Imaging assessment of penetrating craniocerebral and spinal trauma

Analysis of ballistic trajectories and its association with clinical outcomes in civilian penetrating brain injury

PURPOSE

Civilian penetrating brain injuries (PBI) caused by firearms are a medical emergency with high rates of morbidity and mortality. The aim of this study was to evaluate the association between trajectory vectors in CT brain angiography and clinical outcomes in patients with civilian gunshots.

METHODS

This is a retrospective analytical cross-sectional study that includes patients over 15 years of age with PBI due to firearms, admitted from January 2019 to December 2021 at a University Hospital in Cali, Colombia. A brain CT with angio-CT was performed the first day of admission. An XYZ coordinate system centered on the Turk's saddle was developed. Trajectories of projectiles were plotted and compared to a patient 0 in a 3D-Slicer software. A bivariate analysis of the clinical and geometric characteristics of the trajectory was performed. Primary outcomes include mortality and disability at 6 months.

RESULTS

Twenty-eight patients with a mean age of 27.39 ± 11.66 years were included. The vectors of non-survivors show a trend, crossing at a specific area. This area was designated as a "potential lethal zone" and inside this area, injuries around 25.3 mm from the circle of Willis, were associated with greater mortality (p < 0.005).

CONCLUSIONS

In our study PBI avoiding the ventricular system, brain stem, dorsum sellae and the circle of Willis were associated with more survivability. A "potential lethal zone" was detected and associated with poor outcome after civilian PBI due to firearms. A better evaluation of the performance of this "potential lethal zone" in larger studies will be required.

Traumatic penetrating head injury by crossbow projectiles: A case report and literature review

Background

Low-energy penetrating head injuries caused by arrows are relatively uncommon. The objective of this report is to describe a case presentation and management of self-inflicted intracranial injury using a crossbow and to provide a relevant literature review.

Case Report

A 31-year-old man with a previous psychiatric history sustained a self-inflicted injury using a crossbow that he bought from a department store. The patient arrived neurologically intact at the hospital, fully awake and oriented. He was not able to verbalize due to immobilization of the jaw as well as fixation of his tongue to his hard palate secondary to the position of the arrow. The trajectory of the object showed an entry point at the floor of the oral cavity and an exit through the calvarium just off the midline. The oral and nasal cavity, along with the palate and, the skull base of the anterior cranial fossa, and the left frontal lobe, were all breached. No vascular injury was identified clinically or in imaging. The arrow was surgically removed in the operating room after establishing an elective surgical airway. The floor of the mouth, tongue, and palate was repaired next. A planned delayed cerebrospinal fluid leak repair was performed. The patient made a substantial recovery and was discharged home in good functional status. A systematic literature search was done using Medline for cases with intracranial injuries related to crossbows to review and appraise the available literature.

Conclusion

A thorough assessment in a multidisciplinary trauma center and the availability of a subspecialty care team, including neurosurgery and otolaryngology, are paramount in such cases. The vascular imaging should be done before and after any planned surgical intervention. Emergent and elective surgical airway management should be considered and made available throughout the stabilization and care of the acute injury. Surgical management should be planned to remove the object with adequate exposure to facilitate visualization, removal, and the possible need for further intervention, including anticipating aerodigestive and vascular injuries on removal. Finally, access to weapons and the relation to psychiatric illness should not be overlooked, as many reported cases are self-harming in nature.

Particular Surgical Technique for Transorbital-Penetrating Craniocerebral Injury Inflicted by a Screwdriver: Technical Case Report

Surgical techniques for non-missile penetrating brain injuries (PBI) are challenging because they require good preoperative planning. Generally, extraction is performed ipsilaterally at the entry site. In certain cases, the extraction can be performed contralaterally through the inner end of the foreign body; however, this requires special consideration. We present a case report of a patient who had a stab wound on the head via a screwdriver and underwent surgery, during which extraction was performed contralaterally through the inner end of the screwdriver without inducing any neurological deficit. Careful preoperative planning and surgical technique modification are required to minimize morbidity and mortality in patients with PBIs.

