A 5-year-old boy presented to the emergency room 2 hours after a traffic accident with an open skull fracture and exposed brain tissue. CT scan revealed a 8x5cm open wound in the left frontal region with exposed and contaminated bone and brain. The patient was alert and had no neurological deficits. He underwent irrigation, debridement, and duraplasty in the operating room. Post-operatively, the patient recovered well with no neurological deficits. The report discusses management of open skull fractures with brain exposure, including early debridement and closure to prevent infection, use of prophylactic antibiotics and anti-seizure medications, as well as timing of cranioplasty procedures.

1. OPEN SKULL FRACTURE WITH
OPEN BRAIN INJURY
( case report )
Aimaduddin, Azis* ; Alifianto, Untung**
*General Surgery Resident, Faculty of Medicine Sebelas Maret
University
** Neurosurgeon Dr. Moewardi Hospital, Surakarta
2017

2. Background
• Skull Penetrating injuries in pediatric patients are rare.
• A fracture or penetrating wound of the skull associated
with rupture or incision of the dura mater
exposing/perforating the brain is termed an “open brain
injury
• The present case is specially interesting because there is
no extracranial disturbance such as hemodynamic change
in this patient and the patient showed no neurological
deficit before and after surgery.

3. Case Presentation
•A boy 5 years old, was admitted to the hospital 2
hours after traffic accident. He did not lose
conciousness and was taken to his local hospital
where he arrived alert and didn’t show any
neurological deficit in a quick neurological evaluation.
• There was no history of seizures or vomiting.
•Clinically his GCS was 15 and pupils were equal and
reacting

4. Localized status
R. Frontotemporal (S)
I : Open wound on left frontal 8 x 5 cm , bone exposed
(+) , brain expose (+), contaminan (+)

5. Head ct-scan

6. 3D Head CT scan

7. At the emergency room, pasien was given
•O2 3 lpm, head up 30’
•IUFD Nacl 0,9 %
•Ceftriaxone injection
•Phenytoin injection
•Tetanus prophylaxis
•Metamizole injection
•Ranitidine injection

8. Surgical Management
• The incision was extended along the lacerated/ torn skin edges
• Free bone fragments of comminuted fractures were removed.
Tufts of hair, dirt and sand particles were also removed
• The hanging brain matter was irrigated and gently sucked
• Buried fragments of bone in the brain parenchyma were
removed with a blunt probe
• Identification  defect of the durameter 4 x 3 cm
• Performed duraplasty from pericranium an fascia .
• Direct closure of aponeurosis gallea and fascia with
multifilament absorbable. Direct closure of skin with
multifilament , nonabsorbable suture was done.

10. Post Operation
The patient was then taken back to the
Pediatric Intensive Care Unit
When sedation was removed and the patient awoke
with GCS 15.
Patient was conscious and oriented at the time of
discharge He only suffered post operation pain.
The patient was discharged on day 6th.
Patient was planned to consider
cranioplasty after 6 months.

11. 2 weeks after discharged

12. DISCUSSION
•Head trauma is exceedingly common in children and
the most common mode of injury is fall from height
results or traffic accident in coup and countercoup
injuries but penetrating injuries in pediatric patients
are rare.
•Penetrating head injury in children is very uncommon
and mostly occurs due to shrapnel or bone fragment.
Arvind Sharma, S.K. Jain, Sanjeev Chopra, Tea Cup in the brain, a rare case of
penetrating brain injury in pediatric patient, Department of Neurosurgery, S.M.S
Medical College, Jaipur, Rajasthan, India,Romanian Neurosurgery XXX, Number
1,2016

13. • Penetrating head Injury occurs when a projectile breaches
the cranium and its contents.
• Injuries caused by objects with an impact velocity less than
100 m/s non-missile injuries.
• A non-missile object causing penetrating skull injury are
knife (most common) and rarely nails, keys, pencils,chopstick
and bone fragment.
Arvind Sharma, S.K. Jain, Sanjeev Chopra, Tea Cup in the brain, a rare case of
penetrating brain injury in pediatric patient, Department of Neurosurgery, S.M.S
Medical College, Jaipur, Rajasthan, India,Romanian Neurosurgery XXX, Number
1,2016

14. •Surgical procedures mainly included irrigation,
debridement of devitalized tissues, and removal of
space-occupying hematomas, in-driven bone, and
accessible fragments.
•The treatment of most extensive wounds with
nonviable scalp or bone (significant fragmentation
of the skull) is a large debridement with
craniectomy or craniotomy before primary closure
•Rapid removal of the foreign body and bone
fragments along with focal debridement after
achieving absolute hemostasis followed by
meticulous dural and scalp closure are the goals of
surgical treatment

