang C et al.. The Glasgow Coma Scale and prognosis in gunshot wounds of the brain.  J Trauma. 1993;  35 75-77
• 12 Brandvold B, Levi L, Feinsod M et al.. Penetrating craniocerebral injuries in the Israeli involvement in the Lebanese conflict, 1982-1985: analysis of a less aggressive surgical approach.  J Neurosurg. 1990;  72 15-21
• 13 Bhatoe H S, Garg A, Kapoor S et al.. Experiences in the management of splinter injuries of brain in low intensity military conflicts.  Asian Arch Crit Care Med. 1997;  46 63-68
• 14 Aarabi B. Comparative study of bacteriological contamination between primary and secondary exploration of missile head wounds.  Neurosurgery. 1987;  20 610-616
• 15 Bhatoe H S. Retained intracranial splinters: a follow-up study in survivors of low intensity military conflicts.  Neurol India. 2001;  49 29-32
• 16 Splavski B, Vrankovic D, Saric G et al.. Early surgery and other indicators influencing the outcome of war missile skull base injuries.  Surg Neurol. 1998;  50 194-199