Pediatric craniocerebral firearm injuries: literature review, best practices in medical and surgical management, and case report

INTRODUCTION

Civilian craniocerebral firearm injuries are extremely lethal. Management includes aggressive resuscitation, early surgical intervention when indicated, and management of intracranial pressure. Patient neurological status and imaging features should be used to guide management and the degree of intervention. Pediatric craniocerebral firearm injuries have a higher survival rate, but are much rarer, especially in children under 15 years old. This paucity of data underscores the importance of reviewing pediatric craniocerebral firearm injuries to determine best practices in surgical and medical management.

CASE PRESENTATION

A 2-year-old female was admitted after suffering a gunshot wound to the left frontal lobe. Upon initial evaluation, the patient displayed agonal breathing and fixed pupils with a GCS score of 3. CT imaging showed a retained ballistic projectile in the right temporal-parietal region with bifrontal hemorrhages, subarachnoid blood, and a 5-mm midline shift. The injury was deemed nonsurvivable and non-operable; thus, treatment was primarily supportive. Upon removal of the endotracheal tube, the patient began breathing spontaneously and improved clinically to a GCS score of 10-12. On hospital day 8, she underwent cranial reconstruction with neurosurgery. Her neurological status continued to improve, and she was able to communicate and follow commands but retained notable left-sided hemiplegia with some left-sided movement. On hospital day 15, she was deemed safe for discharge to acute rehabilitation.

Transbasal penetrating traumatic brain injury caused by a rifle rod: A case report

Background

Penetrating traumatic brain injury (TBI) caused by a low-velocity object is a rare entity with a potential range of critical complications.

Case Description

We report a unique case of a 30-year-old male presenting with penetrating TBI caused by a rifle's cleaning rod. The rod passes through the left nostril to reach the frontal lobe after transgressing the sella turcica. A cranial computed tomography scan shows the extension of brain damage and the trajectory of the rod with no evidence of an associated vascular injury. Surgical removal of the rifle rod was performed using a transnasal approach by a multidisciplinary with the postoperative course went uneventfully.

Conclusion

Transbasal penetrating TBI through the nose is an extremely rare entity. This type of head injury carries its own peculiarities that deviate from the classic treatment algorithms.

Laminectomy for Penetrating Spinal Cord Injury with Retained Foreign Bodies

Background

Penetrating spinal cord injury (PSCI) with retained foreign bodies (RFB) is rarely observed in clinics and may result in a complete or incomplete neurological deficit. This study was performed to appraise the treatment effect of laminectomy for PSCI with RFB.

Case Presentation

This study presented three patients referred to a tertiary hospital between August 2011 and October 2018 due to PSCI with RFB and receiving laminectomy. The first patient was a 25‐year‐old female with a butcher's knife piercing the T₉ lamina and T₁₀ vertebral body obliquely; the second was a 49‐year‐old male who suffered a perforating wound of the cervical spinal canal and injury of vertebral artery from foreign glass, while the third was a 60‐year‐old male with a wooden stick penetrating stomach and terminating in the L₁ lamina. The first and second patients immediately underwent laminectomy for debridement and removal of RFB, while the third received two‐staged operations to remove the retained stick thoroughly. Unfortunately cases 1 and 3 eventually resulted in total paralysis and case 2 revealed no improvement in myodynamia. Then, Medline/PubMed, Embase and the Cochrane Library were systematically searched, and 23 articles involving 25 additional cases with this kind of injury were included for analysis.

Conclusions

The optimal treatment strategy for penetrating spinal cord injury with retained foreign bodies remains challenging and should be assessed case‐by‐case. If possible, surgical removal of foreign bodies by laminectomy is preferred immediately to prevent delayed presentation and persistent contamination. Meanwhile, a multidisciplinary team is needed to address concomitant injuries.

Life-threatening perforating brain injury by a rusty iron rod - A case report

Background

When an object traverses through the cranium leaving behind both an entry and exit wound, it is called perforating brain injury. Perforating open brain injury is rare. A paucity of published literature on such cases and a lack of a standard management protocol pose significant challenges in managing such cases.

