2025/02/01 by Jeffrey M. Breton, Stefan T. Prvulovic, Rocco A. Armonda +2 · 1 voice
Medicine · #Traumatic Ocular and Foreign Body Injuries #Trauma Management and Diagnosis #Traumatic Brain Injury Research
paper · pdf · doi:10.1093/bjs/znae324
openalex publication_date 2025/02/01 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/30
This case (Video 1) outlines the surgical treatment of a 54-year-old male soldier who suffered a penetrating traumatic brain injury from a drone attack during the war in Ukraine. Although the patient had been equipped with a Kevlar helmet, he experienced a severe ‘under body armour’ injury with bony implosion near the coronal suture, approximately 2 cm right of midline. Such injuries are associated with significant potential morbidity and require timely intervention to maximize the chance for survival and recovery1–5. Initial assessment revealed a Glasgow Coma Scale (GCS) of 8 and the patient underwent endotracheal intubation. Drone strike in Ukraine causing significant penetrating traumatic brain injury: vascular insights A CT scan of the head revealed subarachnoid haemorrhage within the interhemispheric fissure, with multiple bone fragments, including some perforating the falx cerebri, raising suspicion for possible damage to vascular structures, including the anterior cerebral artery. The patient underwent diagnostic cerebral angiography on admission, followed by operative elevation and debridement of this open, depressed skull fracture. Preoperative angiography was imperative to rule out vascular injury, including traumatic arterial dissection and possible pseudoaneurysm formation. In the operating room, the patient was placed in a supine position with Mayfield clamp and pins for rigid fixation. The incision did not include the entry site and pre-incision hydropreparation with local anaesthetic and adrenaline was performed to allow for mobilization of a large pericranial flap. A broad craniotomy surrounding the area of bony implosion was performed to obtain adequate visualization of the interhemispheric fissure and enable the safe removal of bone fragments. Using high-powered operative microscopy, bone fragments embedded in the brain parenchyma and between the branches of the anterior cerebral artery (ACA) were mobilized and removed. Although the preoperative angiogram did not reveal vessel injury, intraoperative visualization confirmed the proximity of bone fragments to ACA branches with compression from sharp bony edges. As decompression was not necessary in this case, primary mesh cranioplasty was performed after bone fragment removal, minimizing the need for future surgery and facilitating the initiation of formal rehabilitation. After the operation, the patient’s neurological condition improved significantly. On the first postoperative day, the GCS was recorded at 10 and by the seventh day it had risen to 12 with persistent left hemiparesis still present. Within one month, the GCS reached 15, with marked improvement in hemiparesis and left-sided strength was measured at 4/5. The patient’s recovery continues to progress with rehabilitation. Significant penetrating cranial injury can occur even while wearing body armour. Early angiography is essential to evaluate for traumatic arterial injury, particularly in patients with injuries involving the Sylvian or interhemispheric fissures. Microsurgical removal of bone fragments should be the standard in such cases, with exposure and vascular control similar to microsurgical clipping of intracranial aneurysms. When decompression is not required, early cranioplasty offers multiple advantages, by eliminating planned return to the operating room for delayed cranioplasty and faster initiation of rehabilitation. Vessel injury may be seen under the microscope, even if not yet diagnosed on angiography. This study did not receive any funding or financial support. This material has not previously been presented or published and has not been submitted to another journal for consideration. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Consent was obtained 2 months after the injury, after the patient was already conscious and came to our centre for a follow-up examination. The consent is written and signed in the Ukrainian language and includes permission to use the results of the clinical examination, neuroimaging study (CT of the brain before and after surgery), intraoperative photos and videos, for scientific and scientific research purposes, and the creation of educational films. The informed consent is stored in paper form, along with the patient’s medical record, in the hospital archive for 25 years. Jeffrey Breton (Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Supervision, Visualization, Writing—original draft, Writing—review & editing), Stefan Prvulovic (Investigation, Methodology, Resources, Writing—original draft, Writing—review & editing), Rocco Armonda (Conceptualization, Methodology, Project administration, Supervision, Visualization, Writing—original draft, Writing—review & editing), Yurii Cherednychenko (Conceptualization, Investigation, Methodology, Resources, Visualization, Writing—review & editing), and Andrii Sirko (Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Supervision, Visualization, Writing—original draft, Writing—review & editing) All relevant data are incorporated into the article and its online supplementary material.