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IRREVERSIBILITY OF ANTIANDROGENIC EFFECT OF LAMBDA-CYHALOTHRIN AFTER THE RECOVERY PERIOD IN THE STUDY ON MALE WISTAR HAN RATS
Prodanchuk N. G., Shepelskaya N. R., Kolianchuk Y. V., Evtushenko T. V.
Abstract. Previously conducted studies showed endocrine-disruptor properties of pyrethroids when exposed to mammals, causing disturbances in the reproductive system.
The purpose of these studies was to identify the hazard of lambda cyhalothrin (LCT) reproductive toxicity, as well as to study the reversibility and/or irreversibility of the resulting damage during the recovery period.
Research methods. Lambda-cyhalothrin 98.06% of purity was administered ex tempore daily, except Saturday and Sunday, by oral gavage to three groups of animals in doses 0,3; 3,0 and 10 mg/kg of body weight for 11 weeks. After the expiry of the exposure period, part of the males was selected to study the parameters of sperm and blood serum testosterone levels, while the remaining males were used for a recovery period without exposure for one full cycle of spermatogenesis (70 days). Morpho-functional indicators of the gonad state and the level of total testosterone in the blood serum were studied in all males after exposure and recovery period. The total amount and the absolute and relative number of motile sperm were determined, the percent of sperm abnormal forms was calculated. Morphometric parameters of testes and epididymis were recorded.
Results. Investigated LCT causes antiandrogenic effect which characterized by impaired of spermatogenesis and oligospermia, as well as a change in the testosterone content in the blood serum of experimental animals compared to the control. Dose dependence of the severity of oligospermia and spermatozoa adynamia is linear in nature both before and after the recovery period, increasing markedly at the end of the recovery period. While the response level of testosterone to increase of the dose is non-monotonic.The most pronounced statistically significant (P <0.01) decrease in the level of testosterone relative to the control is noted at the end of exposure at the dose of 3.0 mg/kg of body weight. When exposed to the minimum and maximum doses, there is a tendency for this parameter to decrease as compared with the control. After the recovery period, the minimum and maximum doses cause the tendency to increase in testosterone compared with the control, while the middle dose of LCT, significantly (P <0.05) induces a decrease in the content of this hormone relative to the control. The analysis of the qualitative and quantitative characteristics of the observed effects at the end of the exposure and recovery periods allows to presume that the tested LCT is irreversible xeno-agonists of estrogenic receptors with an intermediate degree of activity, causing damage to Sertoli cells and the spermogonial population of the germinative cells, depending on the dose level of exposure. The parameters characterizing the processes of spermatogenesis, and the testosterone content did not reach the control level during the recovery period, this indicates the irreversibility of the antiandrogenic effect for 10 weeks, and possibly the complete irreversibility of the observed effects. The systemic toxic effect, induced by the maximum dose tested and characterized by a decrease in the animals body weight, is reversible.
Within the studied range of doses in the experiment on the males of Wistar Han rats, no-observed effect level (NOEL) of LCT is the dose of 0,3 mg/kg of body weight, the low-observed effect level (LOEL) is 3 mg/kg of body weight. Maximum tolerated dose is 10 mg/kg of body weight.
Conclusions. The test system for the gonadotoxic activity identification is an adequate, highly sensitive methodological approach for testing the toxic effects of endocrine-disruptors.
Key words: lambda-cygalothrin, Wistar rats, anti-androgenic effect, recovery period, irreversibility.
Рецензент - проф. Костенко В. О.
Стаття наджшла 20.11.2018 року
DOI 10.29254/2077-4214-2018-4-2-147-181-186 UDC 616.714+616.831+616.216]-001.45-089:355.422 12Sirko A. G., 2Pilipenko G. S., 3Tonchiev M. D.
SURGICAL TREATMENT OF COMBAT CRANIOCEREBRAL GUNSHOT WOUNDS COMBINED WITH PARANASAL SINUSES INJURY 1Dnipropetrovsk Medical Academy, State Institution, Ministry of Healthcare of Ukraine (Dnipro) 2Municipal Institution, Mechnikov Dnipropetrovsk Regional Clinical Hospital (Dnipro) 3Municipal Institution, Sklifosovskyi Poltava Regional Clinical Hospital (Poltava)
Publication relation to planned scientific research projects. This paper is a fragment of the research thesis work: Development of Methods of Diagnosis, Treatment, and Outcomes Forecast in Acute, Intermediate, and Distant Period of Traumatic Brain Injury and Craniocerebral Wounds, subject code: IH. 22.17, state registration number 0117U006495.