Case Description

We present a case of a 24-year-old man who worked as a carpenter at the construction site. He slipped while working and fell from a height of 13 feet onto a rusty, vertically placed 3 feet iron rod located on the ground. Iron rod entered his body from the right upper chest, came out from the neck, and again re-entered through the right upper neck medial to the angle of the mandible and finally came out from the posterosuperior surface of the right side of the head. He presented to the emergency department in a conscious state, but his voice was heavy and slow-paced, and he showed signs of lower cranial nerve palsy on the right side. He underwent numerous radiological investigations. The iron rod was removed in the operation theater under strict aseptic precautions. On day 7 after surgery, he developed right lobar pneumonia, and on day 21, he developed an altered sensorium, followed by a loss of consciousness. He did not regain consciousness and, unfortunately, succumbed after 30 days of sustaining the injuries.

Conclusion

Perforating open brain injuries are rare, especially in civilian society, and are usually associated with significant morbidity and mortality. Due to a lack of standard guidelines for managing such severe injuries and limited knowledge, many patients with these injuries do not survive. Although each case presents differently, certain management principles must be followed.

An Asymptomatic Intracranial Foreign Body in a Child as a Result of Unintentional Firearm Injury

Aerial firing is often used as a form of riot control, but also in certain parts of the world as a celebratory act, often resulting in unintentional injury and/or death. It is uncommon for a patient to walk into an emergency room, seemingly comfortable, only to discover an intracranial foreign body. We report a case of a child who was struck by a stray bullet that pierced his skull through a small entry wound and lodged itself in the falx cerebri. The patient remained asymptomatic and no intervention was required. We wish to highlight the importance of imaging techniques in patients with small wounds who are otherwise asymptomatic as well as point out the salient features regarding stray bullet injuries.

Imaging findings of penetrating spinal cord injuries secondary to stab wounds on magnetic resonance imaging in a tertiary trauma unit, South Africa

BACKGROUND

In South Africa, the leading cause of spinal cord injuries is motor vehicle accidents, followed by violence-related injuries, including gunshot injuries and stab wounds. Controversy regarding management persists. Magnetic resonance imaging (MRI) is the gold standard to rule out surgical causes of neurological deficit.

OBJECTIVES

To determine the spectrum of imaging findings in penetrating spinal cord injuries, specifically related to stab wounds, in a Tertiary Academic Hospital in the Free State province and whether these imaging findings influenced immediate surgical decision-making and outcomes of patients.

METHOD

Consecutive sampling was used to retrospectively select patients who presented with spinal penetrating injuries secondary to stab wounds during the period 01 August 2013-30 September 2016 and received MRI investigation. Fifty-six patients were included. Magnetic resonance imaging investigations were reviewed by the authors, with documentation of MRI findings, relevant patient demographics and clinical information into Excel spread sheets. Statistical analysis was performed by the Biostatistics Department of the University of the Free State.

RESULTS

The most common MRI finding was a high signal intensity wound tract (96.6%), followed by cord signal changes (91.1%) and cord oedema (82.1%). Thirty-nine extra-axial collections were diagnosed in 30 penetrating injuries, of which only one had spinal compressive effects. Four patients (7.1%) demonstrated pseudo-meningoceles. None of the included patients had an indication for emergency spinal surgery on review of imaging.

CONCLUSION

Magnetic resonance imaging findings did not alter the surgical course of action in our study patients. Despite this, MRI is a valuable modality in evaluation of penetrating spinal cord injuries in the post-traumatic phase (<24 h) for the presence of pseudo-meningoceles that pose an infection and delayed complication risk.

Full Recovery After a Bihemispheric Gunshot Wound to the Head: Case Report, Clinical Management, and Literature Review

BACKGROUND

Nearly 33,600 people die each year in the United States as a result of gunshot wounds (GSWs). Penetrating craniocerebral GSWs are often fatal with a nearly 70% death rate at the scene of the trauma. Overall combined mortality rate for patients who die at the scene or at the hospital is almost 91%. Poor outcome is associated with initial low Glasgow Coma Scale score and bihemispheric and transventricular gunshot trajectory. We summarize current understanding in management, prognostic factors, and survival outcomes in patients with a penetrating GSWs to the head. We report a patient with return to full function despite bihemispheric, multilobar involvement. Full function is defined here as ability to return to previous work and perform activities of daily living.

