Management of open craniocerebral injury in a patient with a skull defect: a case report

Management of open craniocerebral injury in a patient with a skull defect: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Management of open craniocerebral injury in a patient with a skull defect: a case report Haihui Qi, Mengruo Song, Ya Xu, Zhenglou Chen, Qunfeng Gui This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3950891/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Open craniocerebral injury is a bodily injury that is characterized by high mortality and poor prognosis. This type of trauma occurs in patients with skull defects; this is a peculiar accident and is relatively rare. Because of its rarity, the treatments for such injuries are complex and nonstandardized. Case presentation: We present the case of a 66-year-old male with a right frontotemporal skull defect who was hit by a tractor in his head and was accompanied by loss of consciousness for 3 h. Computer tomography (CT) demonstrated a hit on the left frontal area and a multifragmented fracture of the bilateral frontal and orbital bone with partial defects and partial elevation of the fractured bone fragments. A hemorrhagic contusion in the bilateral frontal area directly next to the injury was accompanied by a subdural hematoma at the skull defect site, subarachnoid hemorrhage, or ventricular hemorrhage. Early debridement, hematoma evacuation, and decompressive craniectomy were performed, and the patient achieved good postoperative recovery. Conclusions: In this study, we discussed the clinical presentation and successful management of this unique injury in a patient with a skull defect. Our goal is to demonstrate certain general management principles that can improve patient outcomes. Open craniocerebral injury Skull defect Computed tomography Early debridement Figures Figure 1 Figure 2 Figure 3 Introduction In our modern industrialized environment, traumatic brain injury (TBI) contributes to worldwide death and disability more than any other traumatic insult. It is estimated that nearly 69 million individuals suffer TBI from all causes each year, with Southeast Asia experiencing the greatest overall burden of disease [ 1 ] . Severe craniocerebral injury often occurs in young healthy men, and the causes of most such injuries range from traffic accidents and falls to accidents due to the impact of a moving object and assults [ 2 ] . To date, open craniocerebral injury in patients with skull defects is a peculiar accident and is relatively rare. First, open craniocerebral injury is associated with a high risk of morbidity and mortality due to relevant infection, seizures, vascular injury and cerebrospinal fluid leakage [ 3 , 4 ] . Second, for patients with skull defects, secondary traumatic brain injury poses greater difficulties in their treatment and rehabilitation. Therefore, managing such injuries is relatively complex owing to their rarity and characteristics. Here, we introduce the unusual treatment of a patient with a skull defect who suffered from severe open craniocerebral injury caused by a crash of a tractor at home. Case Presentation History A 66-year-old male patient with a right frontotemporal skull defect due to a high-altitude fall accident 7 years ago was admitted to our emergency department due to a crash with a tractor in his head and loss of consciousness for 3 hours. His family members explained that he was injured by a mental attack when the mending tractor was at home, and the tractor part cracked the frontal bone, accompanied by overflow of brain tissue. The injury was associated with immediate coma and bleeding from the bilateral nasal cavities. After being sent to the local hospital and given simple bandaging, the patient was transported to our hospital by a 120 emergency vehicle with no history of vomiting or seizures. Owing to the disorder of vital signs, the patient underwent tracheal intubation in the emergency department; moreover, two peripheral venous catheters were inserted, and physiological saline was administered. Examination Neurological examination revealed a Glasgow Coma Scale (GCS) score of 6/15. The forehead surgical dressing was soaked in a mixture composed of cerebrospinal fluid, fresh blood, and brain tissue. In the left frontal area, a local bleeding skin wound with an irregular shape was found, with the presence of necrotic brain tissue and bone chips exiting the wound and high pressure at the skull defect. The injury was accompanied by bilateral eyelid swelling, bilateral pupillary dilatation (2.5 mm) unresponsive to light, and bleeding through the bilateral nasal cavities. There was no evidence of any other injury. A noncontrast axial computed tomographic (CT) scan showed a hit on the left frontal area and a multifragmented fracture of the bilateral frontal and orbital bone with partial defects and partial elevation of the fractured bone fragments. A hemorrhagic contusion in the bilateral frontal area directly next to the injury was accompanied by a subdural