• Users Online: 377
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 19  |  Issue : 4  |  Page : 640-645

The relationship between brain computed tomography scan findings and prognosis in patients with missile-penetrating head injuries


1 Faculty of Medicine, University of Al-Ameed, Karbala, Iraq
2 Faculty of Medicine, University of Karbala, Karbala, Iraq
3 Faculty of Medicine, University of Warith Al-Anbiyaa, Karbala, Iraq

Date of Submission18-Aug-2022
Date of Acceptance22-Sep-2022
Date of Web Publication09-Jan-2023

Correspondence Address:
Husam Ghazi Al-Anbari
Faculty of Medicine, University of Al-Ameed, Karbala City Karbala-Najaf Highway Front of Pole (1238) P.O. No: 198 Karbala
Iraq
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJBL.MJBL_184_22

Rights and Permissions
  Abstract 

Background: Missile-penetrating head injury is a challenging problem for treating physicians. In Iraq and during 2003–2007, there was a civil war, which led to multiple causalities after suicide bombings or other clashes with coalition forces. A brain computed tomography (BCT) scan is considered as an initial diagnostic test to evaluate the next management plan. The authors tried to find the relationship between BCT scan findings and patients’ outcomes. Objective: This study aimed to explore the relationship between BCT scan findings of patients with missile-penetrating head injury and their prognosis. Materials and Methods: This was a cohort retrospective clinical study performed in Karbala, Iraq in the period from January 2005 till January 2006. Seventy patients with missile-penetrating head injuries were admitted and evaluated in Al-Hussain General Hospital (affiliated with the University of Al-Ameed). All patients had BCT scans and their outcome was evaluated using a modified Glasgow Outcome Scale. Results: In this study, the mortality rate is 15.71%. BCT scan findings are correlated with patients’ outcomes, which revealed the injury of one lobe carries the best outcome, whereas those with more than two lobes or posterior fossa injury carry the worse prognosis. Moreover, intraventricular hemorrhage (IVH) showed the highest mortality rate, whereas tract hematoma alone seems to carry a good prognosis with the least mortality. Conclusion: BCT scan is essential in both diagnosis and prognosis of patients with missile-penetrating head injury. IVH and posterior fossa injury lead to the highest mortality rate.

Keywords: BCT, head injury, missiles, penetrating, prognosis


How to cite this article:
Al-Anbari HG, Salih Al-Zaubai NM, Matloob AH, Hadi AA. The relationship between brain computed tomography scan findings and prognosis in patients with missile-penetrating head injuries. Med J Babylon 2022;19:640-5

How to cite this URL:
Al-Anbari HG, Salih Al-Zaubai NM, Matloob AH, Hadi AA. The relationship between brain computed tomography scan findings and prognosis in patients with missile-penetrating head injuries. Med J Babylon [serial online] 2022 [cited 2023 Feb 6];19:640-5. Available from: https://www.medjbabylon.org/text.asp?2022/19/4/640/367335




  Introduction Top


Penetrating head injuries are reported in history since the Egyptian era when they treated them with wound greasing.[1],[2] Missile wounds are the most common penetrating head injury in the civilian setting. Although they may be highly lethal and most of the patients need urgent neurosurgical care, the majority of them carry a good prognosis.[3],[4] By definition, penetrating (or open) head injury means breaching of dura matter.[5],[6],[7] This can be caused by missiles (high-velocity projectiles) or objects of lower velocity such as knives or bone fragments from a skull fracture that is driven into the brain. Missile-penetrating head injuries came into the field of medicine after the development of war weapons and early literature started to appear from World War I and World War II.[2],[3],[6],[7] In 2003, the US military campaign to invade Iraq yielded a lot of civilian injured people where both US militaries and suicide bombings caused massive injuries to civilian people.[6],[8],[9] On the contrary, gunshot wound injured patients show a big challenge to be treated well. Those patients carry high mortality and poor functional and neurological prognosis.[10] In this study, the patients have all injured civilians with different penetrating missiles.

