Abstract
Context
Penetrating craniocerebral injury associated with depressed skull fracture is an infrequent yet timely neurosurgical emergency. Such injury frequently occurs in the frontal region during traffic accident or stone throw in the civilian setting. As military neurosurgeons, we present our experience in the surgical debridement and reconstruction of this peculiar type of traumatic brain injury.
Methods
The patient lies supine, the head in neutral position heal by a Mayfield head clamp. The first step is the debridement of the frontal wound. Then, the depressed skull fracture is operated on using a tailored coronal approach through Merkel dissection plane, in order to keep a free pericranial flap. The bone flap is cut around the depressed skull fracture. Neuronavigation allows to locate the frontal sinus depending on whether it has been breached and thus requires cranialization. Brain and dura mater debridement and plasty are performed. Cranioplasty is performed using either native bone fragments fixed with bone plates or tailored titanium plate if they are too damaged.
Conclusion
Performing wounded skin closure first and then a tailored coronal approach with free pericranial flap and a craniotomy encompassing the depressed skull fracture allows to treat frontal penetrating craniocerebral injury in an easy-to-reproduce manner.
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The patients have given their written consent for publication of these cases. This study was conducted in accordance with the Declaration of Helsinki of 1964 and any of its further amendments.
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Comments
1. Try not to waste time on surgical indication in face with penetrating craniocerebral injury with depressed skull fracture.
2. Carefully analyze preoperative CT scan looking for involvement of superior sagittal sinus or frontal sinuses.
3. Performing debridement and closure of the wounded skin first may help you to have a clean surgical field later on.
4. The coronal approach can be tailored to the location of the frontal fracture.
5. Dissection in the Merkel’s subgaleal plane can help you preserving an autologous pericranial flap.
6. The use of intraoperative navigation can help localizing the frontal sinuses, the superior sagittal sinus, and also superficially located parenchymal debris.
7. Cutting a too large bone flap encompassing all the bone fragments may help you for the upcoming cranioplasty.
8. Do not hesitate to perform concomitant aggressive cranialization of the frontal sinuses.
9. You may take your time during noble surgical steps such as superficial parenchymal exploration looking for all the accessible debris, and watertight dura mater closure.
10. Titanium mesh may be helpful for single-staged cranioplasty in case of too soiled or comminuted fracture.
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Beucler, N., Rambolarimanana, T. How I do it: single-staged emergency neurosurgical management of frontal penetrating craniocerebral injury with depressed skull fracture. Acta Neurochir 166, 47 (2024). https://doi.org/10.1007/s00701-024-05941-2
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DOI: https://doi.org/10.1007/s00701-024-05941-2