hematoma at the skull defect site. Moreover, subarachnoid hemorrhage and ventricular hemorrhage were also observed via CT (Fig. 1 A-F). Because of the clinical status of the patient, a digital subtraction angiogram and magnetic resonance imaging could not be performed. Operation The patient was emergently taken to the operating room (OR) and immediately given broad-spectrum antibiotics supplemented with penicillin (2.5 g, ivgtt). Afterwards, the frontal skin wound was debrided and disinfected with iodophor and hydrogen peroxide. A leftsided hemicoronal craniectomy of approximately 25 cm was performed, and the multifragmented fracture of the frontal bone was debrided via removal of the loose bone fragments. An extended craniotomy was performed along the skin incision, during which the wound came along and was cleaned. Durianaplasty was performed using neuro-patch type material, and the skin wound was sutured after the intracerebral hematoma and contusive brain tissue were evacuated. The patient's spontaneous breathing was restored, and the tracheal tube was removed from the resuscitation room. The pressure at the right frontotemporal skull defect area decreased obviously after surgery. Postoperative brain CT (Fig. 2 A-C) revealed the condition after the removal of the intracerebral hematoma with the occurrence of hemorrhagic imbibition in the bilateral frontal area. The patient was then transferred to the neurosurgery general ward for postoperative management. Postoperative outcome On postoperative day (POD) 2, brain CT revealed mild edematous lesions in the brain. However, the patient suffered persistent coma, with a GCS of 7/15, complicated by intracranial infection in the subsequent 3 days. Lumbar cistern tube placement was performed to ensure continuous drainage of cerebrospinal fluid and control infection. Moreover, the patient received aggressive broad-spectrum antibiotics, which were maintained for 21 days. Intravenous sodium valproate was given for prophylaxis against posttraumatic seizures. No other serious complications were reported after symptomatic supportive measures such as transfusion, anti-infection treatments or nerve nutrition. The patient’s GCS score improved to 11 on POD 15. A postoperative brain CT scan (Fig. 3 A-C) revealed favorable findings. The patient was discharged on POD 24. Postoperative 6-month follow-up evaluation revealed aphasia and left limb mobility disorder, without further seizures. Discussion Open craniocerebral iujruy is less prevalent than closed head injuries but often causes a worse prognosis, especially in patients with skull defects due to a high-altitude fall accident 7 years ago. The following characteristics are associated with this type of patient: (1) The bone window pressure at the site of the skull defect can be used to simply evaluate the patient's intracranial pressure and serve as a substitute for intracranial pressure monitoring; (2) The presence of skull defects alleviates cranial hypertension caused by brain contusions and intracerebral hematomas and delays the occurrence of brain herniation. To date, there is no standardized treatment for such injuries because of the different injury patterns shared by each scenario. However, some general management principles can be applied in almost any case to improve patient outcomes. The first is prehospital disposal and evaluation. According to a case report of an open traumatic brain injury that occurred during work, appropriate prehospitalization assessment of the condition can reduce secondary damage to the brain injury and produce a good prognosis [ 5 ] . In this case, the patient suffered an open head injury due to being hit by a high-speed ejected metal while repairing a tractor at home. Fortunately, the affected area is far from the skull defect. After the injury, the patient was immediately taken to the local hospital for simple bandaging and rapid evaluation of her condition before being transported to our hospital for further treatment. Finally, a good prognosis was achieved. The second limitation is the preoperative examination. Head CT with a bone window is the investigation of choice for all age groups of elevated skull fracture patients because it reveals bony abnormalities as well as any underlying hematoma or brain parenchymal lesions [ 6 , 7 ] . Nontracting CT of the head is the most sensitive imaging modality for identifying open craniocerebral injury, identifying the extent of bone and parenchymal injuries and formulating an operation plan. In cases suspicious for vascular injury, CT cerebral angiography is also needed to evaluate traumatic aneurysm, which may develop after such damage [ 8 ] . The third is operative management. In this study, the patient had a severe low GCS score of 6/15, which could be attributed to 2 points. 1) The primary brain injury caused by the action of metal parts on brain tissue was severe. 