Missile-penetrating head injuries had been classified several times; one of the former classifications was Cushing’s classification in 1917. This was based on clinical examination findings of the wound with the surgical results.[3],[7],[9] Cushing classified missile-penetrating head injuries into superficial, tangential, penetrating, and perforating types, depending on the relationship between the missile and affected skull and brain tissues.[6],[11],[12] Matson refined Cushing’s classification after World War II, then more improvement was done in the 1970s by Raimondi and Samuelsson who presented the association between neurological condition and mortality rate of civilian injured patients.[3],[6],[7]

Brain computed tomography (BCT) technology has evolved to present a better diagnostic method to assess patients with head injuries. BCT started to give both diagnostic and prognostic value to those with missile-penetrating head injuries.[7],[11],[12],[13] There are few criteria seen in BCT such as how many brain lobes are affected by missiles, the presence of intracranial bleeding, the affection of posterior fossa or brain stem, any bone fragments or missiles particles, the intraventricular hemorrhage (IVH), midline shift, and any signs of infection or possible vascular structures injuries. These variables can be very well integrated with the clinical outcome of patients.[2],[7],[11],[14]

In this study, the patients are all civilians and the authors tried to explore the relationship between BCT scan findings and clinical outcomes. The findings are basically anatomical namely how many lobes are affected and whether the posterior fossa is affected or not, or if any tract hematoma or other hemorrhage in the brain. All these variables are to be correlated with prognosis.

Aims of study

  • To explore the BCT findings of patients with missile-penetrating head injuries.


  • To study the relationship between different BCT scan findings and the prognosis.



  •   Materials and Methods Top


    Patients and study design

    This was a cohort retrospective clinical study that was completed in Karbala, Iraq between January 2005 and January 2006. The study was performed on 70 patients who presented with different missile-penetrating head injuries at Al-Hussain General Hospital (affiliated with the University of Al-Ameed). These injuries are due to blast shells or machine guns or pistols.

    Any patient under the effect of drugs, toxins, or referred from another hospital (after treating them operatively) has not been included in this study.

    All patients included in this study were admitted to the neurosurgical ward in Al-Hussain General Hospital (affiliated with the University of Al-Ameed) after performing necessary resuscitation. All patients had a proper neurological examination and the severity of injured patients is classified according to the Glasgow Coma Scale (GCS) as follows:

  • Mild head injury includes patients with a score of 13–15.


  • Moderate head injury includes patients with a score of 9–12.


  • Severe head injury includes patients with a score of ≤ 8.


  • A BCT scan was performed on all patients to show brain injuries. The BCT scan findings are classified into two major tables:

  • [Table 1] shows BCT scan anatomical findings in relation to the outcome scale. These sites can be one or two or more brain lobes or bi-hemispheric or posterior fossa involvement.


  • [Table 2] shows BCT findings of intracranial hematoma and hydrocephalus in relation to the outcome scale. The hematoma includes brain tract hematoma, IVH (intraventricular hematoma), and SDH (subdural hematoma).
  • Table 1: BCT scan findings according to the anatomical site of injury in relation to outcome scale

    Click here to view
    Table 2: BCT scan findings according to the anatomical site of injury in relation to outcome (anatomical sites collapsed)

    Click here to view


    All patients were admitted to the neurosurgical ward of the hospital; 40 patients were treated conservatively and 30 patients were treated surgically to remove the intracranial hematoma and necrotic or contused brain causing mass effect also to remove accessible bone and metal fragments with wound debridement.

    All of them received prophylactic antibiotics and anticonvulsant agents.

    The outcome was determined by neurological evaluations and classified according to the Glasgow outcome scale with some modifications, into:

  • Good recovery: patients return to preinjury level of function.


  • Moderate disability: patients have neurological deficits but can look after themselves.


  • Severe disability or vegetative state: patients are unable to look after themselves.


  • Death.



