Wartime penetrating sellar/parasellar injuries: a novel classification and management based on trajectory

OBJECTIVE: Penetrating brain injuries (PBIs) involving the sella region are rare, anatomically complex, and associated with high morbidity due to the proximity of critical neurovascular structures. Herein, the authors introduce a novel trajectory-based classification system derived from wartime injuries sustained during the conflict in Ukraine, aiming to improve the diagnostic framework, guide management strategies, and support prognostication in this unique population. METHODS: The authors conducted a retrospective analysis of all PBIs involving an anatomically defined critically important sellar injury zone (CRISIZ) treated at a tertiary care center over a 2.5-year period (February 2022-August 2024). Injuries were classified into 2 main categories based on projectile trajectory to the CRISIZ: transbasal (TB) and transcortical (TC). Each category was further subdivided into 4 anatomical subtypes. Clinical presentation, imaging characteristics, complications, treatment modalities, and outcomes were compared across subgroups. The primary outcome was the Glasgow Outcome Scale (GOS) score at 6 months. RESULTS: A total of 29 patients with PBIs involving the CRISIZ were identified (mean patient age 38 years). TB injuries were more common than TC by a factor of 1.6 (18 vs 11; 62.1% vs 37.9%). TB subtypes included transnasal, transorbital, transmaxillary, and infratemporal trajectories; TC subtypes included transfrontal, transtemporal, transventricular, and transoccipital. TB injuries had a higher prevalence of multiple projectile fragments (88.9% vs 45.5%, p < 0.05) and CSF rhinorrhea (66.7% vs 18.2%, p < 0.05). TC injuries were associated with significantly higher rates of intracranial vascular injury (81.8% vs 22.2%, p < 0.01), subarachnoid hemorrhage, intraventricular hemorrhage, and coma on admission (54.5% vs 11.1%, p < 0.05). Overall, in-hospital mortality was 10.3%, and 75.9% of patients achieved favorable outcomes (GOS scores > 3) at 6 months. CONCLUSIONS: Projectile trajectory is a critical determinant of injury pattern and clinical course in PBIs involving the CRISIZ. TC injuries are associated with a higher incidence of neurovascular complications, while TB injuries more commonly involve CSF leaks. Early identification and management of these complications are critical for optimizing outcomes. The proposed classification scheme provides a practical framework to guide evaluation and management in this high-risk patient population.