CASE DESCRIPTION

A 33-year-old man sustained a GSW to the head under unknown circumstances. On initial presentation, he had a Glasgow Coma Scale score of 15. He was verbalizing and communicating but was amnestic for the event. From a left frontal entry wound, the bullet traversed both frontal lobes of the brain reaching the right frontal-parietal junction. Physical examination and vital signs were normal. Appropriate surgical and medical management resulted in complete recovery.

CONCLUSIONS

Craniocerebral GSWs have a high mortality rate and usually require aggressive management. Evaluation of most GSWs requires appropriate imaging studies followed by proactive treatment against infection, seizure, and increased intracranial pressure. Surgical intervention is often necessary and ranges from local wound débridement to craniectomy, decompression, and wound exploration.

Orbital and Orbitocranial Trauma From Pencil Fragments: Role of Timely Diagnosis and Management

PURPOSE

To emphasize the importance of early detection and radiologic evaluation of retained organic foreign bodies (FBs) in orbital or orbitocranial penetrating injuries by pencil.

DESIGN

Retrospective case series.

METHODS

A retrospective chart review of patients who had penetrating orbital or orbitocranial trauma at 2 tertiary hospitals was conducted. Patients whose mechanism of injury was penetrating trauma by pencil were included. The patients' demographics, time between initial trauma and detection of foreign body, radiologic images, and resulting sequelae were reviewed.

RESULTS

Four patients were included in this study. All patients were male; 3 were less than 2 years of age and 1 was 34 years old. Accidents were witnessed in 2 cases, and initial detections of FBs were delayed in 3 cases, from 2 days to 7 weeks. Three cases involved the right orbit. Computed tomography (CT) imaging of the head demonstrated penetration of the orbital walls in 3 cases. Three-dimensional CT scans were used to differentiate the penetrating graphite pencil fragments from the orbital wall, and catheter angiography was used in 1 case of suspected orbital apex penetration. Vision was lost in 1 patient while other severe neurologic deficits were fully recovered after removal of FB.

CONCLUSIONS

Penetrating injury by pencils to the periorbital structures and delayed detection of retained pencil fragments can result in threat to life and vision. Radiologic examinations are essential to the detection of these retained FBs. Prompt detection and removal of the FBs within 48 hours and treatment with antibiotics can save vision and life.

A systematic review on ricochet gunshot injuries

Ricocheted bullets may still retain sufficient kinetic energy to cause gunshot injuries. Accordingly, this paper reviews the literature surrounding gunshot injuries caused by ricocheted bullets. In doing so, it discusses the characteristics of ricochet entrance wounds and wound tracks, noting several important considerations for assessment of a possible ricochet incident. The shapes of ricochet entrance wounds vary, ranging from round holes to elliptical, large and irregular shapes. Pseudo-stippling or pseudo-gunpowder tattooing, pseudo-soot blackening and tumbling abrasions seen on the skin surrounding the bullet hole are particularly associated with ricochet incidents. Ricocheted bullets have a reduced capability for tissue penetration. Most of the resulting wound tracks are short, of large diameter and irregular-all artefacts of the instability of a bullet that has ricocheted. A ricocheted hollow-point bullet, in particular, may overpenetrate the tissue when the bullet nose is deformed or fails to enter the body in a nose-forward orientation. Similarly, internal ricochet may occur when a bullet strikes hard tissue. Postmortem computed tomographic imaging is useful for localising a bullet and its fragments in the body and characterising the wound track. Ricochet cannot be ruled out in normal-appearing entrance wounds unless that finding is supported by other evidence, including the geometrical constraints of the shooting scene and the absence of ricochet marks and a ricocheted bullet.

Penetrating thoracic spinal cord injury with ice pick extending into the aorta. A technical note and review of the literature

Background:

Penetrating spinal cord injuries pose a great challenge to both patients and the treating physicians. Although the overall incidence of penetrating spinal cord injury is the highest in the military, the ubiquity of guns in our society continues to make penetrating spinal cord injury prevalent in the civilian population. These types of injuries are particularly complicated because, beyond the trauma to the neural elements and supporting structures, other organs can be affected and a team approach is required for successful treatment.

