Prophylactic removal of a migratory missile from the cerebral ventricles: case report.

BACKGROUND AND IMPORTANCE: Nonpowder firearm injuries to the head pose major health risks, with retained fragments potentially causing harmful sequelae that require neurosurgical intervention. CLINICAL PRESENTATION: We report the case of 2-year-old girl who sustained an accidental gunshot wound to the head. She sustained a penetrating ballistic intracranial injury caused by a BB shot from a rifle. At presentation, she was neurologically intact with a punctate laceration on her left forehead. Head CT demonstrated a small depressed left frontal skull fracture, a small intracerebral hematoma, and a 5-mm metallic bullet fragment in the deep left frontal lobe near the frontal horn of the left lateral ventricle. She was admitted to the hospital and managed nonoperatively with levetiracetam and intravenous antibiotics, and discharged home in good condition. Follow-up CT in 1 week showed slight migration of the metallic bullet fragment to the left, placing it at the anterior horn of the lateral ventricle. Six weeks later, follow-up CT showed migration of the bullet to the temporal horn of the left lateral ventricle. Intraventricular migration of the bullet raised concern that it could move further to obstruct the foramen of Monro or cerebral aqueduct. Therefore, we removed the bullet through a small left temporal craniotomy with image guidance using a microsurgical approach through a translucent tube. CONCLUSION: The authors discuss the rationale and technique for removing a nonpowder firearm bullet that has migrated within the cerebral ventricles.

How I do it: single-staged emergency neurosurgical management of frontal penetrating craniocerebral injury with depressed skull fracture.

CONTEXT: Penetrating craniocerebral injury associated with depressed skull fracture is an infrequent yet timely neurosurgical emergency. Such injury frequently occurs in the frontal region during traffic accident or stone throw in the civilian setting. As military neurosurgeons, we present our experience in the surgical debridement and reconstruction of this peculiar type of traumatic brain injury. METHODS: The patient lies supine, the head in neutral position heal by a Mayfield head clamp. The first step is the debridement of the frontal wound. Then, the depressed skull fracture is operated on using a tailored coronal approach through Merkel dissection plane, in order to keep a free pericranial flap. The bone flap is cut around the depressed skull fracture. Neuronavigation allows to locate the frontal sinus depending on whether it has been breached and thus requires cranialization. Brain and dura mater debridement and plasty are performed. Cranioplasty is performed using either native bone fragments fixed with bone plates or tailored titanium plate if they are too damaged. CONCLUSION: Performing wounded skin closure first and then a tailored coronal approach with free pericranial flap and a craniotomy encompassing the depressed skull fracture allows to treat frontal penetrating craniocerebral injury in an easy-to-reproduce manner.

Incidence of surgically treated chronic subdural hematoma after head injury with normal initial computed tomography.

PURPOSE: The objective was to determine the incidence of surgically treated chronic subdural hematoma (cSDH) within six months after head trauma in a consecutive series of head injury patients with a normal initial computed tomography (CT). METHODS: A total of 1941 adult patients with head injuries who underwent head CT within 48 h after injury and were treated at the Tampere University Hospital's emergency department were retrospectively evaluated from medical records (median age = 59 years, IQR = 39-79 years, males = 58%, patients using antithrombotic medication = 26%). Patients with no signs of acute traumatic intracranial pathology or any type of subdural collection on initial head CT were regarded as CT negative (n = 1573, 81%). RESULTS: Two (n = 2) of the 1573 CT negative patients received surgical treatment for cSDH. Consequently, the incidence of surgically treated cSDH after a normal initial head CT during a six-month follow-up was 0.13%. Both patients sustained mild traumatic brain injuries initially. One of the two patients was on antithrombotic medication (warfarin) at the time of trauma, hence incidence of surgically treated cSDH among patients with antithrombotic medication in CT negative patients (n = 376, 23.9%) was 0.27%. Additionally, within CT negative patients, one subdural hygroma was operated shortly after trauma. CONCLUSION: The extremely low incidence of surgically treated cSDH after a normal initial head CT, even in patients on antithrombotic medication, supports the notion that routine follow-up imaging after an initial normal head CT is not indicated to exclude the development of cSDH. Additionally, our findings support the concept of cSDH not being a purely head trauma-related disease.