2) Secondary intracerebral hematoma and swelling of brain tissue further deepen the patient's level of consciousness impairment, which might oppress the brainstem, leading to a disorder of vital signs. However, timely and effective surgical interventions can improve patient prognosis [ 9 , 10 ] . Generally, the goals of surgical intervention for such injuries are to 1) Remove damaged foreign bodies, fracture fragments, and necrotic brain tissue to achieve thorough debridement. 2) Eliminate any hematomas that develop from the injury. 3) The bone window was expanded for decompression when necessary. According to our study, we designed a semicoronal incision based on the patient's skin laceration, which expanded the bone window along the surgical incision to achieve sufficient compression while removing fragmented bone fragments. However, in some cases, bone fragments are removed only during surgery, which leads to delayed injury and poor prognosis [ 4 , 11 ] . 4) Ensure watertight closure of the dura and prevent CSF leakage [ 12 ] . The fourth stage is postoperative management. 1) Prophylactic antibiotics and antiseizure medications are recommended for the first week [ 13 , 14 ] . In this case, despite adequate debridement and preventive anti-infection treatment, intracranial infection was still inevitable due to severe wound contamination. A lumbar drainage tube and extended use of antibiotics ultimately lead to successful treatment of intracranial infection. 2) Postoperative imaging and follow-up are important for evaluating complications such as delayed intracranial hematoma, posttraumatic hydrocephalus and pulmonary infection, which can be delayed [ 8 ] 3). For severe open craniocerebral injury patients with postoperative coma and intracranial infection, correcting postoperative anemia and strengthening nutritional support may contribute to the recovery of neurological function and trauma. This case report has several limitations. First, because the accidents occurred far from our hospital, the time from injury to the first use of anti-infective drugs was too long. Despite the implementation of relevant measures, intracranial infection is still inevitable. Second, the patient’s GCS score upon arrival was 6/15, with unstable vital signs and the possibility of traumatic cerebral hernia. Thus, immediate surgical decompression was needed, which prevented us from performing digital subtraction angiography, magnetic resonance imaging (MRI) and computed tomography angiography (CTA), thus preventing us from identifying intracranial vascular injury. Conclusion In conclusion, this is a unique case of open craniocerebral injury. Although the surgical and treatment processes are full of risk and uncertainty, we achieved a positive outcome in this challenging patient due to thorough wound debridement, dural repair and broad-spectrum antibiotics. With aggressive treatment, good results are possible despite the nature and extent of the injury. Declarations Ethics approval and consent to participate: The patient’s son gave his oral and written informed consent. The study was approved by the Ethics Committee of Yancheng Third People's Hospital. Consent for publication: All authors gave their consent for publication. Written informed consent was obtained from the patient's son for the publication of the case report and images. A copy of the written consent is available. Availability of data and materials: The authors confirm that the data supporting the findings of this study are available within the article. Competing interests: The authors declare that they have no competing interests. Funding: No funding. Authors' contributions: Haihui QI wrote the main manuscript text and prepared figures 1-3. Mengruo Song, Ya Xu, Zhenglou Chen and Qunfeng Gui Provided such a unique case. All authors reviewed the manuscript. Acknowledgements: Over the course of my researching and writing this paper, I would like to express my thanks to all those who have helped me. First, I would like express my gratitude to all those who helped me during the writing of this case report. I am particularly indebted to Mr. Gui who gave me kind encouragement and useful instruction all through my writing. Sincere gratitude should also go to all my learned Professors and warm-hearted teachers who have greatly helped me in my study as well as in my life. And my warm gratitude also goes to my friends and family who gave me much encouragement and financial support respectively. Moreover, I wish to extend my thanks to the library and the electronic reading room for their providing much useful information for my thesis. References Iaccarino C, Carretta A, Nicolosi F, Morselli C. Epidemiology of severe traumatic brain injury[J]. J Neurosurg Sci. 2018;62(5):535–41. Dewan MC, Rattani A, Gupta S, et al. Estimating the global incidence of traumatic brain injury[J]. J Neurosurg. 2018;130(4):1080–97. Mzimbiri JM, Li J, Bajawi MA, et al. Orbitocranial Low-Velocity Penetrating Injury: A Personal Experience, Case Series, Review of the literature, and Proposed Management Plan[J]. World Neurosurg. 