Introduction. Skull base injuries caused by highspeed destruction objects during military operations are fundamentally different from the most injuries of civilian population. Two important aspects regarding
combat-related injuries include weapons kinetics and characteristics of the most common wounds [1]. During Operation Iraqi Freedom and Operation Enduring Freedom, 25% to 40% of American patients had head, face, or neck wounds [2,3]. Skull and brain gunshot wounds were observed in 33.5% of all gunshot wounds of different head parts in local armed conflict in the Eastern Ukraine in 2014 [4,5]. High percentage of head and neck injuries is due to the fact that head and neck are not protected by body armors which are used nowadays by the military in the field [6].
Combat-related gunshot traumatic brain injuries combined with paranasal sinus damages are an important subgroup of fragment (bullet) traumatic brain injuries. Before penetrating into the skull through the anterior part of its base, a fragment crosses facial and orbital sections of the skull. Fragment passing through the face, eye sockets, structures of paranasal sinuses, and skull base creates an open, stable connection between subarachnoid cavity and cavities filled with air and lined with mucous membrane [7]. The most threatening are bacteria that live in oral cavity, in particular on larynx (staphylococci), or gram-positive or gram-negative cocci that contaminate the wound upon fragment penetration [8,9].
Much less common are cases when a fragment crosses skull roof and base and goes outside through maxillofacial area [10]. Fractures of skull base, including frontal sinuses and ethmoid sinuses, can be present without brain injury due to explosive wave. High speed bullets are able to split the skull base without crossing it [11]. In fact, it appeared that size and location of the fracture of anterior section of the skull base are factors contributing to infection and meningitis, regardless of rhinorrhea [12].
In any of these situations, connection of cerebrospinal fluid location with potentially infected sinuses filled with air and lined with mucous membranes is established, and such patients are prone infectious complications. The risk of purulent complications is the highest if fragment (bullet) trajectory goes through the skull base, especially when air sinuses and eye socket are perforated [9,13,14]. Such patients may suffer from recurrent meningitis, brain abscess, and hydrocephalus.
Anterior section of skull base is more likely to be wounded by fragments than other areas of skull base. A pathoanatomical study showed that this area suffered in 82% of cases [11]. According to the survey of patients in the Eastern Ukraine in 2014, it was found that 28% of patients had skull base injuries [4]. Anterior cranial fossa damage was diagnosed in 21% of patients; middle cranial fossa (petrous pyramid), in 6% of patients; of both anterior and middle cranial fossa, in 0.8% of patients.
Although TBI cases are well documented, especially in military medical literature, fragment (bullet) injuries of anterior part of skull base are rarely described as a separate subgroup of injuries [15].
At any time, treatment of combat-related gunshot traumatic brain injuries involving paranasal sinuses requires solution of the two issues: treatment of the brain injury itself and sealing of intracranial contents in order to prevent the infection [6]. Note that there is no consistent approach to management of such patients (surgical treatment or conservative therapy); there is uncertainty in surgical intervention timing (urgent, delayed) and its extent and high percentage of complications upon treatment of such category of patients people (nasal liquorrhea, meningitis, encephalitis, brain abscess, post-traumatic hydrocephalus) [14,16,17]. Thus, the problem of treatment of combat-related gunshot traumatic brain injuries with involvement of paranasal sinuses is poorly solved yet and requires further clinical research to select the optimal treatment approach and improve the outcomes.
The purpose of this paper is a prospective analysis of outcomes of surgical treatment of combat-related gunshot traumatic brain injuries (GTBI) involving paranasal sinuses (PNS).
Object and methods. The research was based on analysis of results of comprehensive prospective examination and treatment of 30 patients with combat-related gunshot traumatic brain injuries (GTBI) involving the paranasal sinuses (PNS). The injuries resulted from local armed conflict in the Eastern Ukraine. The patients were admitted to the Municipal Institution, Mechnikov Dnipropetrovsk Regional Clinical Hospital from May 25, 2014 to December 31, 2017 inclusive. During this period, a total of 184 patients with combat-related gunshot traumatic brain injuries underwent treatment in the Hospital. Thus, combination of traumatic brain injuries with paranasal sinus injury occurred in 16.3% of all patients.