  •   Statistical analysis Top


    For statistical analysis, Pearson chi-squared tests for independence were used whenever appropriate. The significance level was set at P < 0.05. Data were analyzed using the SPSS software program, version 21.0 statistical software. To meet the assumption of the chi-square test, groups of the variables have been collapsed. Then BCT findings (both anatomical sites and hematomas) and outcome scale categories were collapsed into two groups in order not to violate the assumptions of the chi-squared test.


      Ethical consideration Top


    The study was conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki. It was carried out with patients verbal and analytical approval before the sample was taken. The study protocol and the subject information and consent form were reviewed and approved by a local ethics committee according to the document number 145 in 05/01/2005.


      Results Top


    Seventy patients who presented with missile injuries were admitted to the neurosurgical ward in Al-Hussain General Hospital (affiliated with the University of Al-Ameed). In this study, the mortality rate is 15.71% keeping in mind, all victims under drugs or toxins or referred from another hospital (after treating them operatively) are not included in this study.

    Brain computed tomography scan anatomical findings in relation to outcome scale

    In this study, 33 (47.1%) patients sustained injury to one lobe, 19 (827.1%) patients with two lobes, 6 (8.6%) patients with three lobes or more, 10 (14.3%) with bi-hemispheric injuries, and only 2 (2.9%) patients sustained an injury to posterior cranial fossa [Table 1][Table 2][Table 3] and [Figure 1]. [Table 1] and [Figure 2] represent these findings. The outcome scale appears as follows [Table 1]:
    Table 3: BCT scan findings according to the anatomical site of injury in relation to living state (anatomical sites collapsed)

    Click here to view
    Figure 1: BCT findings with hematoma in relation to outcome scale

    Click here to view
    Figure 2: BCT scan anatomical findings in relation to outcome scale

    Click here to view


  • The highest incidence rate is with one lobe injury (33) patients (47.1%). The highest mortality rate is with posterior cranial fossa injury (2) patients (100%) followed by three lobes or more injury than bi-hemispheric injuries.


  • The mortality rate of posterior cranial fossa injury is 100%.


  • The mortality rate of three lobes or more injuries is 66.7% with 23.3% of them sustained severe disability.


  • The mortality rate of bi-hemispheric injury is 50% with (40%) severe disability.


  • The least mortality rate (6.06%) appears with injury to one lobe and (87.8%) of patients showed good recovery.


  • To meet the assumption of the chi-square test, groups of the variables have been collapsed. BCT findings (anatomical sites) and outcome scale categories were collapsed into two groups in order not to violate the assumptions of the chi-squared test

    The chi-squared test showed that there is a significant association between the numbers of affected lobe and patients’ prognosis (P < 0.01).

    The chi-squared test showed that there is a significant association between numbers of affected lobes and mortality rate (P < 0.01).

    Brain computed tomography scan findings of tract hematoma with another brain hemorrhage in relation to outcome scale

    In this study, 45 (64.3%) patients presented with tract hematoma only, 9 (12.9%) patients with tract hematoma and IVH, 9 (12.9%) patients with tract hematoma and SDH, and 6 (8.5%) patients with tract hematoma and ICH [Table 4][Table 5][Table 6] and [Figure 1]. Only one patient (1.4%) presented with tract hematoma and hydrocephalus which appears later after 12 days.
    Table 4: BCT scan findings with tract hematoma and other associated hematoma in relation to outcome scale

    Click here to view
    Table 5: BCT scan findings with tract hematoma and other associated hematoma in relation to outcome scale (hematoma types collapsed)

    Click here to view
    Table 6: BCT scan findings with hematoma in relation to a living state

    Click here to view


    No death was recorded for those patients, with only tract hematoma; whereas 30 (66.7%) of them showed good recovery. Eight patients with tract hematoma and IVH; out of 9 equal to 88.9% died with only 1 patient out of 9, which is equal to 11.1% ended up with a severe disability, 2 patients with SDH out of 9 died which is equal to 22.2%.