Case Description:

In this report, the authors present a unique case of an ice pick penetrating posteriorly through the spinal canal into the aorta. The described surgical management involved careful consideration and planning to prevent worsening vascular and neurological compromise. Among the challenges faced are neurological compromise, vascular injury, spinal instability, and cerebrospinal fluid leak.

Conclusion:

To the author’s knowledge, this challenging case represents the first description of a successful removal of a penetrating thoracic spinal foreign body that terminated within the lumen of the thoracic aorta.

Management of a Low-Energy Penetrating Brain Injury Caused by a Nail

Low-energy penetrating nail injury to the brain is an extremely rare neurosurgical emergency. The most common cause of nail gun injury is work related accidents; other causes result from accidental firing of a nail gun, suicide attempts by firing nail guns into the brain, and bomb blasts containing pieces of nails. Neurosurgical treatment performed by craniotomy still seems to be the safest one; there are reports of complications such as subdural hematoma and intraparenchymal hemorrhages following the blind removal of foreign bodies leading to suggestions that all penetrating foreign bodies should be removed under direct vision. We report a rarely described neurosurgical approach for removal of a penetrating nail from the brain and skull without evidence of associated hematoma and other brain lesions.

Positive Outcome After a Small-Caliber Gunshot Fracture of the Upper Cervical Spine without Neurovascular Damage

BACKGROUND

Gunshot wounds to the cervical spine most frequently concur with serious injuries to the spinal cord and cervical vessels and often have a fatal outcome.

CASE REPORT

We describe the case of a 35-year-old male with a complex fracture of the C2 vertebra body and a mandibular fracture after a penetration gunshot to the cervical spine. Computed tomography (CT) at admission revealed the exact extent of the fractures and the small caliber bullet lodged next to the C2 vertebra. In this rare and extremely lucky case no collateral vascular or neurological damage was detected. Eighteen months after surgical bullet removal and posterior C1-C3 fusion complete bone healing of the C2 vertebra was achieved and there were no secondary neurovascular deficits.

CONCLUSIONS

Immediate surgical C1-C3 fixation resulted in an excellent outcome without secondary neurovascular deficits in this rare case of traumatic complex C2 vertebral fracture caused by a gunshot injury.

Management of Craniocerebral Gunshot Injuries: A Review

Craniocerebral gunshot injuries (CGI) are increasingly encountered by neurosurgeons in civilian and urban settings. Unfortunately this is a prevalent condition in developing countries, with major armed conflicts which is not very likely to achieve a high rate of prevention. Management goals should focus on early aggressive, vigorous resuscitation and correction of coagulopathy; those with stable vital signs undergo brain computed tomography scan. Neuroimaging is vital for surgical purposes, especially for determine type surgery, size and location of the approach, route of extraction of the foreign body; however not always surgical management is indicated, there is also the not uncommon decision to choose non-surgical management. The treatment consist of immediate life salvage, through control of persistent bleeding and cerebral decompression; prevention of infection, through extensive debridement of all contaminated, macerated or ischemic tissues; preservation of nervous tissue, through preventing meningocerebral scars; and restoration of anatomic structures through the hermetic seal of dura and scalp. There have been few recent studies involving penetrating craniocerebral injuries, and most studies have been restricted to small numbers of patients; classic studies in military and civil environment have identified that this is a highly lethal or devastating violent condition, able to leave marked consequences for the affected individual, the family and the health system itself. Various measures have been aimed to lower the incidence of CGI, especially in civilians. It is necessarily urgent to promote research in a neurocritical topic such as CGI, looking impact positively the quality of life for those who survive.