Consciousness was assessed according to Glasgow Coma Score (GCS). Patients status on admission to the in-patient department was assessed according to the Injury Severity Score (ISS). In combined wounds, patients were also examined by ENT specialists and maxillofacial surgeons.
All patients with open head wounds underwent standard set of examinations which included craniogra-phy, lumbar puncture, and high-resolution brain spiral computed tomography (SCT). Brain SCT was performed on Hi Speed CT/e Dual (General Electric). Scanning was performed with a standard slice thickness of 10 mm or, for more detailed examination, of 5 mm or less. The field of view in all cases included all sections of patient's head and upper cervical vertebrae (C1-C3).
During brain CT, the brain matter, ventricular system, subarachnoidal, subdural and epidural spaces, skull bones, and soft head tissues were sequentially studied. Skull bones condition was studied by specially adjusting contrast and brightness (so-called bone window mode). Depending on dura mater integrity, penetrating and non-penetrating GTBIs were distinguished. Depending on wound tract characteristics, gutter, glancing, blunt, and perforating wounds were distinguished. Bound shot injuries were characterized by one entrance skull wound, which was both inlet and outlet. Blunt injuries were only characterized by inlet on skull surface, which lead to a blunt wound tract with a fragment at the tract end. Penetrating wounds were characterized by wound tract closed on all sides in skull cavity with separate inlet and outlet and absence of fragment in the wound tract.
There were two main types of military equipment: explosive devices and portable small arms. Explosive devices included: artillery shells, grenades, mortar bombs, bombs, missiles, mines, and makeshift explosive devices. Portable small arms included: pistols, rifles, assault rifles.
In case of penetrating craniocerebral injuries, an urgent surgical intervention was performed. The purpose of surgical treatment of such patients was, on the one hand, the removal of intracranial hematoma, wound debridement, and hemostasis, and, on the other hand, dura mater defects sealing without tension and skull base restoration while simultaneously sealing ethmoid and frontal sinuses. Surgical intervention was performed
using microsurgical technique and OPMI VARIO 700 microscope (Carl Zeiss, Oberkochen, Germany). The microscope made it possible to minimize the retraction of already damaged and swollen frontal lobes while allowing effective skull base examination and restoration. We did not use external lumbar drainage before surgery. Nor did we use synthetic or biological glue compositions for autotransplants fixation. Patients with non-penetrating injuries underwent conservative treatment which included antibacterial and anti-edema therapy.
After the treatment, incidence of nasal liquorrhea and purulent and septic complications was assessed. Patients state assessment according to Glasgow Outcome Scale was performed 6 months after the injury.
Results and discussion. 30 male patients with GTBI and PNS injuries aged 21 to 49 (avg. (31.7±6.4)) were examined. 26 (87%) patients had penetrating wounds, 4 (13%) patients had non-penetrating brain wounds. In 26 (87%) cases, injuries were caused by fragments of mine and explosive devices and only 4 (13.3%) injuries were caused by small-arm bullets. Blunt wounds were diagnosed in 17 (57%) patients; bound shot wounds, in 7 (23%) patients; penetrating wounds, in 6 (20%) patients.
GCS score after initial resuscitation ranged from 5 to 15 (average 10.6±3.5). ISS score ranged from 16 to 50, avg. 26.4±7.3.
Patients breakdown by paranasal sinus injury location is shown in table 1. Thus, frontal sinus, in various combinations, was damaged in 25 (83%) cases; ethmoid bone, in 13 (43%) cases; sphenoidal sinus, in 1 (3%) case.
In 12 patients, along with paranasal sinus injury, there were numerous orbit roof fractures. Orbit roof fractures were observed in 4 patients with unilateral frontal sinus injury, 4 patients with ethmoid bone injury, 3 patients with bilateral frontal sinus and ethmoid bone injury and one patient with combined frontal sinus, ethmoid bone, and sphenoidal sinus injury.
Craniocerebral injuries involving paranasal sinuses were combined with intracranial hematomas and presence of bone fragments and metal fragments located intracranially. Breakdown of clinical findings by intracranial injuries incidence and structure
Table 1.