    The least mortality rate is with tract hematoma alone, whereas the highest mortality rate is with tract hematoma and IVH.

    All patients have tract contusion: 45 (64.3%) patients have only tract contusion, 9 (12.9%) patients have contusion and IVH, 9 (12.9%) patients have contusion and SDH, 1 (1.4%) patient has contusion and hydrocephalus. The highest mortality rate is associated with IVH.

    Types of hematoma categories were collapsed into two groups in order not to violate the assumptions of the chi-squared test.

    The chi-squared test showed that there is a significant association between type of hematoma and patients’ prognosis (P < 0.01).

    The chi-squared test showed that there is a significant association between type of hematoma and living state (P < 0.01).


      Discussion Top


    The prognosis of patients with missile-penetrating head injuries is variable; however, this depends on many factors such as the severity of the head injury, the age, the other systemic injury, and other factors.[4],[10],[13],[14],[15],[16],[17],[18],[19] Few studies showed the mortality rate of missile-penetrating head injuries varies between 10% and 40%, whereas gunshot head injuries in civilians can be as high as 53.5%–88%.[11],[19],[20]

    In this study, the mortality rate is 15.71% keeping in mind; all victims under drugs or toxins or referred from another hospital (after treating them operatively) are not included in this study. This result is almost similar to other studies since missiles are small particles with a less damaging effect on the brain in comparison to direct gunshot injuries where the mortality rate is higher as seen in other studies.[3],[10],[11] The type of missiles might affect patients’ outcomes; in this study, the victims are civilians and the injury is almost because by suicide bombing which causes different shapes of missiles but they carry less damaging influence than a direct gunshot.

    All patients were subjected to a BCT scan for diagnostic evaluation since it is an easier mode of diagnosis but this added more prognostic value later in patients’ management. Moreover, CT scan pictures usually reveal hemorrhagic tracts, intracerebral hemorrhage, midline shift, and metallic or bone fragments or air or skull fractures.[8],[11],[17],[20]

    In this study, patients with posterior cranial fossa injury as seen in BCT carry the highest mortality rate. This has been demonstrated by other studies as well which can be explained as there are vital structures such as the brain stem in this dangerous anatomical area, which can be a leading cause of death.[5],[11],[13],[14],[17],[21],[22] In addition, bi-hemispheric or more than two lobes’ injuries show a worse prognosis with severe disability or vegetative status patients as seen in other studies.[5],[11],[13],[14],[21],[22],[23] This is mostly because of possible damage of deep structures such as the hypothalamus or thalamus or indirectly by cavitation effect to damage the brain stem.

    The affection of more than one lobe or bi-hemispheric indicates enough energy of the object to enter and cause injury to more than one lobe which correlates positively with damage that happens to the brain with more possibility to affect vital structures such as the hypothalamus or thalamus or indirectly by cavitation effect to affect brain stem. Pabuscu et al.[11] presented in their study a few poor prognostic variables including IVH; in this study, almost the same result was obtained since patients with IVH displayed the worse prognosis.[3],[10],[13],[15],[17],[20],[22],[24],[25],[26] All patients showed tract hematoma in this study which is expected as well in any missile-penetrating head injury; nevertheless, interestingly this sign displayed a good prognosis if it is alone but if it is combined with another intracranial hemorrhage, the prognosis would be worse. This finding was not shown clearly in other studies apart from the fact of a worse prognosis relationship to ICH.[7],[12],[14],[15],[18]

    Unfortunately, BCT fails to show vascular injury[17],[22],[23] and this was not seen in this study however other studies demonstrated post-traumatic aneurysm or other vascular injuries using BCT angiography.[27]

    Study limitations

    1. Retrospective study.


    2. Single-center study.



      Conclusion Top


    Penetrating head injury is a challenging problem and carries high mortality and morbidity rate. Missile injuries in civilian settings appear to be less damaging than in war. BCT scan is essential in both diagnosis and prognosis of patients with missile-penetrating head injury. IVH and posterior fossa injury lead to the highest mortality rate.

