Early multimodal neurointerventional and neurosurgical management of penetrating craniocerebral injuries: wartime experience from Ukraine.

Objective: The war in Ukraine has resulted in a large number of penetrating head wounds with concomitant neurovascular injuries. The aim of this report was to review these patients and demonstrate a multimodal treatment approach used for these complex injuries. This entails a combination of early endovascular and open surgical treatment for optimal outcome.

Methods: This is a prospective study from a single civilian clinical center near the combat frontlines in Dnipro, Ukraine (Mechnikov Dnipropetrovsk Regional Clinical Hospital [MDRCH]). All injuries were sustained during Russia's invasion. Data were collected for a 28-month period from February 24, 2022, to June 24, 2024. The patients with intracranial neurovascular injuries were evaluated and their management and outcomes were documented and analyzed.

Results: Within the study period, 1310 patients with head and neck injuries underwent invasive angiography and, of these, 20 patients (1.5%) were diagnosed with intracranial arterial traumatic injury including traumatic intracranial aneurysms or arteriovenous fistulas. On admission, the Glasgow Coma Scale score ranged from 5 to 15 (median 10). A total of 15 patients (75.0%) were diagnosed with traumatic intracranial aneurysm(s), 2 (10.0%) with traumatic direct carotid cavernous fistulas, and 3 patients (15.0%) had traumatic dural arteriovenous fistulas. In 8 patients (40.0%), there was concurrent damage to the paranasal sinuses. Autologous tissue was used for skull base reconstruction in all cases. Endovascular intervention was performed in 14 patients (70.0%). Surgical intervention immediately followed angiography or endovascular intervention in 14 patients (70.0%). The length of stay at the MDRCH ranged from 3 to 20 days (mean 8.6 days). The Glasgow Coma Scale score at the time of discharge ranged from 8 to 15 (median 13). There was 1 death (5.0%) due to sequelae of severe vasospasm. The Glasgow Outcome Scale score at 1 month after the injury in the other 19 patients ranged from 2 to 5 (median 4).

Conclusions: Early angiographic diagnosis of traumatic neurovascular complications after penetrating head injury allows for their effective management and treatment. The authors propose early comprehensive endovascular and surgical intervention for penetrating craniocerebral injuries. This case series demonstrates that this approach may optimize outcomes in wartime neurovascular injuries.