2016;87:26–34. Kumar A, Kankane VK, Jaiswal G, et al. Compound Elevated Skull Fracture Presented as a New Variety of Fracture with Inimitable Entity: Single Institution Experience of 10 Cases[J]. Asian J Neurosurg. 2019;14(2):410–4. Bujok J, Bobinski R, Dutka M, et al. Open craniocerebral trauma in a patient at work: A case report[J]. Work. 2022;72(3):989–95. Bhaskar S. Compound elevated fracture of the cranium[J]. Neurol India. 2010;58(1):149–51. Mohindra S, Singh H, Savardekar A. Importance of an intact dura in management of compound elevated fractures; a short series and literature review[J]. Brain Inj. 2012;26(2):194–8. Atay M, Alkan A, Hanimoglu H, et al. CT angiography evaluation of unusual transorbital penetrating injury: a toothbrush[J]. J Neuroimaging. 2013;23(2):314–6. Sawa B, Assoumane I, Ngoko Y, et al. Delays in a traumatic brain injury: A case report[J]. Trop Doct. 2022;52(1):147–50. Adeolu AA, Shokunbi MT, Malomo An O, et al. Compound elevated skull fracture: a forgotten type of skull fracture[J]. Surg Neurol. 2006;65(5):503–5. Borkar SA, Prasad GL, Gupta DK et al. Compound elevated skull fracture: A clinical series of three patients with a review of the literature[J].Turkish neurosurgery, 2013, 23(4). Gupta R, Iyengar R, Kayal A, et al. Elevated Skull Fractures: an Under-Recognized Entity[J]. Indian J Surg. 2015;77(Suppl 3):1308–12. Abu Talha K, Selvapandian S, Asaduzzaman K, et al. Compound elevated skull fracture with occlusion of the superior sagittal sinus. A case report[J]. Kobe J Med Sci. 2009;54(5):260–3. Sharma R, Saligouda P, Bhat DI, et al. Compound elevated skull fracture mimicking a frontotemporoorbitozygomatic craniotomy flap[J]. Neurol India. 2012;60(4):448–9. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3950891","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":273277564,"identity":"461cc5a1-8bb0-4803-b375-2ac6842db5fb","order_by":0,"name":"Haihui Qi","email":"","orcid":"","institution":"The Sixth Affiliated Hospital of Nantong University (Yancheng Third People's Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Haihui","middleName":"","lastName":"Qi","suffix":""},{"id":273277565,"identity":"879bba75-7115-4c2a-912e-f2fb2b0fc4f3","order_by":1,"name":"Mengruo Song","email":"","orcid":"","institution":"The Sixth Affiliated Hospital of Nantong University (Yancheng Third People's Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Mengruo","middleName":"","lastName":"Song","suffix":""},{"id":273277566,"identity":"63bba72f-1331-4022-b390-caeda14c3fde","order_by":2,"name":"Ya Xu","email":"","orcid":"","institution":"The Sixth Affiliated Hospital of Nantong University (Yancheng Third People's Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Ya","middleName":"","lastName":"Xu","suffix":""},{"id":273277567,"identity":"d173471d-cc7c-482c-9939-b6446cd997d1","order_by":3,"name":"Zhenglou Chen","email":"","orcid":"","institution":"The Sixth Affiliated Hospital of Nantong University (Yancheng Third People's Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Zhenglou","middleName":"","lastName":"Chen","suffix":""},{"id":273277568,"identity":"0bc5b869-ce6a-4ff3-a451-a64052e2bc74","order_by":4,"name":"Qunfeng Gui","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYFACxgYgIQfEzAcYEkjQYgzEbAnEagEDkBYeA+LUykckN97m3WEgZ86/5vOHhzvsGPjbu/FbZngjsdma94yBseWMt9skEs8kM0icObsBv5YZiW3SvG1/EjfcOLuNIbGNmcFAIpcoLQb1G26cefwhsa2esBZ5CYiWBIPzPQxA9mHCWgx4HjZbzm0zMNxwg80MqOU4D0G/yLenP7zxts1A3uD84ccff7ZVy/G39xKw5QADgwSYJZEApnjwKgfb0gDTwn+AoOJRMApGwSgYoQAALDVJlKUhGMQAAAAASUVORK5CYII=","orcid":"","institution":"The Sixth Affiliated Hospital of Nantong University (Yancheng Third People's Hospital)","correspondingAuthor":true,"prefix":"","firstName":"Qunfeng","middleName":"","lastName":"Gui","suffix":""}],"badges":[],"createdAt":"2024-02-12 11:45:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3950891/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3950891/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51388838,"identity":"be09724b-b166-4a63-ba11-3f1bc7436be2","added_by":"auto","created_at":"2024-02-20 18:07:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1129296,"visible":true,"origin":"","legend":"\u003cp\u003eA-D. Clinical image showing a multifragmented fracture of the bilateral frontal and orbital bones with partial defects and partial elevation of the fractured bone fragments. B. Three‑dimensional reconstructions of the skull showing the right frontotemporal skull defect. E-F. CT scan showing hemorrhagic contusion, subdural hematoma, subarachnoid hemorrhage and ventricular hemorrhage.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3950891/v1/a1191909bbd1b8cd2739d9c8.png"},{"id":51388840,"identity":"7b81e714-f513-4355-aa0b-6e06ddb011bc","added_by":"auto","created_at":"2024-02-20 18:07:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":384053,"visible":true,"origin":"","legend":"\u003cp\u003eA. Postoperative brain CT showing thorough skull debridement. B. Postoperative changes after removal of the intracranial hematoma and brain contusion. C. CT scan showing a high-density corrosion cast on the ventricular system.