A 21-year-old male was involved in a T-bone collision while riding a motorcycle wearing a full face helmet. He was a GCS 3T on arrival to the hospital. His head injuries involved a left parieto-occipital contrecoup contusion and subtle bifrontal hypodensities and multiple orthopedic injuries. An EVD was placed and his intracranial pressures were managed medically for the first 5 days. Eventually the right parieto-occipital contusion and bifrontal hypodensities evolved causing 5 mm of left to right midline shift and medically refractory elevated ICPs > 20 mmHg. A wide bifrontal craniectomy was performed. He developed bilateral subdural hygromas 2 weeks after surgery that resolved spontaneously after 3 days of observation. He underwent a bifrontal cranioplasty 4 months after the craniectomy. He was discharged to neuro-rehab with a GCS 14. He has moderate cognitive changes and emotional lability consistent with his frontal lobe injury.

Case 2: (see Figs. 19.6, 19.7 and 19.8)

A 27-year-old male deployed overseas suffered a gunshot wound to the head from an unknown caliber weapon. He underwent an emergent cricothyroidostomy and was transferred to higher level care with an admission GCS score of 8T. Initial head CT demonstrated significant right maxillary, orbital, frontal, and zygomatic fractures, retained metal fragmentation within the right frontal lobe and effacement of the frontal horn of the right lateral ventricle. A left frontal EVD was placed but within 24 h his ICPs were refractory to medical management. He underwent a right unilateral craniectomy in theater. He was transferred back to Walter Reed for further care and rehabilitation. One month after the accident he was discharged to neuro-rehab with a GCS 14 and moderate impairment in judgment and insight. He underwent cranioplasty 6 months after the injury.

Case 3: (see Figs. 19.9, 19.10, 19.11, 19.12, 19.13, 19.14 and 19.15)

A 30-year-old female ejected from a motor vehicle after an unrestrained, head-on collision sustained direct craniofacial depression from a highway shoulder rail. On arrival, she was GCS 8T (E2-M5-V1T) and moving extremities symmetrically. She had gross brain matter and mixed serosanguinous fluid draining from an open facial laceration that extended from the middle of her forehead through her upper lip.

There are several intra-operative details that should be considered in conjunction with OMFS, Plastics, ENT and Oculoplastics teams to achieve several goals at the time of surgery: (1) decompression of cranial contents if there is a mass lesion or malignant edema, (2) primary repair of dural injuries using autograft, allograft, or dural substitutes, (3) reconstruction of anterior fossa floor and orbital bandeau, (4) thorough cranialization and exenteration of the frontal sinus, (5) reconstruction of severe, displaced facial and orbital injuries. A bicoronal incision was made and the subgaleal space was dissected anteriorly to the superior orbital rim, keeping the pericranium intact. A vascularized pericranial pedicle was incised beyond the incision posteriorly and up to the superior temporal line bilaterally; the pedicle was carefully dissected anteriorly to the superior orbital rim as well. This maneuver is critical for obtaining a large, vascularized autograft used for dural repair and reconstruction of the anterior fossa floor. A wide bifrontal craniotomy was performed, preserving the orbital bandeau to provide a scaffold for repairing her orbito-facial fractures. Her severe, depressed frontal sinus fracture was elevated and then cranialized and exenterated. The nasofrontal ducts were involuted and packed with muscle, bone chips, fat, and fibrin glue. A 7 cm dural laceration was present that extended from the frontal pole to the anterior clinoid process. The dura was elevated from the anterior fossa floor to visualize the extent of dural injury, and the orbital roof was internally reduced. The uninterrupted dura was opened and reflected medially; the anterior falx was dissected from the crista gali with suture ligation of the anterior superior sagittal sinus. A piece of pericranial graft was harvested far from the laceration site, and the dura was primarily repaired with 4-0 Nurulon suture. The orbital bandeau was carefully reconstructed to provide a scaffold for cranial reconstruction in the future. The remaining vascularized pericranial pedicle was laid on top of the reconstructed bandeau and sutured to the dura at the anterior clinoid process to avoid retraction of the pedicle. The dura was covered with moist gauze and the OMFS team reduced and plated her complex facial fractures. The frontal lobes at the time of closure were soft and demonstrated normal pulsations.