15. The goals of surgical intervention in patients with these
injuries are to:
•Remove the penetrating item from the brain
parenchyma
•Remove necrotic tissue, debris and other potential
contaminants
•Evacuate of any haematomas occurring from the
injury and secure haemostasis.
•Ensure watertight closure of the dura to prevent CSF
leakage.
K Regunath, S Awang*, S B Siti, M R Premananda, W M Tan, R H Haron, Penetrating
Injury to the Head: Case Reviews, Department of Neurosurgery, Hospital Kuala
Lumpur, Med J Malaysia Vol 67 No 6 December 2012

16. Management of CSF fistula
•During primary surgery all efforts should be
directed to seal the dura to prevent CSF fistulas.
•Surgical correction is recommended for CSF fistulas
do not close spontaneously or refractory to medical
management.
•The management of fistulas in the inlet and outlet
require the closure of the dura mater, fascia and
skin
Hernando Raphael Alvis-Miranda, MD1, Roberto Adie Villafane,
Management of Craniocerebral Gunshot Injuries: A Review, Korean J
Neurotrauma 2015;11(2):35-43

17. •Infection is the most common complication of
penetrating brain injuries and is directly associated
with increased morbidity and mortality
• Prevention is essential to optimize their prognosis
regardless of the initial management of the injury.

18. Factors considered determinants of infection include:
•Retained fragments of bone or metal
•Time of surgery.
•Use of antibiotics.
•CSF fistulas.
Hernando Raphael Alvis-Miranda, MD1, Roberto Adie Villafane,
Management of Craniocerebral Gunshot Injuries: A Review, Korean J
Neurotrauma 2015;11(2):35-43

19. Antibiotic prophylaxis
• The use of broad spectrum antibiotics is recommended in
patients with penetrating brain trauma.
• The risk of intracranial infection in patients with penetrating
brain trauma is high due to the presence of foreign bodies,
contaminated skin, hair and bone fragments in the path of the
projectile.
• complications that might occur are scalp cellulitis, subdural
abcess formation, osteomyelitis epidural empyemas, subdural
empyemas, meningitis, ventriculitis, cerebritis, and brain
abcess.
K Regunath, S Awang*, S B Siti, M R Premananda, W M Tan, R H Haron, Penetrating Injury to the Head: Case
Reviews, Department of Neurosurgery, Hospital Kuala Lumpur, Med J Malaysia Vol 67 No 6 December 2012

20. Anticonvulsive prophylaxis
•Between 30 and 50% of patients with penetrating
brain trauma develop seizures from 4 to 10% of them
have their first seizure within the first week and 80%
during the first 2 years, however, the risk decreases
with time.
•Anticonvulsant medications in the first week after
penetrating brain trauma are recommended to
prevent early posttraumatic seizures (phenytoin,
carbamazepine, valproic acid, and phenobarbital)
K Regunath, S Awang*, S B Siti, M R Premananda, W M Tan, R H Haron, Penetrating Injury to the Head: Case
Reviews, Department of Neurosurgery, Hospital Kuala Lumpur, Med J Malaysia Vol 67 No 6 December 2012

21. •Patients presenting with dural laceration and or
associated intracranial hemorrhage are also at risk
for developing late seizures and should be treated
for at least six months.

22. CONCLUSION
• Pediatric head injuries are very common in developing
countries and most common mode of injury is fall form
height or traffic accident. Penetrating head injury in children
is very uncommon and mostly occurs due to shrapnel and
bone fragment.
• Surgical treatment is a good option for skull fractures even
with herniation of the brain tissue.
• Prophylactic antibiotic use reduces the risk postoperative/
posttraumatic infection with effective outcomes.
• Prophylactic with anti covulsant is recommended when
given in the first week after penetrating brain trauma

23. Thank You

26. • Rish et al
• ., melaporkan kranioplasti yang dilakukan 1-6 bulan setelah
kraniektomi dekompresimempunyai angka komplikasi yang tinggi,
sedangkan kranioplasti yang dilakukan 12-18 bulan setelah prosedur
kraniektomi dekompresi mempunyai angka komplikasi yang lebih
rendah
• . #lasan utamaumtuk menunda prosedur kranioplasti adalah untuk
mengurangi kemungkinan melakukan intervensi pada luka yang
masih terkontaminasi