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3950891/v1/e090d34e9d8598af048eabb2.png"},{"id":51388839,"identity":"250029a5-94bf-42fe-bc25-e597d9cedf61","added_by":"auto","created_at":"2024-02-20 18:07:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":298628,"visible":true,"origin":"","legend":"\u003cp\u003eA-C. CT of the brain taken on postoperative day 18 showing complete absorption of the hematoma and normal ventricular system.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-3950891/v1/bcd25c9c9c3077dd3e983ff3.png"},{"id":61031395,"identity":"5236093e-c80c-4173-888d-e0b4ecf816e1","added_by":"auto","created_at":"2024-07-24 19:37:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3007097,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3950891/v1/3521bb40-f2be-4764-8271-d48c565ed7ac.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Management of open craniocerebral injury in a patient with a skull defect: a case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn our modern industrialized environment, traumatic brain injury (TBI) contributes to worldwide death and disability more than any other traumatic insult. It is estimated that nearly 69\u0026nbsp;million individuals suffer TBI from all causes each year, with Southeast Asia experiencing the greatest overall burden of disease\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Severe craniocerebral injury often occurs in young healthy men, and the causes of most such injuries range from traffic accidents and falls to accidents due to the impact of a moving object and assults\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. To date, open craniocerebral injury in patients with skull defects is a peculiar accident and is relatively rare. First, open craniocerebral injury is associated with a high risk of morbidity and mortality due to relevant infection, seizures, vascular injury and cerebrospinal fluid leakage\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Second, for patients with skull defects, secondary traumatic brain injury poses greater difficulties in their treatment and rehabilitation. Therefore, managing such injuries is relatively complex owing to their rarity and characteristics. Here, we introduce the unusual treatment of a patient with a skull defect who suffered from severe open craniocerebral injury caused by a crash of a tractor at home.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003e \u003cb\u003eHistory\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA 66-year-old male patient with a right frontotemporal skull defect due to a high-altitude fall accident 7 years ago was admitted to our emergency department due to a crash with a tractor in his head and loss of consciousness for 3 hours. His family members explained that he was injured by a mental attack when the mending tractor was at home, and the tractor part cracked the frontal bone, accompanied by overflow of brain tissue. The injury was associated with immediate coma and bleeding from the bilateral nasal cavities. After being sent to the local hospital and given simple bandaging, the patient was transported to our hospital by a 120 emergency vehicle with no history of vomiting or seizures. Owing to the disorder of vital signs, the patient underwent tracheal intubation in the emergency department; moreover, two peripheral venous catheters were inserted, and physiological saline was administered.\u003c/p\u003e \u003cp\u003e \u003cb\u003eExamination\u003c/b\u003e \u003c/p\u003e \u003cp\u003eNeurological examination revealed a Glasgow Coma Scale (GCS) score of 6/15. The forehead surgical dressing was soaked in a mixture composed of cerebrospinal fluid, fresh blood, and brain tissue. In the left frontal area, a local bleeding skin wound with an irregular shape was found, with the presence of necrotic brain tissue and bone chips exiting the wound and high pressure at the skull defect. The injury was accompanied by bilateral eyelid swelling, bilateral pupillary dilatation (2.5 mm) unresponsive to light, and bleeding through the bilateral nasal cavities. There was no evidence of any other injury. A noncontrast axial computed tomographic (CT) scan showed a hit on the left frontal area and a multifragmented fracture of the bilateral frontal and orbital bone with partial defects and partial elevation of the fractured bone fragments. A hemorrhagic contusion in the bilateral frontal area directly next to the injury was accompanied by a subdural hematoma at the skull defect site. Moreover, subarachnoid hemorrhage and ventricular hemorrhage were also observed via CT (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA-F). Because of the clinical status of the patient, a digital subtraction angiogram and magnetic resonance imaging could not be performed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eOperation\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe patient was emergently taken to the operating room (OR) and immediately given broad-spectrum antibiotics supplemented with penicillin (2.5 g, ivgtt). Afterwards, the frontal