Superior Sagittal Sinus Thrombectomy in Pediatric Head Injury.

INTRODUCTION: Injury and subsequent thrombosis of the cerebral venous sinuses may be caused by closed head injuries secondary to a variety of different mechanisms. Skull fractures can lacerate or otherwise disrupt adjacent dural sinuses. The sequelae of such injuries may include thrombosis and either partial or total occlusion of the sinus, ultimately resulting in significant venous congestion. Sagittal sinus injury is associated with a more serious outcome due to the obligatory flow into the sinus, especially posterior to the coronal suture. In such cases, venous infarction may be a severe and life-threatening complication of head injury. CASE PRESENTATION: A 2-year-old female presented with a depressed skull fracture near the midline and a thrombus in the sagittal sinus. Anticoagulation, the standard treatment cerebral venous sinus thrombosis (CVST), was contraindicated due to intracranial hemorrhage, so immediate thrombectomy was performed with successful neurologic recovery at 9-month follow-up. To our knowledge, this case is the youngest patient documented to receive mechanical thrombectomy for superior sagittal sinus (SSS) thrombosis due to trauma. CONCLUSION: Closed head injuries in pediatric patients may be associated with CVST, with resulting venous drainage compromise and profound neurologic sequelae. Unlike adult patients with spontaneous CVST in which anticoagulation are the standard of care, pediatric patients experiencing traumatic CVST may have contraindications to anticoagulants. If the patient has a contraindication to anticoagulation such as intracranial bleeding, endovascular mechanical thrombectomy may be an effective intervention when performed by an experienced neurointerventionalist.

Pediatric craniocerebral firearm injuries: literature review, best practices in medical and surgical management, and case report.

INTRODUCTION: Civilian craniocerebral firearm injuries are extremely lethal. Management includes aggressive resuscitation, early surgical intervention when indicated, and management of intracranial pressure. Patient neurological status and imaging features should be used to guide management and the degree of intervention. Pediatric craniocerebral firearm injuries have a higher survival rate, but are much rarer, especially in children under 15 years old. This paucity of data underscores the importance of reviewing pediatric craniocerebral firearm injuries to determine best practices in surgical and medical management. CASE PRESENTATION: A 2-year-old female was admitted after suffering a gunshot wound to the left frontal lobe. Upon initial evaluation, the patient displayed agonal breathing and fixed pupils with a GCS score of 3. CT imaging showed a retained ballistic projectile in the right temporal-parietal region with bifrontal hemorrhages, subarachnoid blood, and a 5-mm midline shift. The injury was deemed nonsurvivable and non-operable; thus, treatment was primarily supportive. Upon removal of the endotracheal tube, the patient began breathing spontaneously and improved clinically to a GCS score of 10-12. On hospital day 8, she underwent cranial reconstruction with neurosurgery. Her neurological status continued to improve, and she was able to communicate and follow commands but retained notable left-sided hemiplegia with some left-sided movement. On hospital day 15, she was deemed safe for discharge to acute rehabilitation.

Intracranial penetrating injury by clothes fork in an infant: case report and review of the literature.

Nonmissile intracranial penetrating injury (IPI) in pediatric population is rare. Here, we report the exceedingly rare case of a 5-month-old infant sustained by a metallic clothes fork penetrating into his left forehead. The little baby was identified to carry a traumatic hemorrhagic shock, and a multidisciplinary team (MDT) was immediately established response for whole-course evaluation and decision-making. Computed tomography revealed that the clothes fork had impaled into the left frontal bone and brain parenchyma with about 3.2 cm inside the cranial vault. The infant underwent emergency surgery, and the clothes fork was removed jointly by MDT members under general anesthesia in the retrograde direction. His recovery was uneventful and was followed up 2 years without growth and developmental abnormality. As an extremely rare entity with distinct age-related characteristics, a MDT approach is a best choice and effective strategy to manage infant nonmissile IPI, including preoperative management, surgical treatment, and even following rehabilitation.