Patients breakdown by paranasal sinus injury location
Damaged anatomical area Number of wounded persons vs. the total number of examined persons (%)
Frontal sinus, unilateral 13 (43%)
Frontal sinus, bilateral 4 (13%)
Frontal sinus, unilateral + ethmoid bone 3 (10%)
Frontal sinus, bilateral + ethmoid bone 4 (13%)
Ethmoid bone 5 (17%)
Frontal sinus + ethmoid bone + sphenoidal sinus 1 (3%)
Table 2. Breakdown of clinical findings of intracranial changes on brain SCT
Intracranial changes on SCT Number of wounded persons vs. the total number of examined persons (%)
Focal brain contusion 24 (80%)
Intracerebral traumatic hematoma 16 (53%)
Subarachnoid hemorrhage 11 (37%)
Subdural hematoma 6 (20%)
Intraventricular hemorrhage 3 (10%)
Epidural hematoma 1 (3%)
Brain matter bone fragments 21 (70%)
Brain matter metal debris 10 (33%)
Midline shift 5 (17%)
based on brain SCT data is shown in table 2. Lateral dislocation signs were detected in 5 patients. Midline shift ranged from 2 mm to 9 mm. Axial dislocation signs were detected in 2 patients.
Four non-penetrating brain wound patients were treated conservatively. Initially, 26 (87%) patients underwent surgery. Breakdown of patients by extent of paranasal sinuses or brain surgery is shown in table 3.
High-resolution head and neck spiral computed tomography with the review of axial images in cerebral and bone mode and frontal view reconstruction allowed to clearly determine wound tract and nature of the extra- and intracranial injuries in all cases. Accurate information on the nature of the injury before the surTable 3.
Breakdown of patients by extent of surgical intervention
Extent of surgical intervention on paranasal sinuses Extent of surgical intervention on brain
Revision of basal dura mater OPC + ICH and/or brain contusion foci removal DC + ICH and/or brain contusion foci removal Total(%)
Unilateral frontal sinus obliteration 1 7 8 (31%)
Bilateral frontal sinus obliteration 2 - - 2 (8%)
Unilateral frontal sinus obliteration and ACF base reconstruction - 3 - 3 (12%)
Bilateral frontal sinus obliteration and ACF base reconstruction 2 4 3 9 (35)
Frontal sinus cranializa-tion and ACF plasty 1 - - 1 (4%)
ACF plasty without frontal sinus obliteration 1 2 - 3 (12%)
Total (%) 7 (27%) 16 (62%) 3 (12%) 26 (100%)
Note. ACF = anterior cranial fossa, OPT = ICH = intracerebral hematoma.
osteoplastic craniotomy, DC = decompressive craniectomy,
gery allowed planning all surgery stages and performing them in full during one surgical intervention.
Twenty-six patients were provided with urgent neu-rosurgical care which was required due to fragment (bullet) wounds. In order to open anterior cranial fossa, a scalp dissection was performed with formation of bic-oronal flap. Pericranium was preserved so that it could be used as a separate flap. The following two variants of anterior pericranium flap were most commonly used: with anterior (with supratrochlear and supraorbital arteries) or lateral (with superficial and deep temporal arteries) pedicle. An additional variant of lateral flap was a temporomandibular flap comprised of temporal muscle (with or without fascia). The flap was separated along with the pericranium so that a longer and stronger flap could be formed. In isolated frontal sinus injuries, sinus mucosa removal, frontal and nasal junction tamponade, and frontal sinus obliteration by pericranial periosteal flap with anterior base was performed. In ethmoid bone damages, reconstruction of anterior cranial fossa was performed with a temporomandibular fascia flap with a lateral pedicle. If simultaneous sealing of defects of frontal sinus and ethmoid bone was required, both anterior and intracranial flaps were simultaneously used. In orbit roof defects, 5 of 12 patients underwent reconstruction with a dynamic titanium plate.
In order to remove intracerebral hematomas and focal cerebral contusions, in 16 (62%) patients osteo-plastic craniotomy with bone flap insertion at the end of the surgery was performed. In 3 (12%) patients with severe traumatic intracranial injuries with concomitant cerebral edema, decompressive craniectomy was performed prior to skull base reconstruction to reduce increased intracranial pressure. Only after the decompressive craniectomy was performed and liquor was removed from basal cisterns, it was possible to obtain minimally traumatic access to anterior cranial fossa base. Inlet bone fragments were removed in all the patients. Metal fragments were only removed when they were in sight and their removal would not cause additional brain trauma. In all cases, antibacterial therapy was prescribed for 2 to 3 weeks. Antibacterial therapy was adjusted based on bacteriological CSF examination over time.