skin wound was debrided and disinfected with iodophor and hydrogen peroxide. A leftsided hemicoronal craniectomy of approximately 25 cm was performed, and the multifragmented fracture of the frontal bone was debrided via removal of the loose bone fragments. An extended craniotomy was performed along the skin incision, during which the wound came along and was cleaned. Durianaplasty was performed using neuro-patch type material, and the skin wound was sutured after the intracerebral hematoma and contusive brain tissue were evacuated. The patient's spontaneous breathing was restored, and the tracheal tube was removed from the resuscitation room. The pressure at the right frontotemporal skull defect area decreased obviously after surgery. Postoperative brain CT (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA-C) revealed the condition after the removal of the intracerebral hematoma with the occurrence of hemorrhagic imbibition in the bilateral frontal area. The patient was then transferred to the neurosurgery general ward for postoperative management.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePostoperative outcome\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOn postoperative day (POD) 2, brain CT revealed mild edematous lesions in the brain. However, the patient suffered persistent coma, with a GCS of 7/15, complicated by intracranial infection in the subsequent 3 days. Lumbar cistern tube placement was performed to ensure continuous drainage of cerebrospinal fluid and control infection. Moreover, the patient received aggressive broad-spectrum antibiotics, which were maintained for 21 days. Intravenous sodium valproate was given for prophylaxis against posttraumatic seizures. No other serious complications were reported after symptomatic supportive measures such as transfusion, anti-infection treatments or nerve nutrition. The patient\u0026rsquo;s GCS score improved to 11 on POD 15. A postoperative brain CT scan (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA-C) revealed favorable findings. The patient was discharged on POD 24. Postoperative 6-month follow-up evaluation revealed aphasia and left limb mobility disorder, without further seizures.\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eOpen craniocerebral iujruy is less prevalent than closed head injuries but often causes a worse prognosis, especially in patients with skull defects due to a high-altitude fall accident 7 years ago. The following characteristics are associated with this type of patient: (1) The bone window pressure at the site of the skull defect can be used to simply evaluate the patient's intracranial pressure and serve as a substitute for intracranial pressure monitoring; (2) The presence of skull defects alleviates cranial hypertension caused by brain contusions and intracerebral hematomas and delays the occurrence of brain herniation. To date, there is no standardized treatment for such injuries because of the different injury patterns shared by each scenario. However, some general management principles can be applied in almost any case to improve patient outcomes.\u003c/p\u003e \u003cp\u003eThe first is prehospital disposal and evaluation. According to a case report of an open traumatic brain injury that occurred during work, appropriate prehospitalization assessment of the condition can reduce secondary damage to the brain injury and produce a good prognosis\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. In this case, the patient suffered an open head injury due to being hit by a high-speed ejected metal while repairing a tractor at home. Fortunately, the affected area is far from the skull defect. After the injury, the patient was immediately taken to the local hospital for simple bandaging and rapid evaluation of her condition before being transported to our hospital for further treatment. Finally, a good prognosis was achieved.\u003c/p\u003e \u003cp\u003eThe second limitation is the preoperative examination. Head CT with a bone window is the investigation of choice for all age groups of elevated skull fracture patients because it reveals bony abnormalities as well as any underlying hematoma or brain parenchymal lesions\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Nontracting CT of the head is the most sensitive imaging modality for identifying open craniocerebral injury, identifying the extent of bone and parenchymal injuries and formulating an operation plan. In cases suspicious for vascular injury, CT cerebral angiography is also needed to evaluate traumatic aneurysm, which may develop after such damage\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe third is operative management. In this study, the patient had a severe low GCS score of 6/15, which could be attributed to 2 points. 1) The primary brain injury caused by the action of metal parts on brain tissue was severe. 