Penetrating craniocerebral injuries. Report of two unusual cases

Penetrating intracranial nail-gun injury to the middle cerebral artery: A successful primary repair

BACKGROUND

Penetrating nail-gun injuries to the head are rare, however, the incidence has been gradually rising over the last decade. While there is a large volume of case reports in the literature, there are only a few incidences of cerebrovascular injury. We present a case of a patient with a nail-gun injury to the brain, which compromised the cerebral vasculature. In this article, we present the case, incidence, pathology, and a brief literature review of penetrating nail-gun injuries to highlight the principles of management pertaining to penetration of cerebrovascular structures.

CASE DESCRIPTION

A 26-year-old male presented with a penetrating nail-gun injury to his head. There were no neurological deficits. Initial imaging revealed that the nail had penetrated the cranium and suggested the vasculature to be intact. However, due to the proximity of the nail to the circle of Willis the operative approach was tailored in anticipation of a vascular injury. Intraoperatively removal of the foreign body demonstrated a laceration to the M1 branch of the middle cerebral artery (MCA), which was successfully repaired.

CONCLUSION

To our knowledge, this is the first reported case of a vascular arterial injury to the MCA from a nail-gun injury. It is imperative to have a high clinical suspicion for cerebrovascular compromise in penetrating nail-gun injuries even when conventional imaging suggests otherwise.

Intracranial self-stabbing

BACKGROUND

Little is known about the psychiatric state of patients who stab themselves in the brain (intracranial self-stabbing), including whether the behavior is usually an attempt to commit suicide and whether it is performed in association with symptoms of psychotic illness.

METHOD

A search for cases of intracranial self-stabbing in New South Wales, Australia (NSW), and a systematic search for published case reports of intracranial self-stabbing.

RESULTS

We located 5 cases in NSW in the last 10 years and 47 published case reports of intracranial self-stabbing since 1960. Intracranial self-stabbing was associated with a diagnosis of a psychotic illness in 27 of 49 (55%) cases in which a diagnosis was available. Intracranial self-stabbing was not always performed with the intention of committing suicide and does not usually have a fatal outcome.

CONCLUSIONS

Intracranial self-stabbing appears to be an under-recognized form of self-harm that is associated with, but not limited to, psychotic illness.

Successful repair of an intracranial nail-gun injury involving the parietal region and the superior sagittal sinus

Intracranial nail injuries to the brain are rare. Various techniques for the removal of penetrating nails have been reported, but to date successful nail extraction following an injury involving the superior sagittal sinus (SSS) has not been reported. The authors report the case of a nail-gun injury to the midline parietal region with penetration of the SSS. They describe an original surgical technique involving the use of a graft patch of temporal fascia and muscle to repair the SSS following extraction of the nail. The procedure resulted in preservation of distal flow across the sinus and a good neurological outcome. Technical considerations in the repair of penetrating posterior SSS injuries are discussed. Penetrating nail injuries to the brain involving the SSS can be successfully repaired with maintenance of sinus patency.

Penetrating orbitocranial gunshot injuries

BACKGROUND

The aim of this study was to analyze the effect of a surgical management protocol and other important clinical features on the prognosis of patients who had penetrating orbitocranial gunshot injuries.

METHODS

Thirty-five patients (30 unilateral, 5 bilateral) who had penetrating orbitocranial gunshot injuries were analyzed. The wounds were mainly caused by shrapnel fragments or bullets. Craniotomy was the standard treatment in all patients. Investigated clinical features included Glasgow Coma Scale (GCS) score on admission, the mode and the extent of brain injury, and the presence of an intracranial retained foreign body. The prognostic importance of complications such as infection, intracranial hemorrhage, cerebrospinal fluid leak, and epileptic seizures was also investigated. The mechanism and the injury characteristics of the patients were evaluated by predicting the visual outcome of the victims according to a newer classification system as well as other variables pertinent to this specific clinical setting of severe eye trauma. Final visual acuities of the patients were also measured.

RESULTS

The outcome of 35 penetrating orbitocranial gunshot injured patients was as follows: death in 3 patients, vegetative state in 1, severe disability in 2, moderate disability in 2, and good recovery in 27 cases. Localization and extent of the injury and GCS score on admission were the most important indicator for good neurological outcome. The predictors for good visual outcome were type B, grade 1, zone I, and relative afferent pupillary defect-negative injuries. The predictors for poor outcome were type A, grade 5, zone III, and relative afferent pupillary defect-positive injuries.

CONCLUSION

The prognosis of the injury depends on the course of the bullet or shrapnel fragment and the interdisciplinary care. An extensive preoperative evaluation of penetrating orbital trauma and a combined ophthalmic and neurosurgical approach are recommended to minimize the morbidity of the patients. However, complete removal of the foreign material in a deep or ventricular localization is not mandatory because careful debridement and tight closure of dura provides desired outcome. Evaluation of trauma mechanism and injury characteristics according to the Ocular Trauma Classification System seems to predict accurately the visual outcomes in this series.

Unusual transoral penetrating injury of the foramen magnum: case report

OBJECTIVE AND IMPORTANCE

Penetrating injuries of the cranium and spine are frequent to the civilian neurosurgical practice. Although a variety of unusual objects have been reported, to our knowledge, there has never been a craniocerebral or spinal injury caused by a fish. An unusual case of transoral penetration of the foramen magnum by a billed fish is described. The history, radiographic studies, and treatment are presented.

