PENETRATING WOUNDS OF THE BRAIN: AN EXPERIMENTAL STUDY

A late onset adult seizure due to intracerebral needle: case-based update

BACKGROUND AND AIM

Late-onset seizure due to intracerebral needle is a rare entity. Most of them were clinically asymptomatic and rarely presented with seizure. Sewing needles are used in homicidal attempt in infancy or early childhood before the closure of the fontanels. Because of sociologic, politic, and scientific deficiencies subject remained untouched. We tried shedding some light on this ambiguous phenomenon.

MATERIAL AND METHODS

We report a 54-year-old man who was admitted to our neurosurgery outpatient department with epilepsy due to a sewing needle located in the left frontal lobe of the brain and made extensive literature review.

RESULT

Patient's physical and neurological examinations were completely normal. All biochemical and hematological tests were normal. Cranial tomography demonstrated a linear density at the left frontal lobe compatible with a sewing needle. Patient was followed-up with antiepileptic treatment with no seizure. Sixty cases from up-to-date literature and past cases were reviewed. Patients' ages differ from 4 days to 70 years. Our review showed four cases treated with antibiotics, 19 patients went to surgery, and others just followed-up with antiepileptic and other drugs.

CONCLUSION

Literature needs an autopsy series for a more intimate estimation. Due to psychosocial and legitimacy problems, matter should be handled cautiously and law enforcement agencies must be informed. Follow-up with medication is the first line of treatment with asymptomatic patients. Treatment is dictated by clinic onset, physical examination, and patient consent.

Nonmissile Anterior Skull-Base Penetrating Brain Injury: Experience with 22 Patients

Background:

Nonmissile anterior skull-base penetrating brain injuries (NASBPBIs) have specific characteristic features that are different from missile injuries. Our study presents our experiences on the characteristic features as well as management of NASBPBI.

Materials and Methods:

We retrospectively reviewed 22 consecutive patients with NASBPBI managed at our institute during a 13-year period. The mechanism of injury, clinical investigations, and complications were analyzed, with more emphasis on diagnostic and treatment regimen.

Results:

The 22 cases included in our study comprise of 20 males and 2 females. Majority (72.7%) of the patients were adults with a mean age of 27.5 years. The mechanisms of injury often include accidental fall, either onto a small-diameter sharp object (10 cases) or while carrying such an object in the hand (4 cases). The other common mechanisms were stabbing, accident, or during an altercation (8 cases). Clinical manifestations included periorbital hematoma (10 cases, 45.5%) and cerebrospinal fluid rhinorrhea or orbitorrhea (4 cases, 18.2%) as well as signs of embedded foreign object (8 cases, 36.4%). We performed emergency craniotomy in 21 cases and skin debridement in one case. Postoperative complications were abscess (1 case), epilepsy (1 case), and traumatic carotid-cavernous fistula (1 case).

Conclusion:

Nonmissile injuries are generally on the rise and therefore deserve more attention. We observed that clinical outcomes were excellent in 14 (Glasgow Outcome Scale [GOS] score of 5) and good in the remaining 8 patients (GOS of 4) during 6-month–10-year (mean 4.6 years) follow-ups.

Fatal orbito-cerebral penetration by industrial grease viscous: Rare case report

Assorted projectiles including shrapnel, sling shots, stones, metal and rock fragments and other missiles cause fatal penetrating skull injuries. In this case, a 34-year-old foreman suffered a fatal penetrating orbito-cerebral injury while lubricating a hydraulic rock-splitting machine with industrial grease viscous.