2) Secondary intracerebral hematoma and swelling of brain tissue further deepen the patient's level of consciousness impairment, which might oppress the brainstem, leading to a disorder of vital signs. However, timely and effective surgical interventions can improve patient prognosis\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Generally, the goals of surgical intervention for such injuries are to 1) Remove damaged foreign bodies, fracture fragments, and necrotic brain tissue to achieve thorough debridement. 2) Eliminate any hematomas that develop from the injury. 3) The bone window was expanded for decompression when necessary. According to our study, we designed a semicoronal incision based on the patient's skin laceration, which expanded the bone window along the surgical incision to achieve sufficient compression while removing fragmented bone fragments. However, in some cases, bone fragments are removed only during surgery, which leads to delayed injury and poor prognosis\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. 4) Ensure watertight closure of the dura and prevent CSF leakage \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe fourth stage is postoperative management. 1) Prophylactic antibiotics and antiseizure medications are recommended for the first week\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. In this case, despite adequate debridement and preventive anti-infection treatment, intracranial infection was still inevitable due to severe wound contamination. A lumbar drainage tube and extended use of antibiotics ultimately lead to successful treatment of intracranial infection. 2) Postoperative imaging and follow-up are important for evaluating complications such as delayed intracranial hematoma, posttraumatic hydrocephalus and pulmonary infection, which can be delayed\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e 3). For severe open craniocerebral injury patients with postoperative coma and intracranial infection, correcting postoperative anemia and strengthening nutritional support may contribute to the recovery of neurological function and trauma.\u003c/p\u003e \u003cp\u003eThis case report has several limitations. First, because the accidents occurred far from our hospital, the time from injury to the first use of anti-infective drugs was too long. Despite the implementation of relevant measures, intracranial infection is still inevitable. Second, the patient\u0026rsquo;s GCS score upon arrival was 6/15, with unstable vital signs and the possibility of traumatic cerebral hernia. Thus, immediate surgical decompression was needed, which prevented us from performing digital subtraction angiography, magnetic resonance imaging (MRI) and computed tomography angiography (CTA), thus preventing us from identifying intracranial vascular injury.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eIn conclusion, this is a unique case of open craniocerebral injury. Although the surgical and treatment processes are full of risk and uncertainty, we achieved a positive outcome in this challenging patient due to thorough wound debridement, dural repair and broad-spectrum antibiotics. With aggressive treatment, good results are possible despite the nature and extent of the injury.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe patient\u0026rsquo;s son gave his oral and written informed consent. The study was approved by the Ethics Committee of Yancheng Third People\u0026apos;s Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eAll authors gave their\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003econsent\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003efor\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003epublication.\u003c/em\u003e Written informed consent was obtained from the patient\u0026apos;s son for the publication of the case report and images. A copy of the written consent is available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe authors confirm that the data supporting the findings of this study are available within the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e Haihui QI wrote the main manuscript text and prepared figures 1-3. Mengruo Song, Ya Xu, Zhenglou Chen and Qunfeng Gui Provided such a unique case. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eOver the course of my researching and writing this paper, I would like to express my thanks to all those who have helped me. First, I would like express my gratitude to all those who helped me during the writing of this case report. I am particularly indebted to Mr. Gui who gave me kind encouragement and useful instruction all through my writing. Sincere gratitude should also go to all my learned Professors and warm-hearted teachers who have greatly helped me in my study as well as in my life. And my warm gratitude also goes to my friends and family who gave me much encouragement and financial support respectively. Moreover, I wish to extend my thanks to the library and the electronic reading room for their providing much useful information for my thesis.