Objective: The war in Ukraine has led to a substantial number of penetrating head injuries,
with many involving the skull base and paranasal sinuses. These complex injuries require
intricate reconstruction to prevent infection and manage further complications such
as rhinorrhea. This study reviews the patients treated for such injuries and describes
the techniques employed for their management.
Methods: This is a prospective study conducted at a single civilian clinical center near the
combat frontlines in Dnipro, Ukraine (Mechnikov Dnipropetrovsk Regional Clinical Hospital,
MDRCH). Data were collected over a 30-month period from February 2022 to August 2024.
Patients treated in the first year were analyzed for interventions and outcomes. Those
with penetrating skull base and paranasal sinus injuries were evaluated, and their
management and outcomes were documented. Early neurosurgical interventions, including
debridement/hematoma evacuation, repair of dural defects using vascularized pericranial
flaps, and titanium plating of external and skull base defects, were carried out.
Results: During the study period, 1,879 casualties with penetrating head trauma were treated,
of which 363 (19.3%) had involvement of the skull base and paranasal sinuses. Of the
141 patients treated within the first year, the mean age was 38 years, and 138 (97.9%)
were male. The majority of injuries (134; 95.0%) were due to blast fragmentation.
The median presenting Glasgow coma score was 11. CSF leak was present in 48 (34.0%)
patients from nares, open wound or orbit ([Fig. 1]). Unilateral frontal sinus involvement was the most common (51 patients; 36.2%),
followed by bilateral frontal sinus involvement (33 patients; 23.4%; [Fig. 2]) and combined bilateral frontal and ethmoid sinus involvement (32 patients; 22.7%).
Cranial imaging most frequently revealed subarachnoid hemorrhage in 121 (85.8%) patients
and pneumocephalus in 127 (90.1%) patients. Intracranial vascular injury was noted
in 5 patients (3.5%). Four patients underwent endonasal transsphenoidal surgery for
skull base repair. Ninety-seven patients (68.8%) had other non-brain injuries. One
patient (0.7%) experienced a persistent postoperative CSF leak, requiring a lumbar
drain. There was one case each of meningitis (0.7%) and wound dehiscence (0.7%). The
length of stay at MDRCH ranged from 3 to 8 days (mean: 5). There were nine mortalities
(6.4%), and 118 patients (83.7%) had a favorable outcome (Glasgow outcome score of
4 or 5).
Fig. 1
Fig. 2
Conclusion: Early and appropriate management of penetrating skull base injuries involving the
paranasal sinuses is critical. Our approach, including cranialization of sinuses,
vascularized pericranial flap reconstruction, and skull base plating, may optimize
outcomes in wartime neurovascular injuries. This case series demonstrates the efficacy
of these techniques in reducing complications and improving recovery.
