title: Use of a Minimally Invasive Retractor System for Retrieval of Intracranial Fragments in Wartime Trauma.
abstract: OBJECTIVE
  Wartime penetrating brain injury can result in deep-seated parenchymal and intraventicular shrapnel, bullets, and bone. Large fragments pose a risk of secondary injury from migration, infection, and metal toxicity. It has been recommended that aggressive removal of fragments be avoided. The goal of this study is to report our technique of minimally invasive removal of select deep-seated fragments using a tubular retractor system.
  
  
  METHODS
  A retrospective review of our database of service members presenting with penetrating traumatic brain injuries incurred during Operations Iraqi Freedom and Enduring Freedom and treated at the Walter Reed Army Medical Center and the National Naval Medical Center was performed. Six individuals were identified in which the Vycor ViewSite retractor system (Vycor Medical, Boca Raton, Florida, USA) was used to remove a ventricular or deep intraparenchymal fragment. All patients were male and ranged in age from 21 to 29 years. Fragment location included the foramen of Monro; the atrium of the right lateral ventricle; parasagittally within the right occipital lobe; the occipital horn of the right lateral ventricle; the deep white matter of the dominant temporal lobe; and within the posterior right temporal lobe deep to the junction of the transverse and sigmoid dural venous sinuses. Fragments included in-driven bone, shrapnel from improvised explosive devices, and bullets.
  
  
  RESULTS
  In all cases the fragment was successfully removed. No patient had worsening of their neurologic condition following surgery.
  
  
  CONCLUSIONS
  Deep parenchymal and intraventricular fragments can be safely removed using a tubular retractor system.
authors.affiliation: Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA. Electronic address: george.n.rymarczuk.mil@mail.mil.
authors.forename: George N
authors.initials: GN
authors.lastname: Rymarczuk
authors.affiliation: Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Laurence
authors.initials: L
authors.lastname: Davidson
authors.affiliation: Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Meryl A
authors.initials: MA
authors.lastname: Severson
authors.affiliation: Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Rocco A
authors.initials: RA
authors.lastname: Armonda
mesh_terms: D000328:Adult; D002552:Cerebral Ventricles / Q000601:surgery; D020197:Head Injuries, Penetrating / Q000601:surgery*; D006801:Humans; D054542:Iraq War, 2003-2011; D020547:Lateral Ventricles / Q000601:surgery; D008297:Male; D008887:Military Medicine; D008889:Military Personnel; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation* / Q000379:methods; D019635:Neurosurgical Procedures / Q000295:instrumentation* / Q000379:methods; D009778:Occipital Lobe / Q000601:surgery; D012189:Retrospective Studies; D013702:Temporal Lobe / Q000601:surgery; D014857:Warfare; D066127:White Matter / Q000601:surgery; D055815:Young Adult
keywords: Minimally invasive; Penetrating brain injury; Shrapnel; Tubular retractor system; War trauma