The historical rationale for operating on cranial fissures.

OBJECTIVE: Cranial fissures are not an indication for surgical intervention. It should be emphasised that the term fissure refers to linear skull fractures as defined in MESH. However, it was the universal term for this injury in the literature which forms the basis of this paper. Nonetheless, for over two millennia, their management was a major reason for opening the skull. The reasons for this deserve analysis, in particular taking into account the available technology and conceptual background. MATERIALS AND METHODS: The texts of significant surgical practitioners from Hippocrates to the eighteenth century were examined and analyzed. RESULTS: The need for fissure surgery was based on Hippocrates' teaching. It was considered that extravasated blood would suppurate, and extracranial suppuration could leak inwards through a fracture. Trepanation to facilitate pus drainage and cleansing was considered vital. Avoiding surgical damage to the dura was also emphasized with a preference for operating only when the dura had separated from the cranium. The enlightenment with an increasing reliance on personal observation rather than the teachings of received authority enabled the accumulation of a more rational basis for treatment concerned with the effects of injury on brain function. This culminated in the teachings of Percivall Pott, who despite some minor errors, provided the framework on which modern treatments would develop. CONCLUSIONS: Examination of the surgical management of cranial trauma from Hippocrates to the eighteenth century shows that cranial fissures were judged to be of great importance and required active treatment. This treatment was not aimed at improving the healing of the fracture but at avoiding deadly intracranial infection. It is worth noting that this sort of treatment persisted for over two millennia while modern management has only been practiced for just over a century. Who can say how it will change in the next hundred years.

Effective Epilepsy Surgery for Post-Traumatic West Syndrome Following Abusive Head Trauma.

West syndrome, an infantile developmental and epileptic encephalopathy with a deleterious impact on long-term development, requires early treatment to minimize developmental abnormality; in such cases, epilepsy surgery should be considered a powerful therapeutic option. We describe a 10-month-old female admitted with West syndrome associated with a hemispheric lesion following abusive head trauma. Her seizures were suppressed by hemispherotomy at 12 months of age, leading to developmental improvement. Surgical treatment of West syndrome following traumatic brain injury has not been reported previously but is worth considering as a treatment option, depending on patient age and brain plasticity.

Repair of the superior sagittal sinus following penetrating intracranial injury caused by nail gun accident: case report and technical note.

We report a 45-year-old man who suffered a penetrating nail gun injury resulting in damage to the lateral edge of the superior sagittal sinus. The injury was successfully treated via a parasagittal craniotomy that enabled removal of the nail under direct vision, allowing for rapid suturing of the sagittal sinus. Two neurosurgeons worked together; one carefully withdrew the tip of the nail back into the sinus itself while the second rapidly sutured the hole in the inner superior sagittal sinus leaflet. Postoperatively, the patient made a rapid recovery without neurological deficit.

History of Cranial Surgery in World War I: Experience on the Italian Front.

Since ancient history, men have been attempting to intervene when skull trauma occurs. The majority of traumas were always linked to war injuries, and in the modern era, the culprit was reached during World War I. Cranial traumas in wartime were very common, and consequently, physicians in wartime became particularly interested in the subject of cranial traumatology. In the following text, we want to bring to light the experience of some of the pioneers of cranial surgery in Italy during the First Great War. In fact before the war, very few medical officers had received training in central nervous system surgery. In addition, the surgical instruments for that clinical activity were inadequate and obsolete, but to deal with the medical emergency that had arisen on the front lines, the Italian government established Battlefield Medical Schools. And it is also from the reports and lectures of surgeons working on the front lines that the next generations of neurosurgeons were able to develop this surgical field into the complex and well-established surgical specialty that it is today.

[Application Effect of Continuous Lumbar Cistern Fluid Drainage Combined With Decompressive Craniectomy in the Treatment of Severe Craniocerebral Injury].

