1Division of Neurosurgery, University of Stellenbosch; and.
2Division of Epidemiology and Biostatistics, Department of Global Health, University of Stellenbosch, Western Cape, South Africa; and.
J Neurosurg. 2020 Jun 19;134(5):1658-1666. doi: 10.3171/2020.4.JNS20122. Print 2021 May 1.
While high-velocity missile injury (gunshot) is associated with kinetic and thermal injuries, non-missile penetrating head injury (NMPHI) results in primary damage along the tract of the piercing object that can be associated with significant secondary complications. Despite the unique physical properties of NMPHI, factors associated with complications, expected outcomes, and optimal management have not been defined. In this study, the authors attempted to define those factors.
Consecutive adult patients with NMPHI who presented to Tygerberg Academic Hospital (Cape Town, South Africa) in the period from August 1, 2011, through July 31, 2018, were enrolled in a prospective study using a defined treatment algorithm. Clinical, imaging, and laboratory data were analyzed.
One hundred ninety-two patients (185 males [96%], 7 females [4%]) with 192 NMPHIs were included in this analysis. The mean age at injury was 26.2 ± 1.1 years (range 18-58 years). Thirty-four patients (18%) presented with the weapon in situ. Seventy-one patients (37%) presented with a Glasgow Coma Scale (GCS) score of 15. Weapons included a knife (156 patients [81%]), screwdriver (18 [9%]), nail gun (1 [0.5%]), garden fork (1 [0.5%]), barbeque fork (1 [0.5%]), and unknown (15 [8%]). The most common wound locations were temporal (74 [39%]), frontal (65 [34%]), and parietal (30 [16%]). The most common secondary complications were vascular injury (37 patients [19%]) and infection (27 patients [14%]). Vascular injury was significantly associated with imaging evidence of deep subarachnoid hemorrhage and an injury tract crossing vascular territory (p ≤ 0.05). Infection was associated with delayed referral (> 24 hours), lack of prophylactic antibiotic administration, and weapon in situ (p ≤ 0.05). A poorer outcome was associated with a stab depth > 50 mm, a weapon removed by the assailant, vascular injury, and eloquent brain involvement (p ≤ 0.05). Nineteen patients (10%) died from their injuries. The Glasgow Outcome Scale (GOS) score was linearly related to the admission GCS score (p < 0.001). One hundred forty patients (73%) had a GOS score of 4 or better at discharge.
The most common NMPHI secondary complications are vascular injury and infection, which are associated with specific NMPHI imaging and clinical features. Identifying these features and using a systematic management paradigm can effectively treat the primary injury, as well as diagnose and manage NMPHI-related complications, leading to a good outcome in the majority of patients.
高速弹丸伤（枪伤）与动能和热损伤有关，而非弹丸穿透性头部损伤（NMPHI）会沿穿透物体的轨迹造成原发性损伤，可能导致严重的继发性并发症。尽管 NMPHI 具有独特的物理特性，但与并发症、预期结果和最佳治疗相关的因素尚未确定。在这项研究中，作者试图确定这些因素。
连续纳入 2011 年 8 月 1 日至 2018 年 7 月 31 日期间在南非开普敦 Tygerberg 学术医院就诊的 NMPHI 成年患者，使用既定的治疗算法进行前瞻性研究。分析临床、影像学和实验室数据。
本分析纳入了 192 例（185 例男性[96%]，7 例女性[4%]）NMPHI 患者。受伤时的平均年龄为 26.2±1.1 岁（18-58 岁）。34 例（18%）患者的武器仍在原位。71 例（37%）患者格拉斯哥昏迷量表（GCS）评分为 15 分。武器包括刀（156 例[81%]）、螺丝刀（18 例[9%]）、钉枪（1 例[0.5%]）、园艺叉（1 例[0.5%]）、烧烤叉（1 例[0.5%]）和未知（15 例[8%]）。最常见的伤口部位是颞部（74 例[39%]）、额部（65 例[34%]）和顶叶（30 例[16%]）。最常见的继发性并发症是血管损伤（37 例[19%]）和感染（27 例[14%]）。血管损伤与影像学证据表明存在深度蛛网膜下腔出血和损伤轨迹穿过血管区域显著相关（p≤0.05）。感染与延迟转诊（＞24 小时）、未预防性使用抗生素以及武器仍在原位有关（p≤0.05）。较差的预后与刺伤深度＞50mm、凶器被攻击者移除、血管损伤和语言相关脑区受累有关（p≤0.05）。19 例（10%）患者因伤死亡。格拉斯哥结局量表（GOS）评分与入院时 GCS 评分呈线性相关（p＜0.001）。出院时 140 例（73%）患者的 GOS 评分为 4 分或更高。
NMPHI 最常见的继发性并发症是血管损伤和感染，这些并发症与特定的 NMPHI 影像学和临床特征相关。识别这些特征并使用系统的管理模式，可以有效地治疗原发性损伤，以及诊断和治疗 NMPHI 相关并发症，从而使大多数患者获得良好的预后。
