Combat Cranial

Operations
Syah Reza Manefo

Neurosurgery Department
Faculty of Medicine
Padjadjaran University
RSHS Bandung 2022
 INTRODUCTION
This chapter covers the procedure for a large
hemicraniectomy following severe penetrating
combat trauma with massive soft tissue
involvement

Combat Injuries Massive soft tissue/bone/brain injury, gross

contamination (often with aggressive organisms), concurrent
injuries to face/neck/extremities/trunk, and extended patient
transfers

Major goals of surgery  Removal of contaminants (including

devitalized tissue), brainstem decompression, hemostasis, skull base
reconstruction (with obliteration of air- filled sinuses), dural coverage,
soft tissue coverage, and stabilization for transport with appropriate
monitoring in place and functioning
 INDICATIONS
Combat operations
Absence of major disruption of
Blunt trauma with midline deep cerebral nuclei in
the region of the sella (zona
• Severe penetrating significant mass effect fatalis). Disruption of the zona
fatalis (associated with Glasgow
trauma from hemispheric Coma Scale (GCS) 3) relative
swelling or hematoma contraindication to operative
intervention

• Low GCS score (5) is not necessarily a

contraindication to surgical intervention.
• Pupillary asymmetry or dilation  Traumatic
iridoplegia or chemical irritation. The overall
clinical picture and wounding history must be
taken into account before m aking a decision
to categorize a patient as expectant.
 PREPROCEDURE CONSIDERATIONS
Consultation/Teamwork
• Successful management in combat
operations Multidisciplinary effort
• Multiple surgical specialists are often
involved(anesthesiology, nursing, and
laboratory/blood bank). A single patient
may present with an extremity
amputation, an abdominal
penetration, exposed brain, a partially
enucleated globe, and severe soft
tissue/bone loss involving the
maxilla, requiring simultaneous
evaluation and surgical management by
five specialists.
Radiographic Imaging
• Computed tomography (CT) scan is routinely
available at the medical facilities
• Angiography is not routinely available. Where
angiographic capability is available in theater, it
has proven useful in the management of
penetrating trauma of the neck and head.
Angiography is often performed (Blunt or
penetrating mechanism) —due to the increased
incidence of vasospasm associated with blast-
related trauma, even in the absence of cranial
penetration.
PREPROCEDURE CONSIDERATIONS
Radiographic Imaging
 MEDICATION

• Recommend antibiotic prophylaxis with Cefazolin.

Prophylaxis typically is continued until 24 hours following
removal of EVD or (ICP) monitor, or a total of 48 hours if no
such devices are present.
• Coverage with Gentamicin and Penicillin gross
contamination is present. Patients allergic to penicillin
Vancomycin and Ciprofloxacin.
• Seizure prophylaxis with Diphenylhydantoin is initiated
preoperative
 PREPROCEDURE CONSIDERATIONS
Radiographic Imaging Intracranial Blunt Injury

Dissection
All patients suspected of having an intracranial dissection should undergo a CTA or MRA as a
first-line imaging modality. However, if a dissection is strongly suspected, conventional
angiography remains the gold standard.

Aneurysm
◦ CTA is the recommended screening modality. However, traumatic aneurysms are often
located distally and can be dangerous even when 3 mm . These two features render CTA less
reliable.
◦ Angiography is recommended for all patients in whom a traumatic aneurysm is
suspected.
 PREPROCEDURE CONSIDERATIONS
Radiographic Imaging Intracranial Blunt Injury

Arteriovenous fistula

◦ Angiography is the gold standard to image arteriovenous fistulas

◦ CTA and MRA are static studies.
 PREPROCEDURE CONSIDERATIONS
Radiographic Imaging Intracranial Penetrating Injury

• A screening CTA or MRA (unless contraindicated) should be performed

for any patient presenting with penetrating head injury.
• Metallic foreign bodies may compromise CT images secondary to scatter
artifact
• MRI and MRA are useful in cases of a wooden foreign body injury, as it
is difficult to visualize wooden material on a CT
• Repeat, delayed angiography should be performed 3 to 6 months later
for patients in whom an arteriovenous fistula is suspected
Management Extracranial Blunt Injury
Management Extracranial Penetrating Injury
Management Intracranial Blunt Injury
Management Intracranial Penetrating Injury
 OPERATIVE PROCEDURE

Positioning Skin incision Initial dissection

Proximal and Distal Carotid Artery

Repair of Arterial Injury Control Dissection
 OPERATIVE PROCEDURE

Place a roll between the shoulder blades to extend the patient’s neck, and rotate the patient’s head away
from the side of injury
Make a longitudinal incision along the anterior border of SCM.
Use monopolar cautery to divide the platysma muscle. Mobilize and retract the sternocleidomastoid muscle
laterally. Ligate and divide the transverse facial vein
Use both blunt and sharp dissection to expose the carotid sheath.
Once the ICA distal to the injury and the CCA or ICA proximal to the injury have been exposed, place
either a clamp or an aneurysm clip on the artery in each location.
Repair the arterial injury primarily, when possible, with a running 6-0 nonabsorbable polypropylene mono
lament stitch.
Remove the arterial clamps in the following order: ECA, CCA, and ICA
 POSTOPERATIVE MANAGEMENT
Monitoring

• All patients with cerebrovascular injuries should be monitored in a neurologic intensive care
unit during the acute phase, with frequent neurologic examinations, vital sign monitoring, and
daily laboratory studies.
• Blood pressure monitoring wIth an arterial line is preferable for patients with labile blood
pressure or for those requiring continuous medication infusions for blood pressure control.
• The need for invasive intracranial monitoring is dictated by standard neurosurgical criteria
(e.g., for patients w ith elevated intracranial pressure due to head injury).
 POSTOPERATIVE MANAGEMENT
Medication

• Antithrombotic therapy with aspirin (325 m g daily) is indicated for most patients with
traumatic cerebrovascular injury.
• More aggressive antithrombotic therapy, with systemic anticoagulation, may be
necessary for patients with significant intraluminal arterial or venous thrombosis.
• Dual antiplatelet therapy (e.g., aspirin and clopidogrel) is necessary for all patients
receiving a vascular stent.
• In most cases, antithrombotic therapy for 3 months is appropriate.
 POSTOPERATIVE MANAGEMENT

Radiographic Imaging
Follow -up imaging of traumatic cerebrovascular lesions w ith CTA at a 3- to 6-month interval is
useful to monitor dissections and to check for the development or progression of traumatic
aneurysms.
Further management

An outpatient clinic follow-up evaluation should be completed 3 to 6 months after discharge..

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