Objective: To analyze the application effect of continuous lumbar cistern fluid drainage combined with decompressive craniectomy in the treatment of severe craniocerebral injury. Methods: A total of 87 patients with severe craniocerebral injury admitted to our hospital between March 2016 and March 2021 were retrospectively enrolled. They were divided into two groups according to the decompression methods applied, with 42 patients who received standard decompressive craniectomy assigned to the control group and 45 patients who received continuous lumbar cistern fluid drainage combined with standard decompressive craniectomy assigned to the observation group. The primary indicators that were monitored and compared between the two group included the amount of time for patient CT imaging to be clear of subarachnoid hemorrhage, the length-of-stay, the duration of post-operative intubation, the mannitol dose, scores for Glasgow Coma Scale (GCS), prognosis, the incidence of cerebral edema and cerebral infarction, and complications. The secondary indicators that were monitored and compared included intracranial pressure, cerebrospinal fluid antinucleosome protein SP100, and red blood cell count of the two groups before treatment and after continuous drainage for 7 days. Results: The amount of time for CT imaging to be clear of subarachnoid hemorrhage and the length-of-stay of the observation group were shorter than those of the control group, the mannitol dose of the observation group was lower than that of the control group, the incidence of cerebral edema and the incidence of complications of the observation group were lower than those of the control group, and the rate of patients with good prognosis in the observation group was higher than that in the control group ( P<0.05). There was no significant difference in the rate of poor prognosis or mortality between the two groups ( P>0.05). The duration of postoperative intubation of the observation group was (8.24±1.09) d, while that of the control group was (9.22±1.26) d, and the difference between the two groups was statistically significant ( t=3.887, P<0.05). There were 2 cases (4.44%) of cerebral infarction in the observation group, with the infarct volume being (8.36±1.87) cm 3, while there were 9 cases (21.43%) of cerebral infarction in the control group, with the infarct volume being (8.36±1.87) cm 3, and there were statistically significant differences in the incidence and volume of cerebral infarction between the two groups ( χ 2=5.674, t=9.609, P<0.05). After treatment, the intracranial pressure and red blood cell count decreased in both groups and the intracranial pressure, cerebrospinal fluid SP100, and red blood cell count of the observation group were significantly lower than those of the control group ( P<0.05). The cerebrospinal fluid SP100 of the observation group decreased after treatment in comparison with the level before treatment ( P<0.05), while the pre- and post-treatment levels of the control group did not demonstrate any significant difference. Conclusion: Continuous lumbar cistern fluid drainage in patients with severe craniocerebral injury effectively shortens the time required for the body to recover, significantly reduces the level of intracranial pressure, improves the levels of cerebral edema and cerebral infarction, and has a high degree of safety for prognosis and recovery.

Interpretation of Emergency CT Scans of the Head in Trauma: Neurosurgeon vs Radiologist.

BACKGROUND: Traumatic brain injury (TBI) is a major cause of mortality and morbidity across all ages in all countries. Management of the patient with TBI is time critical. Emergency computed tomography (CT) scans of the head are often assessed by neurosurgeons and patient management plans are implemented before the final radiological report is released in hospitals, particularly where there is a shortage of radiologists in LMIC. The aims of this study were to identify discrepancies in the interpretation of CT scans of the head in patients with isolated head injury between the neurosurgeon and radiologist and to assess if these differences impacted patient management. METHODS: This 6-month long prospective observational study was performed at a tertiary hospital in South Africa. The study population comprised 347 patients with isolated head injury who had a CT scan of the head performed on admission. The neurosurgeons' initial CT scan interpretation and the final radiological report were compared. RESULTS: Out of 347 CT head scans, the neurosurgeons correctly interpreted 318 cases. Of the 29 incorrectly interpreted cases, there were 17 false negatives and 12 cases with mismatching abnormalities. The concordance rate was 91.64% (95% CI 88.73-94.55) with a kappa of 0.78. An accuracy rate of 95.33% (95% CI 92.63-97.26) was achieved by the neurosurgeon. No patient was negatively impacted by any neurosurgical error in misinterpretation. CONCLUSIONS: In the interpretation of CT head scans in trauma, there is good neurosurgical and radiological interobserver agreement without negative patient impact. The neurosurgeons' interpretation of CT scans of the head in TBI is safe especially when radiology reports are not timeously available.