    Data availability statement

    The data analyzed during this study are available from the corresponding author (Dr. Husam Ghazi Al-Anbari, e-mail: [email protected]) upon request.

    Acknowledgement

    The authors extend their gratitude to all medical staff at Al-Hussain General Hospital (affiliated to University of Al-Ameed) for their participation and support for this study.

    Financial support and sponsorship

    Not applicable.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    Paciaroni M, Arnao V Neurology and war: From antiquity to modern times. Front Neurol Neurosci 2016;38:1-9.  Back to cited text no. 1
        
    2.
    Agarwalla PK, Dunn GP, Laws ER An historical context of modern principles in the management of intracranial injury from projectiles. Neurosurg Focus 2010;28:E23.  Back to cited text no. 2
        
    3.
    Carey ME Cushing and the treatment of brain wounds during world war I. J Neurosurg 2011;114:1495-501.  Back to cited text no. 3
        
    4.
    Kaufman HH, Schwab K, Salazar AM A national survey of neurosurgical care for penetrating head injury. Surg Neurol 1991;36:370-7.  Back to cited text no. 4
        
    5.
    de Lanerolle NC, Kim JH, Bandak FA Neuropathology of traumatic brain injury: Comparison of penetrating, nonpenetrating direct impact and explosive blast etiologies. Semin Neurol 2015;35:12-9.  Back to cited text no. 5
        
    6.
    Kinsman M, Pendleton C, Quinones-Hinojosa A, Cohen-Gadol AA Harvey Cushing’s early experience with the surgical treatment of head trauma. J Hist Neurosci 2013;22:96-115.  Back to cited text no. 6
        
    7.
    Alvis-Miranda HR, M Rubiano A, Agrawal A, Rojas A, Moscote-Salazar LR, Satyarthee GD, et al. Craniocerebral gunshot injuries: A review of the current literature. Bull Emerg Trauma 2016 4:65-74.  Back to cited text no. 7
        
    8.
    Ramasamy A, Harrisson SE, Stewart MP, Midwinter M Penetrating missile injuries during the Iraqi insurgency. Ann R Coll Surg Engl 2009;91:551-8.  Back to cited text no. 8
        
    9.
    Breeze J, Bowley DM, Harrisson SE, Dye J, Neal C, Bell RS, et al. Survival after traumatic brain injury improves with deployment of neurosurgeons: A comparison of US and UK military treatment facilities during the Iraq and Afghanistan conflicts. J Neurol Neurosurg Psychiatry 2020;91:359-65.  Back to cited text no. 9
        
    10.
    Gressot LV, Chamoun RB, Patel AJ, Valadka AB, Suki D, Robertson CS, et al. Predictors of outcome in civilians with gunshot wounds to the head upon presentation. J Neurosurg 2014;121:645-52.  Back to cited text no. 10
        
    11.
    Pabuscu Y, Bulakbasi N, Kocaoglu M, Ustünsöz B, Tayfun C A different approach to missile induced head injuries. Comput Med Imaging Graph 2003;27:397-409.  Back to cited text no. 11
        
    12.
    Wyck DV, Grant G, Laskowitz D. Penetrating traumatic brain injury: A review of current evaluation and management concepts. J Neurol Neurophysiol2015;6:6.  Back to cited text no. 12
        
    13.
    Splavski B, Vranković D, Saftić R, Muzević D, Kosuta M, Gmajnić R [Clinical predictors correlated to outcome of war missile penetrating brain injury]. Acta Med Croatica 2006;60:369-73.  Back to cited text no. 13
        
    14.
    Smith JE, Kehoe A, Harrisson SE, Russell R, Midwinter M Outcome of penetrating intracranial injuries in a military setting. Injury 2014;45:874-8.  Back to cited text no. 14
        