Clinical Presentation and Outcome of Impalement Craniocerebral Injuries - A CASE SERIES

Non-missile, low-velocity penetrating craniocerebral injuries are uncommon among civilians and unlike missile injuries, are associated with localized brain injury and subsequent good outcome if managed appropriately. Penetrating injuries to the brain caused by a retained, relatively blunt or sharp object that perforate the brain along its longitudinal axis producing a wound track corresponding to its length of penetration, are called impalement injuries. Most of the impalement craniocerebral injuries are accidental and varying objects have been reported. We report our experience with the management of seven cases of impalement craniocerebral injuries. Five of the patients were adult male while two female children were involved. One case was from assault, others resulted from accidental injury. Left side of the cranium was more commonly involved. The impaled objects in this study included a lead pencil, a screw driver, a branch of a tree, and other metallic objects. Most of the patients had craniectomy and water tight dura repair during remover of the impaled object. All patients made good recovery following surgical intervention. Management principles entail early recognition, deliberate and careful debridement, and judicious antibiotic therapy. The surgical approach to these injuries varies, depending on the route of entry.

Nonmissile Penetrating Injury to the Head: Experience with 17 Cases

BACKGROUND

Penetrating nonmissile injuries to the head are far less common than missile penetrating injuries. Here we describe our experience in managing 17 cases of nonmissile injury to the head, likely the largest such series reported to date. We also highlight the surgical steps and techniques used to remove in situ objects (including weapons) in the penetrating wounds that have not been described previously.

METHODS

We conducted a retrospective study of cases of nonmissile, low-velocity penetrating injuries of the head managed in our department. The recorded data of patients with penetrating head injuries were studied for the cause of the injury, type of object, type and extent of penetration, Glasgow Coma Scale score on admission, other clinical issues, evaluation and assessment, interval from penetration to operation, surgical steps and notes, difficulty during the operation, major and minor complications, follow-up, and ultimate outcome.

RESULTS

Our 17 cases included 6 cases of accidental penetration and 11 cases of penetration as the result of violence. Weapons and other foreign objects causing injury included a teta (a pointed metal weapon with a wooden handle and a barb near the tip, used for hunting and fishing) in 4 cases, a dao (a sharp metal cutting instrument with a wooden handle used for cutting vegetables, fish, meat, bamboo, wood, etc.) in 3 cases, a bamboo stick in 3 cases, a metal rod in 2 cases, a knife in 2 cases, a sharp stone in 1 case, a metal steam chamber cover in 1 case, and a long peg in 1 case. GCS on admission was between 13 and 15 in 15 cases. Only 1 patient exhibited limb weakness. Four patients with an orbitocranial penetrating injury had 1-sided vision loss; 2 of these patients had orbital evisceration, and 1 of these patients died. In 14 patients, the foreign object was in situ at presentation and was removed surgically. Computed tomography scan and plain X-ray of the head were obtained in all patients. Postoperatively, 2 patients (11.7%) needed support in the intensive care unit but died early after surgery. One patient developed late osteomyelitis. The remaining patients were doing well at the most recent follow-up.

CONCLUSIONS

The presenting picture of nonmissile penetrating injury to head may be daunting, but these cases can be managed with very good results with proper (clinical and radiologic) evaluation and simple neurosurgical techniques.

Management and outcome of low velocity penetrating head injury caused by impacted foreign bodies

BACKGROUND

Penetrating head injuries with impacted foreign bodies are rare, associated with a high incidence of morbidity and potentially life-threatening. In this study, we aimed at investigating the outcome of these cases as well as analyzing the factors affecting the prognosis.

METHODS

A retrospective study in which the records of 16 patients who had penetrating head injuries caused by low-velocity impacted foreign bodies were revised. All patients were males with a mean age of 28.9 years (range, 18 to 50 years). The follow-up period ranged from 4 to 13 months with a mean of 8.1 months. Causes of injury were construction accidents in 6 (37.5 %) patients, assault in 6 (37.5 %) and road traffic accidents in 4 (25 %). The impacted objects included a bar of iron, a piece of wood, a nail, a sickle and a piece of glass. Diagnostic computerized tomography (CT) of the brain was carried out on admission in all patients. Thirteen (81.3 %) patients were submitted to surgery, and all had the appropriate management in the form of antibiotics and dehydrating measures as required. The primary outcome measure was the Glasgow Outcome Scale (GOS) at the end of follow-up.

RESULTS

At the end of follow-up, ten (62.5 %) patients had a GOS score of 5, two (12.5 %) patients had a score of 4, and four (25 %) patients had a score of 1.

