| Abstract | Retrospektivno su analizirani rezultati liječenja 116 ranjenika sa penetrantnim kraniocerebralnim ranama uzrokovanih projektilom, koji su nakon ranjavanja primarno zbrinuti u Odjelu za neurokirurgiju KB Osijek, u periodu od 1991. do 1996. godine. Cilj istraživanja je bio utvrđivanje prognostičke vrijednosti kliničkih i radiografskih pokazatelja u ranjenika sa strijelnim kraniocerebralnim ozljedama (KCO), radi određivanja dostatno točnog prognoziranja preživljavanja i neurološkog oporavka, posebice ranjenika s teškim KCO. Neurokirurško liječenje ranjenika sa strijelnim KCO opravdano je ako je vrijednost GCS skora veća od 4, a zjenice nisu obostrano proširene i ukočene (u istraživanoj skupini preživjelo je 72%, a dobar oporavak polučen je u 28% ovakvih slučajeva), dočim je upitna učinkovitost neurokirurškog liječenja ranjenika s vrijednostima GCS skora 3 i 4, u kojih su obje zjenice proširene i ukočene. Dostatno točno razlučivanje ranjenika koji će umrijeti, od onih koji će preživjeti, nije bilo moguće isključivo temeljem vrijednosti GCS skora. Jedino su obostrano proširene i ukočene zjenice dostatno točno upućivale na smrtni ishod istraživanih ranjenika. Preživjelo je 40% ranjenika s oštećenjem obje mozgovne polutke, 31% ranjenika s multilobarnim oštećenjima i 23% ranjenika s penetracijom projektila kroz mozgovne klijetke, te 17% ranjenika s potpunom ili jednostranom obliteracijom mezencefaličke cisterne. Vjerojatnost umiranja bila je povećana u ranjenika s intraparenhimskim pneumokranijem. Prognoza preživljavanja istraživanih ranjenika isključivo temeljem radiografskih (CT) pokazatelja nije bila dostatno točna, i nije bilo moguće točnije predviđati preživljavanje temeljem samo jednog od radiografskih pokazatelja. Dobar ishod liječenja (GOS 4 i 5) bio je značajno manje vjerojatan u istraživanih ranjenika s vrijednostima GCS skora manjim od 9 i u ranjenika s poremećajima inervacije zjenica, te u onih s radiografskim pokazateljima opsežnih mozgovnih oštećenja (projektilna penetracija kroz sagitalnu i koronarnu ravninu endokranija; bihemisferalna, multilobarna i transventrikulska oštećenja; intraventrikulsko i subarahnoidalno krvarenje (Fischer 3 i 4); brojni sekundarni projektili), kao i u onih s radiografskim pokazateljima povišenja intrakranijskog tlaka (intrakranijski hematom, pomak središnjih mozgovnih tvorbi i potpuna obliteracija mezencefaličke cisterne). Nije bilo razlika u provođenju prehospitalne reanimacije, niti u vremenu proteklom od ranjavanja do početka neurokirurškog liječenja, između istraživanih ranjenika ranjenih u ratnim i u neborbenim okolnostima, kao što nije zabilježena niti značajna razlika u uspješnosti liječenja između istraživanih ranjenika ranjenih u različitim okolnostima. Kod selekcioniranih ranjenika s KCO, u kojih je interakcija projektila i endokranijskih tkiva bila ograničena i bez posljedičnog razvoja kompresijskih hematoma (kraniocerebralni ustrijeli uzrokovani malim metalnim krhotinama i praćeni visokim vrijednostima GCS skora), potrebno je razmotriti i mogućnost obradbe rane mekog oglavka bez istodobne intrakranijske obradbe kraniocerebralne rane i rekonstrukcije tvrde mozgovne ovojnice, obzirom na moguću uspješnost takvog neurokirurškog postupka. Kasni rezultati liječenja 116 ranjenika sa strijelnom KCO, liječenih tijekom Domovinskog rata u bolnici uz prvu liniju bojišta i u tadašnjem ratnom zdravstvenom sustavu, upućuju na potrebu redefiniranja smjernica ratne medicinske doktrine o liječenju teških ranjenika. Rezultati liječenja promatranih ranjenika sa strijelnim KCO naglašavaju važnost definiranja adekvatnog postupnika za razvrstavanje svih ranjenika u redoslijedu evakuacije i kirurške hitnosti, kao i što detaljnijeg definiranja kriterija za odustajanje od liječenja ranjenika za koje se procjenjuje da se ne mogu spasiti. U nemalom broju promatranih ranjenika sa teškom strijelnom KCO (GCS 3-8) postignut je, unatoč nedostatne prehospitalne skrbi i nepotpune provedbe svih oblika suvremenog neurokirurškog liječenja, prihvatljiv rezultat liječenja, što upućuje da se ranjenicima takvih značajki ozljede treba osigurati adekvatan stupanj prioriteta u smjernicama ratno-medicinske doktrine. |