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eIaccarino C, Carretta A, Nicolosi F, Morselli C. Epidemiology of severe traumatic brain injury[J]. J Neurosurg Sci. 2018;62(5):535\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDewan MC, Rattani A, Gupta S, et al. Estimating the global incidence of traumatic brain injury[J]. J Neurosurg. 2018;130(4):1080\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMzimbiri JM, Li J, Bajawi MA, et al. Orbitocranial Low-Velocity Penetrating Injury: A Personal Experience, Case Series, Review of the literature, and Proposed Management Plan[J]. World Neurosurg. 2016;87:26\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar A, Kankane VK, Jaiswal G, et al. Compound Elevated Skull Fracture Presented as a New Variety of Fracture with Inimitable Entity: Single Institution Experience of 10 Cases[J]. Asian J Neurosurg. 2019;14(2):410\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBujok J, Bobinski R, Dutka M, et al. Open craniocerebral trauma in a patient at work: A case report[J]. Work. 2022;72(3):989\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhaskar S. Compound elevated fracture of the cranium[J]. Neurol India. 2010;58(1):149\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohindra S, Singh H, Savardekar A. Importance of an intact dura in management of compound elevated fractures; a short series and literature review[J]. Brain Inj. 2012;26(2):194\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtay M, Alkan A, Hanimoglu H, et al. CT angiography evaluation of unusual transorbital penetrating injury: a toothbrush[J]. J Neuroimaging. 2013;23(2):314\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSawa B, Assoumane I, Ngoko Y, et al. Delays in a traumatic brain injury: A case report[J]. Trop Doct. 2022;52(1):147\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdeolu AA, Shokunbi MT, Malomo An O, et al. Compound elevated skull fracture: a forgotten type of skull fracture[J]. Surg Neurol. 2006;65(5):503\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorkar SA, Prasad GL, Gupta DK et al. Compound elevated skull fracture: A clinical series of three patients with a review of the literature[J].Turkish neurosurgery, 2013, 23(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGupta R, Iyengar R, Kayal A, et al. Elevated Skull Fractures: an Under-Recognized Entity[J]. Indian J Surg. 2015;77(Suppl 3):1308\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbu Talha K, Selvapandian S, Asaduzzaman K, et al. Compound elevated skull fracture with occlusion of the superior sagittal sinus. A case report[J]. Kobe J Med Sci. 2009;54(5):260\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma R, Saligouda P, Bhat DI, et al. Compound elevated skull fracture mimicking a frontotemporoorbitozygomatic craniotomy flap[J]. Neurol India. 2012;60(4):448\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Open craniocerebral injury, Skull defect, Computed tomography, Early debridement","lastPublishedDoi":"10.21203/rs.3.rs-3950891/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3950891/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eOpen craniocerebral injury is a bodily injury that is characterized by high mortality and poor prognosis. This type of trauma occurs in patients with skull defects; this is a peculiar accident and is relatively rare. Because of its rarity, the treatments for such injuries are complex and nonstandardized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation: \u003c/strong\u003eWe present the case of a 66-year-old male with a right frontotemporal skull defect who was hit by a tractor in his head and was accompanied by loss of consciousness for 3 h. Computer tomography (CT) demonstrated a hit on the left frontal area and a multifragmented fracture of the bilateral frontal and orbital bone with partial defects and partial elevation of the fractured bone fragments. A hemorrhagic contusion in the bilateral frontal area directly next to the injury was accompanied by a subdural hematoma at the skull defect site, subarachnoid hemorrhage, or ventricular hemorrhage. Early debridement, hematoma evacuation, and decompressive craniectomy were performed, and the patient achieved good postoperative recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e In this study, we discussed the clinical presentation and successful management of this unique injury in a patient with a skull defect. Our goal is to demonstrate certain general management principles that can improve patient outcomes.\u003c/p\u003e","manuscriptTitle":"Management of open craniocerebral injury in a patient with a skull defect: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-20 18:07:36","doi":"10.21203/rs.3.rs-3950891/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1bf5488f-ae49-4830-9904-c2ff22bb5827","owner":[],"postedDate":"February 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-24T19:29:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-20 18:07:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3950891","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3950891","identity":"rs-3950891","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}