SURGICAL OUTCOME AND PROGNOSTIC FACTORS AFTER OPHTHALMIC SURGERY IN ABUSIVE HEAD TRAUMA.

PURPOSE: To analyze the clinical characteristics, surgical outcomes, and risk factors associated with visual outcomes in patients with abusive head trauma (AHT). METHODS: We retrospectively reviewed surgical outcomes of patients with AHT who underwent vitrectomy from 2001 to 2019. The patients' demographics, comprehensive preoperative and postoperative ocular findings, surgical treatments, visual outcomes, and postoperative complications in the medical records were reviewed. Univariable and multivariable analyses were performed to identify the prognostic factors associated with visual outcomes. RESULTS: Fourteen children (18 eyes) diagnosed with AHT who underwent vitrectomy were evaluated. The most common surgical indication was vitreous hemorrhage (n = 6, 33%). Retinal attachment at the final visit was noted in 17 eyes (94%). Thirteen eyes (72%) had a best-corrected visual acuity less than 20/200 after vitrectomy. In the multivariable analysis, optic nerve atrophy (n = 9, 50%) was significantly associated with a poor visual prognosis (final best-corrected visual acuity worse than 20/200) after vitrectomy in children with AHT (95% confidence interval, 1.041-517.963, P = 0.0471). CONCLUSION: The general visual prognosis was poor for patients with AHT needing vitrectomy, although a high rate of retinal attachment was observed. Optic nerve atrophy is a prognostic factor for poor visual outcomes in patients with AHT who received ophthalmic surgery.

Non-accidental head injury of infants: legal implications for the pediatric neurosurgeon.

BACKGROUND: Though the neurosurgeon's role in non-accidental head injury (NAHT) is the prompt recognition and care of the inflicted injuries, he/she should be aware of the possible legal implications related to this particular neurosurgical condition. MATERIAL AND METHODS: Based on published data and their own clinical and medico-legal practice, the authors review the role of the neurosurgeon in NHAT. RESULTS: Besides the contribution that can be given by the neurosurgeon to a correct differential diagnosis, he/she is likely to be involved in the interpretations of the pathological findings in the case where the judge may request for a medical opinion concerning etiology, circumstances, severity, and consequences. As a member of a multidisciplinary team, usually the neurosurgeon is only requested for information regarding the lesions he was called to recognize and treat. Nevertheless, such information may have a pivotal part in the evaluation process. Consequently, the neurosurgeon should be able to reach a correct differential diagnosis of NAHT among all the events that may share similar clinical and anatomo-pathological characteristics and be aware of the ongoing scientific controversies related to the diagnosis and pathophysiology. CONCLUSIONS: In practical terms, the pediatric neurosurgeon is called to individuate and record all the precise details of the condition to be eventually offered to the judge in case of controversy. Whereas the diagnosis of NAHT should be evoked at the initial phase in order not to leave the child unprotected, all possible alternative hypotheses should be ruled out "beyond reasonable doubt" for the court. The medical file should be maintained in the record carefully and be accessible even after a long time.

The role of the pediatric neurosurgeon in abusive head injuries: a survey of members of the International Society for Pediatric Neurosurgery.

