Penetrating craniocerebral injuries in the Israeli involvement in the Lebanese conflict, 1982–1985

Abstract

From June, 1982, through June, 1985, 113 patients were evacuated to Rambam Maimonides Medical Center with penetrating craniocerebral injuries sustained in ongoing military hostilities in Lebanon. Two factors distinguished this group of patients from those presenting in earlier conflicts: 1) this was the first large series in which computerized tomography (CT) was routinely used to initially evaluate combat head injuries; and 2) in an effort to preserve maximum cerebral tissue, intracranial debridement was significantly less vigorous than that advocated during the Korean or Vietnam conflicts. No efforts were made to locate or remove in-driven bone or metal fragments visualized on CT unless they readily presented themselves on gentle irrigation. In fact, it was elected to treat a number of patients without intracranial hematomas nonoperatively. The acute outcome was quite similar to that reported in Vietnam series in respect to both complications and mortality. Of the 83 survivors, 46 were Israeli citizens and thus were available for follow-up review. These 46 patients were reevaluated in late 1988, a mean follow-up period of 5.9 years. None had died in the interim; 10 had developed chronic seizure disorders, and there was one case of delayed meningitis in a patient with no retained fragments. Repeat CT scans were performed on 43 patients; 22 (51%) were found to have retained intracranial bone fragments. No relationship existed between the presence of retained fragments and the development of either a seizure disorder or an infection of the central nervous system. These findings suggest that not only is it unnecessary to reoperate for retained bone fragments, but it may also be possible to temper the initial debridement in an effort to preserve additional cerebral tissue.

An historical context of modern principles in the management of intracranial injury from projectiles

“…Outcomes were similar to Vietnam-era patient series and most interestingly, long-term incidence of postoperative seizures or infection due to retained fragments was low. 8 A similar conclusion was obtained from a large series of patients suffering from low-velocity penetrating head injuries in the Iran-Iraq conflict.…”

“…Although Hammon 36,37 echoed the need for aggressive debridement based on his large series from the Vietnam War, other studies since that time have shown the benefits of a more limited debridement. 8 In particular, Brandvold et al 8 studied 113 patients in Israel during the Lebanese conflict from 1982 to 1985. With the advent of CT imaging, a less aggressive surgical debridement was studied in which patients underwent initial simple debridement with no specific effort to remove indriven bone or metal fragments identified on CT unless easily accessible by gentle irrigation.…”

High-Velocity Gunshot Wounds to the Head: Analysis of 135 Patients

“…17) Recently, the suggested treatment for missile or shrapnel head wounds has been divided into four groups: Large craniotomy or craniectomy and aggressive deep debridement, no surgical operation, minimal or superficial debridement, and simple debridement of the entrance gutter through a small craniotomy. 6,10,15,33,40) There is no consensus about the surgical indications or aggressiveness because of the great number of variables to be considered, such as the number and distribution of fragments, the occurrence of different types of lesions caused by different types of missiles and shrapnel particles, and the involvement of eloquent areas. Only superficial debridement of the entrance gutter and closure of the wound has been suggested.…”

Epilepsy Related to Traumatic Brain Injury

“…Based on epidemiologic studies on civilian or military populations, most of which were conducted before modern imaging era, the risk factors for PTE include old age, penetrating injuries, injury severity (GCS<10), biparietal or multiple contusions, intracranial hemorrhage, frontal or temporal location of the lesion, >5 mm brain midline shift, duration of coma >24 h, loss of consciousness >24 h, prolonged length of posttraumatic amnesia, multiple intracranial procedures, and the occurrence of early post-traumatic seizures [10,[12][13][14][15][16][17]. Related to methodology, many of the identified risk factors directly or indirectly reflect the severity of brain injury, and strengthen the view that the risk for PTE increases with the severity of TBI.…”