    15.
    Weisbrod AB, Rodriguez C, Bell R, Neal C, Armonda R, Dorlac W, et al. Long-term outcomes of combat casualties sustaining penetrating traumatic brain injury. J Trauma Acute Care Surg 2012;73:1525-30.  Back to cited text no. 15
        
    16.
    Zafonte RD, Wood DL, Harrison-Felix CL, Valena NV, Black K Penetrating head injury: A prospective study of outcomes. Neurol Res 2001;23:219-26.  Back to cited text no. 16
        
    17.
    Solumsmoen S, Lilja-Cyron A, Buch KF, Kelsen J [Traumatic penetrating brain injury]. Ugeskr Laeger. 2018;180:V03180201.  Back to cited text no. 17
        
    18.
    Vrankovic D, Splavski B, Hecimovic I, Glavina K, Dmitrovic B, Mursic B Analysis of 127 war inflicted missile brain injuries sustained in north-eastern Croatia. J Neurosurg Sci 1996;40:107-14.  Back to cited text no. 18
        
    19.
    Eftekhar B, Sahraian MA, Nouralishahi B, Khaji A, Vahabi Z, Ghodsi M, et al. Prognostic factors in the persistence of posttraumatic epilepsy after penetrating head injuries sustained in war. J Neurosurg 2009;110:319-26.  Back to cited text no. 19
        
    20.
    Martins RS, Siqueira MG, Santos MT, Zanon-Collange N, Moraes OJ Prognostic factors and treatment of penetrating gunshot wounds to the head. Surg Neurol 2003;60:98-104; discussion 104.  Back to cited text no. 20
        
    21.
    Zafonte RD, Wood DL, Harrison-Felix CL, Millis SR, Valena NV Severe penetrating head injury: A study of outcomes. Arch Phys Med Rehabil 2001;82:306-10.  Back to cited text no. 21
        
    22.
    Besenski N, Jadro-Santel D, Jelavić-Koić F, Pavić D, Mikulić D, Glavina K, et al. Ct analysis of missile head injury. Neuroradiology 1995;37:207-11.  Back to cited text no. 22
        
    23.
    Kim PE, Zee CS The radiologic evaluation of craniocerebral missile injuries. Neurosurg Clin N Am 1995;6:669-87.  Back to cited text no. 23
        
    24.
    Mahoney PF, Carr DJ, Miller D, Teagle M The effect of helmet materials and simulated bone and tissue layers on bullet behaviour in a gelatine model of overmatch penetrating head injury. Int J Legal Med 2017;131:1765-76.  Back to cited text no. 24
        
    25.
    Mackerle Z, Gal P Unusual penetrating head injury in children: Personal experience and review of the literature. Childs Nerv Syst 2009;25:909-13.  Back to cited text no. 25
        
    26.
    Amirjamshidi A, Abbassioun K, Rahmat H Minimal debridement or simple wound closure as the only surgical treatment in war victims with low-velocity penetrating head injuries. Indications and management protocol based upon more than 8 years follow-up of 99 cases from Iran–Iraq conflict. Surg Neurol 2003;60:105-10; discussion 110–1.  Back to cited text no. 26
        
    27.
    Dubey A, Sung WS, Chen YY, Amato D, Mujic A, Waites P, et al. Traumatic intracranial aneurysm: A brief review. J Clin Neurosci 2008;15:609-12.  Back to cited text no. 27
        


        Figures

      [Figure 1], [Figure 2]
     
     
        Tables

      [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



     

    Top
     
      Search
     
        Similar in PUBMED
       Search Pubmed for
       Search in Google Scholar for
     Related articles
        Access Statistics
        Email Alert *
        Add to My List *
    * Registration required (free)  

     
      In this article
    Abstract
    Introduction
    Materials and Me...
    Statistical analysis
    Ethical consider...
    Results
    Discussion
    Conclusion
    References
    Article Figures
    Article Tables

     Article Access Statistics
        Viewed78    
        Printed8    
        Emailed0    
        PDF Downloaded17    
        Comments [Add]    

    Recommend this journal