CONCLUSIONS

Low-velocity penetrating head injuries are most common in young adult males. With the appropriate management, a majority of even the most severe cases can have a favorable outcome.

A late-onset seizure in a child due to intracranial needle

Placing of sewing needles in the brain through the anterior fontanel is a rare entity. There are very few cases reported in literature. Most of them were asymptomatic, but some of them presented with seizure. We report here a 14-year-old boy, who was admitted to the Pediatric Neurology Department with a history of generalized tonic-clonic seizures due to sewing needle located in the frontal lobe.

An unusual case of orbito-frontal rod fence stab injury with a good outcome

Background

High-energy non-missile penetrating injuries (stab injuries) account for a small percentage of penetrating head injuries and they present a series of special features.

Case presentation

A 35-year-old man suffered orbito-frontal? and trans-cranial injuries after falling five meters from a terrace onto a rod iron fence. The removal of the metal rod was performed outside the operating room. The orbital roof was exposed and repaired through a bifrontal craniotomy and the frontal sinuses were cranialised. The orbital floor and zygoma were plated with micro-screws.

Conclusion

The patient recovered without significant complications, apart from a slight paresis of the right superior rectus; the ocular globe remained intact.

The positive outcome obtained in this very challenging case is attributable to the competency of the Neurotrauma Unit and to the use of a synergistic approach which involved the contribution of neurosurgeons, maxillo-facial surgeons, radiologists and anaesthesiologists.

Low velocity penetrating head injury with impacted foreign bodies in situ

Penetrating head injury is a potentially life-threatening condition. Penetrating head injuries with impacted object (weapon) are rare. The mechanism of low velocity injury is different from high velocity missile injury. Impacted object (weapon) in situ poses some technical difficulties in the investigation and management of the victims, and if the anticipated problems are not managed properly, they may give rise to serious consequences. The management practice of eight patients with impacted object in situ in context of earlier reported similar cases in literature is presented.

Management of nonmissile penetrating brain injuries: a description of three cases and review of the literature

Nonmissile penetrating intracranial injuries are uncommon events in modern times. Most reported cases describe trajectories through the orbit, skull base foramina, or areas of thin bone such as the temporal squama. Patients who survive such injuries and come to medical attention often require foreign body removal. Critical neurovascular structures are often damaged or at risk of additional injury resulting in further neurological deterioration, life-threatening hemorrhage, or death. Delayed complications can also be significant and include traumatic pseudoaneurysms, arteriovenous fistulas, vasospasm, cerebrospinal fluid leak, and infection. Despite this, given the rarity of these lesions, there is a paucity of literature describing the management of neurovascular injury and skull base repair in this setting. The authors describe three cases of nonmissile penetrating brain injury and review the pertinent literature to describe the management strategies from a contemporary cerebrovascular and skull base surgery perspective.

Intracranial sewing needle in a man with seizure: a case of child abuse?

Physical abuse in infancy can cause persistent neurological deficits. Although intracranial foreign bodies are generally secondary to penetrating trauma or surgical procedures, rarely they also occur as a result of child abuse. A 32-year-old man presented with the complaint of generalized tonic clonic seizures to the Neurology Department of Marmara, University Hospital. Computerized tomography (CT) scan revealed a sewing needle located within the temporal lobe. The location and the position of the needle suggested that it must have been introduced in infancy through the lamdoid suture before the closure of it, as an unsuccessful deliberate homicide attempt or accidental injury.

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.

Unrecognized penetrating intracranial foreign body

Low-velocity penetrating craniocerebral trauma may present as an apparently trivial injury. A case is presented which illustrates the need to suspect a penetrating injury whenever a low velocity object strikes the head.

Stab wounds of the brain

Unlike the penetrating injuries to the brain caused by missiles, injuries by stabbing are largely restricted to the wound tract. Early recognition, debridement and judicious antibiotic therapy can limit or prevent complications in the management of stab wounds. Among the common sequelae of stab wounds of the brain are pneumocephalus, meningitis, intracerebral hemorrhage and direct blood vessel or nerve injury.