Sharp penetrating wounds: spectrum of imaging findings and legal aspects in the emergency setting

The main cause of severe civilian trauma is not the same all over the world; while in Europe the majority of cases are due to blunt traumatic injury, in the United States, penetrating gunshot wounds are the most common. Penetrating wounds can be classified into two different entities: gunshot wounds, or more technically ballistic traumas, and sharp penetrating traumas, also identifiable with non-ballistic traumas. Sharp penetrating injuries are mainly caused by sharp pointed objects such as spears, nails, daggers, knives, and arrows. The type of injuries caused by sharp pointed objects depends on the nature and shape of the weapon, the amount of energy in the weapon or implement when it strikes the body, whether it is inflicted upon a moving or a still body, and the nature of the tissue injured. In the assessment of hemodynamically stable patients with sharp penetrating wounds, the main imaging procedure is Multidetector Computed Tomography (MDCT), especially used in complicated cases of penetrating injuries with an important impact on the final therapeutic choice. The diagnostic approach has been changed by MDCT due to its technical improvements, in particular, faster data acquiring and upgraded image reconstructions.

[Paraplegia complicating anterior abdominal stab wound]

Les traumatismes médullaires sont des complications rares des plaies abdominales antérieures par arme blanche. Son diagnostic est difficile parfois retardé. L'imagerie par résonance magnétique reste l'examen de choix. Le traitement dépend du tableau clinique et de la gravité de la souffrance médullaire. Le pronostic est corrélé à l’étendue et à la nature de la lésion médullaire. Nous rapportons un cas exceptionnel d'un traumatisme médullaire chez une patiente victime d'une plaie abdominale antérieure par arme blanche.

Neuroimaging in adult penetrating brain injury: a guide for radiographers

Penetrating brain injuries (PBI) are a medical emergency, often resulting in complex damage and high mortality rates. Neuroimaging is essential to evaluate the location and extent of injuries, and to manage them accordingly. Currently, a myriad of imaging modalities are included in the diagnostic workup for adult PBI, including skull radiography, computed tomography (CT), magnetic resonance imaging (MRI) and angiography, with each modality providing their own particular benefits. This literature review explores the current modalities available for investigating PBI and aims to assist in decision making for the appropriate use of diagnostic imaging when presented with an adult PBI. Based on the current literature, the authors have developed an imaging pathway for adult penetrating brain injury that functions as both a learning tool and reference guide for radiographers and other health professionals. Currently, CT is recommended as the imaging modality of choice for the initial assessment of PBI patients, while MRI is important in the sub-acute setting where it aids prognosis prediction and rehabilitation planning, Additional follow-up imaging, such as angiography, should be dependent upon clinical findings.

Serious penetrating craniocerebral injury caused by a nail gun

Penetrating cerebral injuries caused by foreign bodies occur rarely due to the substantial mechanical protection offered by the skull. Throughout most of history, the brain, residing in a "closed box" of bone, has not been vulnerable to external aggression. Recently, we encountered a serious penetrating craniocerebral injury caused by a nail gun. Total excision of the offending nail via emergency craniotomy was performed, but the patient's neurologic status was not improved in spite of aggressive rehabilitative treatment. Here, we report on this troublesome case in light of a review of the relevant literature.

Penetrating brain injury after suicide attempt with speargun: case study and review of literature

Penetrating cranial injury by mechanisms other than gunshots are exceedingly rare, and so strategies and guidelines for the management of PBI are largely informed by data from higher-velocity penetrating injuries. Here, we present a case of penetrating brain injury by the low-velocity mechanism of a harpoon from an underwater fishing speargun in an attempted suicide by a 56-year-old Caucasian male. The case raised a number of interesting points in management of low-velocity penetrating brain injury (LVPBI), including benefit in delaying foreign body removal to allow for tamponade; the importance of history-taking in establishing the social/legal significance of the events surrounding the injury; the use of cerebral angiogram in all cases of PBI; advantages of using dual-energy CT to reduce artifact when available; and antibiotic prophylaxis in the context of idiosyncratic histories of usage of penetrating objects before coming in contact with the intracranial environment. We present here the management of the case in full along with an extended discussion and review of existing literature regarding key points in management of LVPBI vs. higher-velocity forms of intracranial injury.

Imaging assessment of penetrating injury of the neck and face

Background

Penetrating trauma of the neck and face is a frequent presentation to acute emergency, trauma and critical care units. There remains a steady incidence of both gunshot penetrating injury to the neck and face as well as non-missile penetrating injury—largely, but not solely, knife-related. Optimal imaging assessment of such injuries therefore remains an on-going requirement of the general and specialised radiologist.

