Lessons Learned from War: A Comprehensive Review of the Published Experiences of the Iranian Neurosurgeons During the Iraq-Iran Conflict and Review of the Related Literature

Abstract

Abstract:Background: The present study was aimed to review the articles published by Iranian neurosurgeons regarding their experiences during Iraq-Iran 8-year conflict and compare it with reports from other conflicts. Methods: The relevant papers and studies, published up to December 2011, were searched from three databases including MEDLINE, and two Iranian databases of Iran Medex and Scientific Information Database with the keywords Iran, Iraq, conflict, battle, war, traumatic aneurysm (TA), post-traumatic epilepsy (PTE), brain infection, penetrating head wound (PHW), cerebrospinal fluid (CSF) leakage, spine injury and peripheral nerve injury. Results: A total of twenty-eight papers were found that presented PHW, development of TA, infections, PTE and peripheral nerve injuries. There were two different protocols for management of PHWs: radical surgery and minimal debridement protocol. The overall CNS infection rate was 10%. The cumulated incidence of TA was 6%. Conclusion: Conservative minimal debridement of the wounds was indicated in patients with small entrance wounds, or those with GCS greater than or equal 8 and no progressive neurological deficit. To diagnose TA before rupture angiography was performed in patients with shells or bone fragments, passed through the crowded vasculature, or with large/delayed hematoma, or if the surgeon had high index of suspicion based on neuroimaging and early debridement surgery. Surgery in a well-equipped nearby hospital after quick and safe evacuation of the victims by trained-salvaging-ancillary groups, administration of broad-spectrum antibiotics and proper antiepileptic drugs decreased the morbidity and mortality of casualties after PHW in war situations. The biases of the case selection, data collection, confounders and decreasing biases by conducting blinded controlled clinical trials were discussed.

Traumatic pseudoaneurysms of the head in war time: report of two unusual cases

“…The lesion was explored and removed by excision under local anesthesia. The histological examination of the aneurysm showed no vessel wall layer and it was diagnosed as a pseudoaneurysm ( Figure 3A-C (22). After that report, we found one TICA (9), and one TECA on STA 21; and a series of 11 patients with 13 TECAs reported by Cox et al which was dismissed in that study (12).…”

“…The limitation of the first case reported here was not to use CT-angiography or DSA for detecting any possible vascular injury. Doppler ultrasonography (DU) and/or CT-angiography may be sufficient for detecting STA aneurysm (19,22). In the second case, CTangiography definitely revealed a pseudoaneurysm of the STA.…”

“…Gunshot wound or blast injury to head may cause traumatic extra-(TECA) or intracranial pseudoaneurysm (TICA) (5). Combat-related traumatic aneurysms located on the distal middle cerebral artery (MCA) or on the superficial temporal artery (STA) are rarely seen (5,12,22). We found only eight cases of pseudoaneurysm located on the distal MCA (M4) and six cases of pseudoaneurysm located on the STA following a gunshot or blast injury in the literature (Table I).…”

Treatment of War-related Penetrating Brain Injury during Syrian Conflict: Importance of Debridement and Meticulous Closure

“…Brandvold et al, in long-term analysis of Israeli survivors found that 48% had retained in-driven intracranial bone and further questioned the need to aggressively remove all penetrating fragments (8) . The Iran-Iraq war also led to a wealth of published data, including reports on the causes of infections and the vascular complications of penetrating head injuries (7,9,10) . Closed head injury data from bomb blasts in the Lebanon conflict, and later from the Iraq conflict emphasize the complexity of blast injuries, which combine the elements of both penetrating and blast effects (11) .…”

“…More recently, some reports have appeared wherein wartime brain wounds have been treated by minimal brain debridement with little or no attention to tight dural closure. Many of these reports claimed that debridement would also affect partially devitalized adjacent brain tissue, and might have led to additional neurologic deficits or lesser degree of recovery of functions (8)(9)(10)12) . The aim of this paper is to present the experience with the management of a group of patients with warrelated penetrating brain injuries during the Syrian conflict in early 2013.…”