Nasal liquorrhea at admission was observed in 12 (40%) patients. After the treatment, nasal liquorrhea was observed in 2 (7%) patients. Liquorrhea was detected in one (4%) patient in a series of surgical treatment of 26 patients and in one of 4 patients (25%), they were treated conservatively. In both cases, nasal liquorrhea was eliminated by prolonged use of external lumbar drainage.
Purulent and septic complications in the form of meningoencephalitis, ventriculitis, and subdural empyema were found in one patient. Thus, the incidence of purulent-septic complications was 3% (1 out of 30) and 4% (1 out of 26) in the general group of GTBI patients with PNS injuries (operated and non-operated) and in surgical treatment group, respectively. Purulent and septic complications were much less severe than those presented in the literature. For instance, Bhatoe H. S. (13) claims that meningitis incidence in his study group
was 13%. Other authors claim meningitis incidence of 18.8% to 25% [9,18].
Unfavourable prognostic factors of purulent and septic complications in patients from our series included: severe brain contusion, initial postresuscitation GCS score 9, multilobar trauma and transventricular wound, delayed patient delivery for specialized treatment, wound-related liquorrhea, and tamponade of lateral brain ventricle with blood. The patient underwent frontal bone craniotomy, removal of brain detritus, intraventricular hematoma, and metal fragments, obliteration of frontal sinus, and reconstruction of anterior cranial fossa with pericranial flap on pedicle. After the surgery, nasal liquorrhea was absent. However, the patient suffered from purulent meningocephalitis and subsequently, he underwent surgery for subdural empyema. In order to eliminate post-traumatic hydrocephaly, a four-month-old patient underwent CSF shunting surgery. The patient survived, a treatment outcome in 6 months was a severe disability.
In the study group, a treatment outcome in 6 months was good recovery in 13 (43%) patients; moderate disability, in 11 (37%) patients; severe disability, in 4 (13) patients. 2 (7%) patients died. No cases of vegetative state were diagnosed.
In one case, the cause of death was a multiple organ failure in a patient with a moderate brain contusion and severe internal organ injuries (abdominal cavity and lungs). In the second case, severe primary brain injury with cerebral edema, intracranial hypertension, and secondary cerebral ischemia occurred. In both of these lethal cases, we did not detect episodes of liquorrhea or purulent and septic complications after the surgery. Thus, the lethal cases were not directly related to paranasal sinus injury and concurrent pathological conditions.
Conclusions. Head and neck spiral computed tomography with the review of axial images in cerebral and bone mode and frontal view reconstruction allows to clearly determine wound tract and nature of the extra-and intracranial injuries in all cases. Aggressive surgical approach which includes urgent intervention with removal of intracranial hematomas and sealing of cranial cavity in the area of damaged paranasal sinuses can ensure satisfactory immediate and distant outcomes The use of anterior and lateral pericranial flaps on pedicle has proved its effectiveness in reconstructive skull base surgery.
Further study prospects. Although received from a small group of patients, our data give reason to believe that performing a surgery to the full extent, both on brain and paranasal sinuses during initial intervention, reduces incidence of purulent and septic complications if compared with historical data. Combination of anterior pericranial flap with additional lateral flap helps preventing spinal fluid leakage and reduces the risk of liquorrhea from 40% to 7%. The question of whether really urgent surgical interventions performed in full with the use of vascularized pericranial flaps are better than conservative treatment or phased surgical interventions shall be addressed in further major studies.
References
1. Stevens JR, Brennan J. Management of battlefield injuries to the skull base. J Neurol Surg B. 2016 Oct;77:430-8.
2. Lew TA, Walker JA, Wenke JC, Blackbourne LH, Hale RG. Characterization of craniomaxillofacial battle injuries sustained by United States service members in the current conflicts of Iraq and Afghanistan. J Oral Maxillofac Surg. 2010 Jan;68(1):3-7.