BACKGROUND AND PURPOSE: Pediatric neurosurgeons are at the forefront of the clinical management of abusive head injuries (AHI) all over the world. However, the discrepancies regarding medical practice and legal requirements in different centers have not been assessed before. MATERIAL AND METHODS: We decided to perform an online survey among members of the International Society for Pediatric Neurosurgery (ISPN) regarding their activity, their usual clinical practice regarding the medical and legal management of AHI, and their involvement in judiciary proceedings, research, and prevention campaigns. RESULTS: Ninety members of the ISPN participated in the survey, representing 26% of the registered members. Most responders were senior pediatric neurosurgeons practicing in a university hospital. Their responses show great homogeneity regarding surgical, intensive care, and legal management. We also noted the widespread use of invasive intracranial pressure monitoring and decompressive craniotomy. By contrast, the responses show great disparity regarding the circuit of patients. This disparity may be an obstacle to the collection of data and clinical research, as well as for the involvement of neurosurgeons in multidisciplinary evaluation. A minority of neurosurgeons were engaged in research and actions of prevention. CONCLUSION: Pediatric neurosurgeons play a pivotal role in the diagnosis and medical management of AHI. Because of their proficiency in head trauma and cerebrospinal fluid disorders, it is desirable that they become more implicated in multidisciplinary meetings, medical expertise, and scientific research, as well as actions of prevention.

Abusive head injury in the very young: outcomes from a Singapore children's hospital.

PURPOSE: Abusive head trauma (AHT) is a serious problem in children. The aims of this study are to identify risk factors that correlate with outcomes for those requiring neurosurgical intervention for very young children with AHT, assessment of variables associated with outcomes, and corroboration of our results with literature. METHODS: This is an ethics-approved, retrospective study. Inclusion criteria consisted of patients aged 2 years old or less with a diagnosis of AHT managed by the Neurosurgical Service, KK Women's and Children's Hospital. Demographical and clinical variables are incorporated in the statistical analyses. Logistic regression was applied to statistically significant variables for the risk prediction model. RESULTS: From 2000 to 2020, 24 patients required surgery for AHT. Timepoint was set at 12 months post-diagnosis. Univariate analyses demonstrated that patients with mild TBI were likely to have a favourable GOS-E Peds (p = 0.01), whereas radiological presence of cerebral oedema (p < .001), development of scar epilepsy (p = 0.021), and progression to cerebral palsy (p = 0.001) were associated with unfavourable GOS-E Peds. CONCLUSION: This is the first study focused on neurosurgical outcomes for very young children with AHT in Singapore. We advocate multidisciplinary efforts to improve outcomes for this devastating condition.

Decompressive surgery in abusive head injury: Experience from a Singapore children's hospital and a review of literature.

PURPOSE: Abusive head trauma (AHT) is a major cause of morbidity and mortality in children. Studies on pediatric head injury observe that AHT patients often have a higher incidence of malignant cerebral oedema and, overall, worse prognosis. There are limited studies with a focus on the outcome of decompressive surgery in children with AHT. This is a study undertaken to review our institutional experience on the role of decompressive surgery in AHT patients and objectively assess its outcomes, in corroboration with current literature. METHODS: This is an ethics-approved, retrospective study. Inclusion criteria consist of all children with a diagnosis of AHT managed by the Neurosurgical Service, KK Women's and Children's Hospital. Demographical and clinical variables are incorporated in the statistical analyses. RESULTS: From 2011 to 2021, a total of 7 patients required decompressive surgery for AHT. Mean age of the cohort was 17.1 months (with the majority of patients being male (n = 5, 71.4%). During the follow-up period, there was 1 mortality (14.3%), 3 patients developed cerebral palsy (42.9%), and 3 patients had post-traumatic epilepsy (42.9%). With regards to functional outcome, 4 patients (57.1%) had a favorable KOSCHI score at 6 months follow-up. CONCLUSION: Decompressive surgery in children with AHT presents with its own unique challenges. We therein present our neurosurgical experience in decompressive surgery for this extremely vulnerable group of patients. Given the potential role of decompressive surgery in AHT, the development of an objective marker to select such patients who may benefit most from intervention should be the way forward.

Seemingly inconsequential yet catastrophic: the importance of wound washout with minute depressed skull fracture from a dog bite.