| Abstract (english) | The treatment outcome of 116 patients who sustained the projectile penetrating craniocerebral wound is analyzed retrospectively. The patients were primarily treated at the Division of Neurosurgery of Clinical hospital Osijek in the period from 1991 till 1996. The aim of the study is to determine the prognostic value of clinical and radiographic indicators in the patients with projectile penetrating craniocerebral wounds, in order to estimate their survival span and the potential for their neurological recovery, especially among the patients with severe craniocerebral wounds. The neurosurgical treatment is justified and indicated in the patients with penetrating craniocerebral wounds, if their GCS is higher than 4 and the pupils are not bilaterally dilated and unreactive (72% survived in the studied group and good outcome had 28% in such cases). The success of neurosurgical treatment is doubtfull in the patients whose GCS is 3 or 4 and the pupils bilaterally dilated and unreactive. However, if we use GCS scores as the only prognostic indicator, it is rather difficult to differentiate accurately patients who would die. The fatal outcome in the patients could be accurately predicted in the case when both pupils are dilated and unreactive. Considering the extent of the brain damage, 40% of the wounded with bihemisferal damage survived, 31% of wounded with multilobar injuries and 23% wounded with projectile penetration through ventricles, as well as 17% wounded with unilateral or complete obliteration of the mesencephalic cisterns. The studied patients with intraparenchymal pneumocranium were twice more likely to die than other patients. Nevertheless, we could not predict the survival span of the studied patients only according to radiographic indicators, since they are not accurate enough. Furthermore, only one radiographic (CT) indicator can not determines the patients survival. The likelihood of a good treatment outcome (GOS 4 and 5) was significantly less among the patients with GCS score lower than 9, as well as among the patients with distorted pupil innervations and among those whose radiographic indicators showed severe brain damage like: projectile penetration through sagittal and coronar endocranium surface, bihemispheral multilobar and transventricular damages, extensive intraventricular and subarachnoidal bleeding (Fischer 3 and 4), and numerous secundary projectiles). The same poor outcome had patients whose CT scan showed an increase of intracranial pressure (intracranial hematoma, midline shift of brain formations and complete obliteration of mesencephalic cistern). We can conclude that there was no difference in the treatment between the patients treated in the war from those treated in non-combat circumstances regarding prehospital reanimation and period of the time before the surgery. There was also no difference in the treatment outcome between studied patients and those who sustained injuries under various circumstances. The treatment of the scalp wound without concomitant intracranial debridement of the craniocerebral wound and dural reconstruction, could be successful in the patients with limited interaction between projectile and intracranial structures and without compressive hematoma development (cases of small craniocerebral penetrating wounds due to small metallic fragment with high GCS score). The simple surgical treatment of scalp wound is alternative treatment option in selected patients. Based on the long-term results of the treatment of 116 wounded with penetrating projectile craniocerebral injuries, who were treated during war in the hospital situated on the front line and got medical care in the war period, we suggest the redefinition of the medical guidelines applied in the treatment of the seriously wounded patients (GCS 3-8). The treatment outcome of the studied patients with projectile penetrating craniocerebral injuries point out the necessity to define the appropriate manual for the patients selection according to urgency for the evacuation and surgery, as well as to set the criteria for the patients who would not be further treated since they can not be helped. Great deal of the patients with severe penetrating craniocerebral injuries, in spite of poor prehospital care and inadequate surgical treatment, had satisfactory outcome, meaning that the patients with these injuries should be given appropriate priority in the further redefinition of the war medicine. |