3. Owens BD, Kragh JFJr, Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma. 2008 Feb;64(2):295-9.
4. Sirko AG, Dzyak LA. Boiovi vohnepalni cherepno-mozkovi poranennia. Kyiv: Perham; 2017. 280 s. [in Ukrainian]
5. Sirko AG. Vohnepalni poranennia cherepa ta holovnoho mozku pid chas zbroinoho konfliktu na skhodi Ukrainy. Povidomlennia 1. Klinichni ta strukturno-funktsionalni osoblyvosti. Ukrainskyi neirokhirurhichnyi zhurnal. 2015;(2):40-5. [in Ukrainian]
6. Archer JB, Sun H, Bonney FA, Zhao YD, Hiebert JC, Sanclement JA, et al. Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps. J Neurosurg. 2016 Mar;124(3):647-56.
7. Dillon JD Jr, Meirowsky AM. Facio-orbito-cranial missile wounds. Surg Neurol. 1975 Dec 1;4:515-8.
8. Aarabi B, Taghipour M, Alibii E, Kamgarpour A. Central nervous system infections after military missile wounds. Neurosurgery. 1998 Mar;42:500-9.
9. Aarabi B. Comparative study of bacteriological contamination between primary and secondary exploration of missile head wounds. Neurosurgery. 1987 Apr;20:610-6.
10. Bhatoe HS. Missile injuries of the anterior skull base. Skull Base: an interdisciplinary approach. 2004 Feb;14(1):1-8.
11. Betz P, Stiefel D, Hausmann R, Eisenmenger W. Fractures at the base of the skull in gunshots to the head. Forensic Sci Int. 1997 May 5;86:155-61.
12. Sakas DE, Beale DJ, Ameen AA, Whitwell HL, Whittaker KW, Krebs AJ, et al. Compound anterior cranial base fractures: classification using computerized tomography scanning as a basis for selection of patients for dural repair. J Neurosurg. 1998 Mar;88:471-7.
13. Bhatoe HS. Retained intracranial splinters: a follow-up study in survivors of low intensity military conflicts. Neurol India. 2001 Mar;49:29-32.
14. Brandvold B, Levi L, Feinsod M, George ED. Penetrating craniocerebral injuries in the Israeli involvement in the Lebanese conflict, 1982-1985: analysis of a less aggressive surgical approach. J Neurosurg. 1990 Jan;72:15-21.
15. Jankovic S, Buca A, Busic Z, Zuljan I, Primorac D. Orbitocranial injuries: report of 14 cases. Mil Med. 1998 Jul;163:490-3.
16. Kim DW, Yoon ES, Lee BI, Dhong ES, Park SH. Fracture depth and delayed contour deformity in frontal sinus anterior wall fracture. J Craniofac Surg. 2012 Jul;23(4):991-4.
17. Thomas RF, Bothwell NE. Delayed management of paranasal sinus fractures. In Brennan JA, Holt GR, Thomas RW, eds. Otolaryngology/Head and Neck Surgery Combat Casualty Care in Operation Enduring Freedom. Fort Sam Houston, TX: Borden Institute; 2015.
18. Levin S, Nelson KE, Spies HW, Lepper MH. Pneumococcal meningitis: the problem of the unseen cerebrospinal fluid leak. Am J Med Sci. 1972 Oct;264(4):319-27.
Х1РУРГ1ЧНЕ Л1КУВАННЯ БОЙОВИХ ВОГНЕПАЛЬНИХ ЧЕРЕПНО-МОЗКОВИХ ПОРАНЕНЬ, ПО6ДНАНИХ З УШКОДЖЕННЯМ ПАРАНАЗАЛЬНИХ СИНУС1В CipKO А. Г., Пилипенко Г. С., Тончев М. Д.
Резюме. Проведено аналiз результат xipyprnHoro лтування 30 потертлих з бойовими вогнепальними черепно-мозковими пораненнями (ВЧМП), поеднаними з ушкодженнями параназальних синуав (ПНС). По-ранення були отриман в результат локального збройного конфлтту на сxoдi УкраТни.
