Surgical management of penetrating brain injury.

C. Options Treatment of small entrance bullet wounds to the head with local wound care and closure in patients whose scalp is not devitalized and have no “significant” intracranial pathologic findings is recommended. (Note: The term “significant” has yet to be clearly defined. However, the volume and location of the brain injury, evidence of mass effect, e.g., displacement of the midline 5 mm or compression of basilar cisterns from edema or hematoma, and the patient’s clinical condition all pertain to significance.) Treatment of more extensive wounds with nonviable scalp, bone, or dura with more extensive debridement before primary closure or grafting to secure a watertight wound is recommended. In patients with significant fragmentation of the skull, debridement of the cranial wound with either craniectomy or craniotomy is recommended. In the presence of significant mass effect, debridement of necrotic brain tissue and safely accessible bone fragments is recommended. Evacuation of intracranial hematomas with significant mass effect is recommended. In the absence of significant mass effect, surgical debridement of the missile track in the brain is not recommended, on the basis of Class III evidence that outcomes are not measurably worse in patients who do not have aggressive debridement. Routine surgical removal of fragments lodged distant from the entry site and reoperation solely to remove retained bone or missile fragments are not recommended. Repair of an open-air sinus injury with watertight closure of the dura is recommended. Clinical circumstances dictate the timing of the repair. Any repairs requiring duraplasty can be at the discretion of the surgeon as to material used for closure.