CLINICAL PRESENTATION

A fisherman struck by a jumping fish initially presented with severe neck pain and stiffness, bleeding from the mouth, and a laceration in the right posterior pharynx. A computed tomographic scan of the cervical spine revealed a wedge-shaped, hyperdense object extending from the posterior pharynx into the spinal canal between the atlas and the occiput. Because of the time factor involved, the fisherman was brought directly to surgery for transoral removal of the object.

INTERVENTION

The patient was placed under general anesthesia, and with a tonsillar retractor, a kipner, and hand-held retractors, the object was visualized and identified as a fish bill. Further dissection above the anterior aspect of the atlas permitted removal of the object by means of a grabber from an arthroscopic set. No expression of cerebrospinal fluid was noted, and a Penrose drain was placed.

CONCLUSION

The patient was treated under the assumption that penetrating foreign objects in continuity with the cerebrospinal fluid space and the outside environment should be removed as soon as possible. The patient was provided appropriate antibiotics to treat potential infection of normal pharyngeal flora and organisms unique to the marine environment. The patient recovered and did not experience any residual neurological deficit.

Suicide by a power drill

This is the report of a 62-year-old man who committed suicide by drilling through his anterior chest wall with an electric power drill. Death was caused by pericardial tamponade combined with bleeding into the pleural cavity. The skin lesion at the left hemithorax was similar to a bullet entrance wound.

Penetrating intracranial wooden object: case report and review of CT morphology, complications, and management

BACKGROUND

Penetrating intracranial wooden fragments after vehicular accidents are uncommon. The CT morphology, complications, and management in such cases are quite variable.

CASE REPORT

A 27-year-old male was seen with a "twig" from a tree embedded firmly just below the right medial canthus after a motorcycle accident. Diagnosis of intracranial penetrating wooden object was made on CT scanning. The wooden stick, which had splintered into two, was extricated through a craniotomy in two operative sessions. However the patient succumbed to septicemia and meningitis on the twelfth day after the accident.

CONCLUSIONS

The need for prompt extrication of these objects and the causes of high mortality in this condition are discussed. The importance of imaging the intracranial compartment in injuries involving the periorbital region is emphasized.

[Suicide attempt by introducing 2 nails in the head. Case report]

Case report of a 39 years old male patient who attempted suicide by introducing two nails in the midline of the head. He was successfully submitted to an extensive paramedian bifrontotemporal craniotomy, and survived without motor deficits.

Self-inflicted orbital and intracranial injury with a retained foreign body, associated with psychotic depression: case report and review

Reports of intracranial self-mutilation by psychotic individuals are associated with severe mental disorders, criminality, or both. We describe a psychotically depressed male who drove a ballpoint pen through his right medial canthus and into his intracranial compartment. The patient developed a cavernous sinus syndrome and a traumatic dissection of the cavernous portion of the carotid artery. The pen was removed intraoperatively. Postoperatively, the patient was placed on a course of broad-spectrum antibiotics, antidepressants, and antipsychotic medications, and he has received long-term psychiatric follow-up. The literature related to these unusual cases is reviewed, and relevant surgical, medical, and psychiatric aspects of treatment are discussed.

Cranial nerve palsy as a delayed complication of attempted infanticide by insertion of a stylet through the fontanel. Case report

A child suffered a sixth and seventh cranial nerve palsy due to intracerebral insertion of a stylet. The stylet was introduced through the anterior fontanel, most probably in an attempt at infanticide. The migration of the stylet through the brain was monitored because the child was first examined 6 years earlier. At operation the cranial part of the stylet lay in the fourth ventricle, compressing the facial nerve as well as the nucleus of the abducens nerve. The lower part of the stylet had reached the C-5 level.

Unusual craniocerebral penetrating injury by a chopstick

The case of a 53-year-old man who attempted suicide by introducing a wooden chopstick through his nostril into his brain is reported. The importance of computed tomography is stressed in the diagnosis of intracranial wooden foreign bodies.

Unusual penetrating craniocerebral injury

We report a 29-year-old patient who was operated on for a penetrating craniocerebral injury caused by an underwater fishing harpoon. It had penetrated through the roof of the left orbit, upward toward the calvaria. The patient was immediately operated upon and the foreign body was easily removed through a small left parietal craniectomy. In spite of the spectacular appearance of the injury on admission to the hospital, neurological impairment before and after the operation was minimal.

Penetrating cranio-cerebral injuries due to unusual foreign bodies

Seven cases of penetrating cranio-cerebral injury by peculiar foreign bodies are described. The clinical-pathological picture is reported wherever possible. Lack of adequate safety measures and untrained careless handling of instruments were at the root of these tragic accidents. Greater awareness of such dangers in industry and in school might help to promote the adoption of adequate safety measures.

Unusual intracranial foreign bodies. Report of five cases

Five patients surgically treated for unusual intracranial foreign bodies are presented. They include representative cases of the three most commonly encountered types of these injuries: industrial accidents, suicidal attempts and the result of criminal assault. Immediate radiological examination is mandatory because the deceptively small entrance wound is usually in no way commensurate with the large size of the foreign body the presence of which is frequently not suspected. The surgical removal of these foreign bodies requires careful pre-operative assessment to avoid hemorrhages and undue injury to the surrounding normal brain tissue.