Об'ект i методи. Пoстpаждалi були послщовно включен до проспективного дослщження в перюд з 25 травня 2014 року по 31 грудня 2017 року. Дана група потертлих склала 16,3% вщ вах постраждалих з ВЧМП, як були пролтоваш за цей перюд. При госпп^заци вам патентам робили КТ дослщження головного мозку з високою роздтьною здатшстю. Ушкодження лобного синусу вщзначеш у 25 (83%) спостереженнях, решп"-частоТ шстки у 13 (43), клиновидного синусу - в 1 (3%) спостереженш. 26 (87%) постраждалих мали проника-ючi поранення, 4 (13%) - непpoникаючi поранення головного мозку. У 26 (87%) випадках вщзначеш уламков1 мiннo-вибyxoвi поранення, у 4 (13,3%) поранення були спричинен кулями. Сл^ поранення дiагнoстoванo у 17 (57%) постраждалих, pикoшитyючi - у 7 (23%), нас^зш - у 6 (20%) постраждалих. Оцшка за ШКГ тсля первинноТ ресусцитаци коливалась вщ 5 до 15 балiв, у середньому 10,6±3,5 бали. Чотирьох потертлих з не-проникаючими пораненнями головного мозку лтували консервативно. Первинно оперован 26 (87%) пора-нених. Проводили невщкладне втручання з метою видалення внутршньочерепноТ гематоми, герметичного закриття дефемчв твердоТ мозковоТ оболонки та вщновлення основи черепа при одночаснш герметизаци рештастих i лобних повпряних синуав. Для закриття лобного синусу та дефемчв передньоТ черепноТ ямки використовували добре васкуляризований переднш та латеральн перикрашальш клапт на живлячш шжц у piзниx модифтащях.
Результати. Назальна лтворея при гoспiталiзацiТ зyстpiчалася у 12 (40%) потертлих, тсля лтування - у 2 (7%) потертлих. Гншно-септичш ускладнення були виявлеш лише у 1 (3%) пораненого. Вони були представлен у виглядi меншгоенцефалп"у, вентpикyлiтy та субдуральноТ емтеми одночасно. Спpиятливi результати лiкyвання (добре вщновлення та пoмipна iнвалiдизацiя) через 6 мкящв вiдзначенi у 24 (80%), несприятлив1 (глибока iнвалiдизацiя та летальшсть) - у 6 (20%). Вегетативних сташв серед пpoлiкoваниx хворих не вщзна-чали. Два летальн випадки не були пoв'язанi з ушкодженнями параназальних синуав. В одному випадку мало мкце тяжке первинне ушкодження головного мозку, в шшому - тяжк пoеднанi ушкодження внутршшх oprанiв з пoлioprаннoю недoстатнiстю.
^K>40Bi слова: бoйoвi вorнепальнi поранення, чеpепнo-мoзкoвi поранення, паpаназальнi синуси, назальна лтворея, xipypriчне лiкyвання, пластика основи черепа, перикрашальний клапоть, результати лтування, rнiйнo-септичнi ускладнення.
ХИРУРГИЧЕСКОЕ ЛЕЧЕНИЕ БОЕВЫХ ОГНЕСТРЕЛЬНЫХ ЧЕРЕПНО-МОЗГОВЫХ РАНЕНИЙ, СОЧЕТАННЫХ С ПОВРЕЖДЕНИЯМИ ПАРАНАЗАЛЬНЫХ СИНУСОВ
Сирко А. Г., Пилипенко Г. С., Тончев М. Д.
Резюме. Проведен анализ результатов хирургического лечения 30 пострадавших с боевыми огнестрельными черепно-мозговыми ранениями (ОЧМР), сочетанными с повреждениями параназальных синусов (ПНС). Ранения получены в результате локального вооруженного конфликта на востоке Украины.
Объект и методы. Пострадавшие были последовательно включены в проспективное исследование в период с 25 мая 2014 года по 31 декабря 2017 года. Данная группа пострадавших составила 16,3% от всех пострадавших с ОЧМР, которые были пролечены за этот период. При госпитализации всем пациентам выполняли КТ головного мозга с высокой разрешающей способностью. Повреждение лобного синуса отмечено в 25 (83%) наблюдениях, решетчатой кости - в 13 (43%), клиновидного синуса - в 1 (3%) наблюдении. 26 (87%) пострадавших имели проникающие ранения, 4 (13%) - непроникающие ранения головного мозга. В 26 (87%) случаях отмечены осколочные минно-взрывные ранения, в 4 (13,3%) случаях - пулевые ранения. Слепые ранения диагностированы у 17 (57%) пострадавших, рикошитирующие - у 7 (23%), сквозные - у 6 (20%) пострадавших. Оценка по ШКГ после первичной ресусцитации колебалась от 5 до 15 баллов, в среднем 10,6±3,5 балла. Четыре пострадавших с непроникающими ранениями мозга лечили консервативно. Первично оперированы 26 (87%) раненных. Выполняли неотложное хирургическое вмешательство с целью удаления внутричерепной гематомы, герметического закрытия дефектов твердой мозговой оболочки и восстановления основания черепа при одновременной герметизации решетчатых и лобных воздушных синусов. Для закрытия лобного синуса и дефектов передней черепной ямки использовали хорошо васкуляризированный передний и латеральные перикраниальные лоскуты на питающей ножке в различных модификациях.
