Introduction

This chapter covers the procedure for a large hemicraniectomy following severe penetrating combat trauma with massive soft tissue involvement. Similar operative principles apply for less severe penetrating wounds, as well as for hemicraniectomy for blunt trauma. Where blunt trauma is concerned, the most significant divergence involves preoperative decision making. We have tended throughout recent conflict to be quite aggressive with surgical intervention for both blunt and penetrating trauma. Long-term outcome studies are pending, but initial experience justifies continuing this aggressive approach in our patient population. ^{1 , 2}

Comparisons between civilian and combat cranial trauma may be difficult because of the service members’ very young average age and high overall level of fitness, the nearly immediate availability of basic and advanced life support care, and extraordinarily robust resources on the battlefield and within close proximity of wounding. Additionally, combat injuries are notable for massive soft tissue/bone/brain injury, gross contamination (often with aggressive organisms), concurrent injuries to face/neck/extremities/trunk, and extended patient transfers. Evacuation to facilities in Germany and, then, onward to national military medical centers in Bethesda, Maryland, consists of two flights of more than 6 hours duration without in-flight neurosurgical capability. ³

However, the major goals of surgery in both situations are 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

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  Severe penetrating trauma.

  
  
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  Blunt trauma with significant mass effect from hemispheric swelling or hematoma.

  
  
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  Absence of major disruption of midline deep cerebral nuclei in the region of the sella (zona fatalis). Disruption of the zona fatalis—typically associated with Glasgow Coma Scale (GCS) 3—is a relative contraindication to operative intervention. ⁴

  
  
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  In the combat setting, low GCS score (< 5) is not necessarily a contraindication to surgical intervention. Additionally, pupillary asymmetry or dilation may be the result of traumatic iridoplegia or chemical irritation. The overall clinical picture and wounding history must be taken into account before making a decision to categorize a patient as expectant. Because of the differences in patient population as outlined, this indication may not fully translate into civilian practice.

Preprocedure Considerations

Radiographic Imaging

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  Computed tomography (CT) scan is routinely available at the medical facilities in theater where neurosurgical capability is present.

  
  
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  Angiography is not routinely available and requires the presence of both specialized equipment and a trained neurointerventionalist. Where angiographic capability is available in theater, it has proven useful in the management of penetrating trauma of the neck and head. Upon arrival to the United States, angiography is often performed—whether blunt or penetrating mechanism—due to the increased incidence of vasospasm associated with blast-related trauma, even in the absence of cranial penetration. ⁵

  
  
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  Preoperative imaging ( Fig. 23.1a, b ).

Operative Procedure

Positioning and Preparation (Fig. 23.2)

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24 Combat-Associated Penetrating Spine Injury 7 Invasive Neuromonitoring Techniques 5 Surgery for Cerebellar Stroke and Suboccipital Trauma 18 Treatment of Acute Cauda Equina Syndrome 22 Pituitary Apoplexy 29 Special Considerations in Pediatric Cervical Spine Injury

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