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

Abstract

Background: Principles of treating war-related penetrating brain injury had been developed long time ago. Some neurosurgeons advocate the traditional surgical repair with thorough debridement and tight closure especially the dura. Other minimalists prefer simple wound closure. Aim: Presentation of 28 patients with penetrating brain injury who had been surgically treated during Syrian conflict. The author reviews related literature and compares between minimal and traditional approaches. Methods: A descriptive study of 28 patients who had been operated in North Syria during March-April 2013. Operative technique included thorough debridement, removal of accessible in-driven bone fragments and foreign bodies, hemostasis, watertight repair of the dura and scalp closure. Karnofsky score and Glasgow Outcome scale were used for outcome assessment. Results: We performed 30 operations in 28 patients (24 males / 4 females). Age was 22±15 years (range 3-55). At admission, Glasgow Coma Score of 15-13 was (35.7%), 12-9 was (21.4%), and 8-3 was (42.9%). Outcome evaluation after 1 month showed good recovery in (39.3%), moderate recovery in (21.4%), severe disability in (28.6%), vegetative states in (3.6%), and death in 2 (7.1%). Complications were very minor (10.7% superficial infection). Two patients needed reoperation; 1 for bullet removal and the other for evacuation of collected hematoma. Conclusion: Minimal brain debridement is more likely to require an additional debridement and may result in higher incidence of life-threatening CSF leak or fatal meningitis. Adequate debridement, removal of bone chips, foreign bodies, and tight closure of the dura should be performed in penetrating brain injury.