Methods

The anatomy of the neck and face—in particular, vascular, pharyngo-oesophageal, laryngo-tracheal and neural anatomy—demands a more specialised and selective management plan which incorporates specific imaging techniques.

Results

The current treatment protocol of injuries of the neck and face has seen a radical shift away from expectant surgical exploration in the management of such injuries, largely as a result of advances in the diagnostic capabilities of multi-detector computed tomography angiography (MDCTA), which is now the first-line imaging modality of choice in such cases.

Conclusion

This review aims to highlight ballistic considerations, differing imaging modalities, including MDCTA, that might be utilised to assist in the accurate assessment of these injuries as well as the specific radiological features and patterns of specific organ-system injuries that should be considered and communicated to surgical and critical care teams.

Teaching points

• MDCTA is the first-line imaging modality in penetrating trauma of the neck and, often, of the face

• The inherent deformability of a bullet is a significant factor in its tissue-damaging capabilities

• MDCTA can provide accurate assessment of visceral injury of the neck as well as vascular injury

• Penetrating facial trauma warrants radiological assessment of key adjacent anatomical structures

• In-driven fragments of native bone potentiate tissue damage in projectile penetrating facial trauma

The role of MRI in spinal stab wounds compared with intraoperative findings

INTRODUCTION

Spinal stab wound injuries are quite rare and only few patients have been reported on the basis of MRI scan.

METHODS

A 25-year-old man was stabbed at C1/2 and had an incomplete Brown-Sequard syndrome. He underwent surgical exploration because of CSF leakage on the fourth day.

RESULTS

After a follow-up period of 32 months, he was left with a remaining loss of the proprioception of the right foot. We show detailed CT and MR images with the focus on the lesions of the dura and myelon and compared them with intraoperative images. In addition, we contrast our findings with a review of literature published over the last three decades.

CONCLUSION

MRI gives the most detailed view of soft tissue lesions in SSWs and is in accordance with our intraoperative findings.

Management of penetrating brain injury

Penetrating brain injury (PBI), though less prevalent than closed head trauma, carries a worse prognosis. The publication of Guidelines for the Management of Penetrating Brain Injury in 2001, attempted to standardize the management of PBI. This paper provides a precise and updated account of the medical and surgical management of these unique injuries which still present a significant challenge to practicing neurosurgeons worldwide. The management algorithms presented in this document are based on Guidelines for the Management of Penetrating Brain Injury and the recommendations are from literature published after 2001. Optimum management of PBI requires adequate comprehension of mechanism and pathophysiology of injury. Based on current evidence, we recommend computed tomography scanning as the neuroradiologic modality of choice for PBI patients. Cerebral angiography is recommended in patients with PBI, where there is a high suspicion of vascular injury. It is still debatable whether craniectomy or craniotomy is the best approach in PBI patients. The recent trend is toward a less aggressive debridement of deep-seated bone and missile fragments and a more aggressive antibiotic prophylaxis in an effort to improve outcomes. Cerebrospinal fluid (CSF) leaks are common in PBI patients and surgical correction is recommended for those which do not close spontaneously or are refractory to CSF diversion through a ventricular or lumbar drain. The risk of post-traumatic epilepsy after PBI is high, and therefore, the use of prophylactic anticonvulsants is recommended. Advanced age, suicide attempts, associated coagulopathy, Glasgow coma scale score of 3 with bilaterally fixed and dilated pupils, and high initial intracranial pressure have been correlated with worse outcomes in PBI patients.

Imaging of head trauma

This article reviews the fundamental concepts related to the imaging of head trauma, and it is vital for radiologists to have a thorough understanding of the principal imaging findings in this setting and of the underlying mechanisms which are involved. There is a large and continually expanding body of literature on this subject, and imaging technologies and techniques continue to evolve. Radiologists continue to play an integral role in the assessment and care of patients with head trauma, and in order to maintain and strengthen this role, it is incumbent upon them to stay abreast of these developments.