Depressed skull fractures from dog bites are common pediatric head injuries which are contaminated with native skin and canine oral flora. Outcomes can potentially be catastrophic. Thus, these injuries require proper initial management to prevent future complications. We present an 18-month-old female who was bitten by a Great Dane dog and resulted in a small left temporal depressed skull fracture with an underlying brain contusion. This was initially treated conservatively with antibiotics and bedside irrigation. Five weeks later, she developed a large multiloculated abscess with mass effect, which required surgical aspiration and wound debridement. After long-term antibiotics, she made a full neurologic recovery. Our case illustrates the importance of washing out a seemingly inconsequential depressed skull fracture from a dog bite to avoid development of a cerebral abscess.

Neurosurgery during the Greco-Italian War (World War II): the management of war-related head injuries at the Italian field hospital of Sinanaj in Albania.

During the Greco-Italian War (World War II [WWII], 1940-1941), an Italian field hospital was set up in Sinanaj, Albania. The hospital's military surgeons carefully collected information about the characteristics and management of patients with war-related injuries. In 1942, they published a detailed report, with a section dedicated to the management of war-related head injuries. The aim of this report is to analyze that section, to describe the characteristics and neurosurgical management of war-related head injuries, and to depict the status of war neurosurgery in the Royal Italian Army during WWII. The analysis revealed that, during the Greco-Italian War (November 1940-April 1941), 149 patients with war-related head injuries were admitted to the Sinanaj hospital, and 48 patients underwent surgery. Head injuries were caused by bomb fragments in 126 patients, bullets in 5 patients, and other causes (falls from height, vehicle accidents, or rock fragments) in 18 patients. Six patients (12.5%) died after surgery. Before surgery, patients underwent resuscitation with blood transfusions and fluid. Preoperatively, a plain head radiograph was usually acquired to locate metallic and bone fragments. The surgical technique consisted of craniotomy or craniectomy, aggressive debridement of metallic and bone fragments, and watertight dural closure. Surgical drainage, overall aseptic technique, serial spinal taps, and perioperative antibiotics were used to prevent infections. The surgical aims and technique used by the Italian surgeons for the management of head injuries were similar to those of the Allied surgeons during WWII. Operative mortality was also comparable. Although the surgical technique for war-related head injuries has evolved since WWII, many aspects of the technique used by the Italian and Allied surgeons during WWII are still in the standard of care today.

From Henry Shrapnel (1761-1842) to today's neurosurgery: how antipersonnel weapons have laid the foundation of clinical and surgical management of head injury fractures and penetrating brain injuries.

Henry Shrapnel invented an antipersonnel weapon capable of defragmenting with the explosion of charge. Modern grenades or improvised explosive devices may be seen as an evolution of Shrapnel's ammunition. Starting by analyzing the ballistics of these weapons, it is possible to understand the historical evolution of the management of skull fractures and penetrating brain injuries (PBIs). A circular crack line with a splinter at the center, depressed in bone, was a characteristic feature of fractures due to Shrapnel's bullet. Three longitudinal fissures, one medial and two lateral, may be present due to tangential blows. Craniectomy and/or fracture reduction were almost always necessary in these cases. The first document describing medical examination and therapeutic strategies for head-injured patients dates back to 1600 bc (the Edwin Smith Papyrus). Several doctors from the past century, such as Puppe, Matson, and Cushing, proposed different theories about skull fractures and the management of craniocerebral injuries, paving the way for diagnosing and treating these injuries. Shrapnel fractures required wider craniotomies and in the past surgeons had to deal with more severe injuries. Based on past military experiences during what could be called the postshrapnel age, guidelines for the management of PBIs were introduced in 2001. In these guidelines various concepts were reviewed, such as the importance of antibiotics and seizure prevention; included as well were prognostic factors such as hypotension, coagulopathy, respiratory distress, and Glasgow Coma Scale score. Furthermore, they highlight how it has not been possible to reach a common viewpoint on surgical management. Nevertheless, in contrast with the past, it is preferable to be less aggressive regarding retained fragments if there is no intracranial mass effect. Although military situations were useful in building basic principles for PBI guidelines, civilian PBIs differ noticeably from military ones. Therefore, there is a need to review modern guidelines in order to apply them in every situation.