Surgical management of battle gunshot injuries to the dural venous sinuses, combined with brain injury: an analysis of series of observations
Keywords:combat head injury, venous sinus injury, superior sagittal sinus
The present study aimed to summarize the literature data about wounds to the dural venous sinus (DVS) and validating the importance of surgery in a series of clinical observations in patients with craniocerebral gunshot wound (CGW) sustained in battles with the DVS wound.
Materials and methods. We conducted a retrospective analysis of the clinical records and long-term outcomes in patients who were admitted to our medical center from 05/2014 to 12/2017. The study included soldiers with gunshot DVS wounds sustained in battles, who presented with the Glasgow Coma Scale (GCS) score ≥4. Upon admission, damage to the DVS was diagnosed based on spiral computed tomography (SCT) imaging and/or was identified during surgery. All the patients underwent SCT imaging on admission and 12 hours after surgery. When severe damage to the DVS was suspected, cerebral angiography (CAG) was performed. The age, initial GCS score, the Injury Severity Score, location and nature of injuries to the DVS, the location and nature of brain injury, the volume of surgical interventions and the presence of complications in a postoperative period were taken into account. The outcome data included an assessment of the Glasgow Outcome Scale (GOS) in 6 and 12 months.
Results. Of 241 patients with CGW sustained in battles, 21 (8.7 %) presented with wounds to the DVS. The average initial GCS score was 10.0 ± 3.7. Superior sagittal sinus wound was identified in 20 (95.2%) patients and straight sinus wound – in one (4.8 %) patient. Wound to one DVS wall was identified in 15 (68.2 %) cases, wound to two DVS walls – in five (22.7 %) cases, and complete DVS damage (transection) – in two (9.1 %) cases. Twenty (95.2 %) patients presented with DVS wound combined with brain injury: one in the lobe in 10 (47.6 %) patients and ≥2 lobes in 10 (47.6 %) patients. All the patients underwent surgery. CAG was performed in five (23.8 %) patients. DVS ligation was performed in four (19 %) patients.
Five (23.8 %) patients had meningitis, three (14.3 %) patients died. After 6 months, five (23.8 %) patients recovered well (GOS score of 5), 12 (57.1 %) had moderate disability (GOS of 4), and one (4.8%) had severe disability. The significant factors of good outcome within 6 months after the injury were age (P = 0.04) and GCS score on admission (P = 0.01).
Conclusions. The DVS repair via surgery in case of concomitant brain matter injury must be performed very cautiously because of a high risk of developing hemorrhagic complications due to early use of anticoagulants. The feasibility of surgical DVS repair in case of transection can be assessed in large neurosurgical centers for such pathology management to obtain more data.
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