Результаты. Назальная ликворея при госпитализации отмечена у 12 (40%) пострадавших, после лечения - у 2 (7%) пострадавших. Гнойно-септические осложнения выявлены только у 1 (3%) раненного. Они были представлены в виде менингоэнцефалита, вентрикулита и субдуральной эмпиемы одновременно. Благоприятные результаты лечения (хорошее восстановление и умеренная инвалидизация) через 6 месяцев с момента ранения отмечены у 24 (80%), неблагоприятные (глубокая инвалидизация и смертельный исход) - у 6 (20%). Вегетативных состояний у пролеченных больных не отмечали. Два летальных случая не были связаны с повреждениями параназальных синусов. В одном случае имело место тяжелое первичное повреждение головного мозга, в другом - тяжелые сочетанные ранения внутренних органов с полиорганной недостаточностью.
Ключевые слова: боевые огнестрельные ранения, черепно-мозговые ранения, параназальные синусы, назальная ликворея, хирургическое лечение, пластика основания черепа, перикраниальный лоскут, результаты лечения, гнойно-септические осложнения.
SURGICAL TREATMENT OF COMBAT CRANIOCEREBRAL GUNSHOT WOUNDS COMBINED WITH PARANASAL SINUSES INJURY
Sirko A. G., Pilipenko G. S., Tonchiev M. D.
Abstract. Results of surgical treatment of 30 patients with combat-related gunshot traumatic brain injuries (GTBI) combined with paranasal sinuses injury (PNS) were analyzed. The injuries resulted from local armed conflict in the Eastern Ukraine.
Object and methods. The patients were consistently enrolled in the prospective study in the period from May 25, 2014 to December 31, 2017. This group of patients made up 16.3% of all GTBI patients treated during that period. All patients underwent high-resolution cranial CT at admission. Frontal sinus injuries were observed in 25 (83%) cases; ethmoid bone injuries, in 13 (43) cases; sphenoidal sinus injuries, in 1 (3%) case. 26 (87%) patients had penetrating wounds; 4 (13%) patients, non-penetrating cerebral wounds. Fragment mine blast wounds were observed in 26 (87%) cases; 4 (13.3%) wounds were caused by bullets. Blunt wounds were diagnosed in 17 (57%) patients; bound shot wounds, in 7 (23%) patients; penetrating wounds, in 6 (20%) patients. GCS score after initial resuscitation ranged from 5 to 15 (average 10.6±3.5). Four non-penetrating brain wound patients were treated conservatively. Initially, 26 (87%) patients underwent surgery. Emergency intervention was performed to remove intracranial hematoma, close dura mater defects and restore skull base while simultaneously sealing ethmoid and frontal air sinuses. Well-vascularized frontal and lateral pericranial flaps on pedicle in various modifications were used to close frontal sinus and anterior cranial fossa defects.
Outcomes. Nasal liquorrhea was observed in 12 (40%) patients at admission and in 2 (7%) patients after treatment. Purulent and septic complications were only detected in 1 (3%) patient. The complications had the form of combined meningoencephalitis, ventriculitis, and subdural empyema. Favourable treatment outcomes (good recovery or moderate disability) in 6 months after treatment were detected in 24 (80%) patients; unfavourable outcomes (severe disability or death), in 6 (20%) patients. Vegetative state was not observed in treated patients. Two lethal cases were not associated with paranasal sinus injury. In one case, there was a severe primary brain injury; in the other case, severe combined internal organ injuries with multiple organ failure.
Key words: combat-related gunshot wounds, traumatic brain injuries, paranasal sinuses, nasal liquorrhea, surgical treatment, skull base reconstruction, pericranial flap, treatment outcomes, purulent and septic complications.
Рецензент - проф. Безшапочний С. Б.
Стаття надшшла 25.11.2018 року
