The brain is surrounded by a very strong and solid membrane layer in a liquid space. Apart from this strong and durable membrane layer, it is also more protected by the skull bones. In other words, the brain is in a constant pressure balanced state in a closed box. This fluid, which we call cerebrospinal fluid in every person daily, averages 400-500 cc. made and absorbed. That is, this fluid circulates within itself. In this balanced space, our brain, cerebellum, brainstem, spinal cord organs remain fixed in relation to each other. In head traumas, this balance in the brain and related organs and cerebrospinal fluid in the head is disrupted in cases such as hitting with a hard object, collision, falling, traffic accident, injury with a sharp object, injury with a firearm. This balance varies according to the type of trauma, its severity and the location of the trauma. For example, after a simple head injury, there are no signs other than a headache that lasts for only a few days, while deaths may occur after a serious head injury.
1. We can classify head traumas in three ways as simple, moderate and severe. We always apply imaging methods to every patient with head trauma who applies to us. In the first place, we can take a computerized brain tomography and evaluate the result immediately. We can send our patients to their homes after making their first interventions by making suggestions in cases that we see as normal according to the results of tomography. Especially in children and the elderly, it is necessary to be more cautious after head trauma. It would be more appropriate to have follow-ups in the hospital. In cases where there are fractures in the skull bones, if there is no partial pressure on the brain, we follow up again. We follow up some minor bleeding if the person’s neurological status is good and does not press on the brain. Situations in which we perform surgical intervention; Fragmented fractures that cause pressure on the brain in the head, bleeding between the skull bone and the cerebral cortex on the cerebral cortex, hemorrhages under the cerebral cortex, hemorrhages in the brain and brain injuries in penetrating sharp instrument injuries, injuries caused by firearms.
The primary purpose of our operation is to reduce the pressure on and inside the brain, remove the pressure and try to minimize the damage. The type of trauma can be very different, especially in gunshot wounds. If there is a close shot, a long shot, the type of weapon, an entrance to the skull and an exit, the exit location is very important. The damage it causes varies accordingly. The chance of survival is almost non-existent in tangential firearm injuries. If the bullet breaks the vascular structure at the base of the brain, if it damages the vital organ we call the brain stem, it is incompatible with life. In other cases, if the bullet entered and exited from the same side, for example, entered the right half of the skull and exited from the same place, the chance of survival is higher. The left hemisphere of the brain is the dominant hemisphere. The left hemisphere controls the speech and comprehension center and controls our right arm and leg. Therefore, it leaves more serious sequelae in damage to the left hemisphere. The right hemisphere of the brain also controls our left arm and leg. Speech and comprehension are generally not affected by damage to this area, but the left arm and leg may be paralyzed.
The surgical intervention we perform varies according to the severity of the damage. Brain damage in gunshot wounds is bleeding along the tracing of the bullet. In general, all bone fragments in the entrance hole are dragged into the brain, the cerebral cortex is torn, and it creates a disintegrating effect with a burning effect, causing damage. First of all, the bullet entrance hole is opened wide with the bones. In order to reduce the pressure, in life-threatening situations, we can put this bone under the skin in the abdominal cavity without replacing it, and replace the bone after it has passed the life-threatening situation. After the brain membrane is opened, the damaged brain tissue is cleaned with bleeding. Sometimes the meninges can be left open or covered with synthetic patches to reduce pressure. After repairing the damage without damaging the normal brain tissue, we perform operations to reduce the pressure in the head.
2. In traumas caused by gunshot wounds or other reasons, different findings may occur depending on the severity of the damage. There are various scales used in these neurological conditions among physicians. Rankings are made. It is classified from severe coma to a patient who performs every normal function, depending on whether the patient speaks openly during the examination and obeys the commands. The condition of the patient at the time of admission to the hospital is a guide for the future. Patients who are in a severe coma and whose respiration is not sufficient, who are in a coma and partially breathing, and who are in a moderately severe condition are followed in the intensive care units. It is important to keep the intracranial pressure at normal levels together with computerized brain tomography and brain MRI, together with the neurological picture, whether the patient is operated or not. In order to reduce this pressure, it is tried to be controlled with drugs by non-surgical means. Giving sedatives to minimize brain functions is also intended to reduce this pressure. Because the brain, which is stimulated from outside, needs more energy and intracranial pressure may increase. For this reason, pressure balance is tried to be achieved by controlled sleep and controlled awakening. In this process, since patients in severe coma cannot react to the outside, sedative drugs are not given. But patients in mild coma are gradually awakened.
3. The first of the factors affecting the success of the surgery is the severity and location of the damage caused by the trauma on the brain. If the damage is very high, it is difficult for the patient to benefit even if surgical intervention is performed. Mild and moderate injuries receive serious benefit from surgery. The place where the damage occurs in the brain is also very important. The first thing we surgeons do is to remove the pressure on the brain. We do not have a chance to fix the damaged brain tissue. In some injuries, permanent or temporary paralysis, speech disorders, comprehension disorders, sensory defects (sight, hearing, taste, etc.) may occur. Especially in firearm injuries, these damages can be very high. For example, if the bullet has passed through the brain tissue that provides arm and leg control and damaged it, we have no chance to revive this brain tissue with surgery.
4- The first intervention in brain damage caused by firearms or trauma is aimed at restoring vital functions. Infection, other intervening causes and additional diseases may also threaten the patient during the intensive care unit. The patient, whose intracranial pressure returns to normal levels, can be discharged from the intensive care unit if there are no additional problems after the life-threatening situation. This process varies from patient to patient, from trauma to trauma. Some patients are followed up in the intensive care unit for 3-5 days, some for months or even years. If the patient’s consciousness complies with clear commands, treatment is directed according to the condition of the next neurological picture. For example, in people who develop arm and leg weakness and paralysis, this process is a physical therapy rehabilitation process.
5- Paralysis may be permanent in some people, and in some people it may take months to years to recover. If there is no improvement in the two-year period, it means that it will no longer improve. Impairment of speech and understanding is also tried to be controlled with supportive treatment. However, in most patients, permanent sequelae unfortunately continue for life.
