Physiological and radiological parameters predicting outcome from penetrating traumatic brain injury treated in the deployed military setting

INTRODUCTION

Penetrating traumatic brain injury (TBI) is the most common cause of death in current military conflicts, and results in significant morbidity in survivors. Identifying those physiological and radiological parameters associated with worse clinical outcomes following penetrating TBI in the austere setting may assist military clinicians to provide optimal care.

METHOD

All emergency neurosurgical procedures performed at a Role 3 Medical Treatment Facility in Afghanistan for penetrating TBI between 01 January 2016 and 18 December 2020 were analysed. The odds of certain clinical outcomes (death and functional dependence post-discharge) occurring following surgery were matched to existing agreed preoperative variables described in current US and UK military guidelines. Additional physiological and radiological variables including those comprising the Rotterdam criteria of TBI used in civilian settings were additionally analysed to determine their potential utility in a military austere setting.

RESULTS

55 casualties with penetrating TBI underwent surgery, all either by decompressive craniectomy (n=42) or craniotomy±elevation of skull fragments (n=13). The odds of dying in hospital attributable to TBI were greater with casualties with increased glucose on arrival (OR=70.014, CI=3.0399 to 1612.528, OR=70.014, p=0.008) or a mean arterial pressure <90 mm Hg (OR=4.721, CI=0.969 to 22.979, p=0.049). Preoperative hyperglycaemia was also associated with increased odds of being functionally dependent on others on discharge (OR=11.165, CI=1.905 to 65.427, p=0.007). Bihemispheric injury had greater odds of being functionally dependent on others at discharge (OR=5.275, CI=1.094 to 25.433, p=0.038).

CONCLUSIONS

We would recommend that consideration of these three additional preoperative clinical parameters (hyperglycaemia, hypotension and bihemispheric injury on CT) when managing penetrating TBI be considered in future updates of guidelines for deployed neurosurgical care.

Self-inflicted very-low-velocity penetrating head injury: A CARE-compliant case report

RATIONALE

Low-velocity penetrating head injury (PHI) is rare, comprising 0.2% to 0.4% of head traumas, but can be devastating and is associated with significant morbidity and mortality. No previous case of very-low-velocity PHI due to self-inflicted stabbing with a gimlet has been reported.

PATIENT CONCERNS

A 62-year-old man was admitted to the hospital with bleeding head and abdominal wounds after stabbing his abdomen with a gimlet, and then hammering the same gimlet into his forehead and removing the gimlet himself.

DIAGNOSES

Upon examination at admission, stab wounds were present on the forehead and the right upper quadrant. Computed tomography (CT) of the head revealed a bone defect in the left frontal bone and showed the intracranial path of the gimlet surrounded by mild hemorrhage and pneumocephalus. Magnetic resonance imaging (MRI) confirmed a small amount of hemorrhage with pneumocephalus but no vascular injury.

INTERVENTIONS

Conservative treatment without surgery.

OUTCOMES

Follow-up MRI on hospital day 58 showed no abscess or traumatic intracranial aneurysm. The patient achieved full recovery of motor and mental functions with conservative treatment and was discharged on hospital day 69.

LESSONS

Very-low-velocity PHI might be successfully treated with conservative treatment.

Multiple nail gun injuries: suicide or homicide?

Nail gun injuries are a forensic problem; it can be difficult to distinguish self-inflicted injuries from accident and homicide instances. This kind of injuries shares some characteristics with both gunshot and puncture wounds. We describe a peculiar case of a man who committed suicide driving nails into his skull using a pneumatic nail gun. Entrance wounds were found on both temporal regions of the head. Reviewing scientific literature, this is the first case in Italy reporting the macroscopic data of bilateral head and brain nail gun injuries during an autopsy. Circumstantial elements were not sufficient to clarify if these lesions were self-inflicted, inflicted by accident, or else. Radiological examination can be helpful to show the exact location of the nails, but it has also its own limitations. We firmly believe that autopsy, especially the head section, is crucial to identify the nature and the extension of these lesions, thus giving us much more information about the mechanism of death and the circumstances in which it occurred.

Construction Industry-Associated Penetrating Craniocerebral Injuries

BACKGROUND

 Various high-energy tasks in the construction industry can lead to craniocerebral injuries. Construction industry-associated penetrating craniocerebral injuries due to metal foreign bodies have unique characteristics. However, no norms exist for removing metal foreign bodies and preventing secondary trauma. This study aimed to explore the characteristics and treatment of construction industry-associated penetrating craniocerebral injuries due to metal foreign bodies.

METHODS

 Data of patients who suffered from penetrating injuries due to metal foreign bodies and were treated in the Zhongshan People's Hospital from 2001 to 2021 were collected based on the causes of injuries to explore disease characteristics and therapeutic effects.

RESULTS

 A total of six patients with penetrating craniocerebral injuries due to metal foreign bodies, who underwent surgeries, were included in the study. Five patients recovered well after the surgery, and one patient died. In four patients, intracranial infection complicated the course after surgery, and two patients had delayed intracranial hematoma.

CONCLUSION

 Patients with construction industry-associated penetrating craniocerebral injuries due to metal foreign bodies are prone to coma and intracranial vascular injuries. Early surgical removal and prevention of intracranial infection are key to achieving good therapeutic effects.

Intracranial Pressure and Brain Tissue Oxygen Multimodality Neuromonitoring in Gunshot Wounds to the Head in Children

OBJECTIVE

Gunshot wounds to the head (GSWH) are a cause of severe penetrating traumatic brain injury (TBI). Although multimodal neuromonitoring has been increasingly used in blunt pediatric TBI, its role in the pediatric population with GSWH is not known. We report on 3 patients who received multimodal neuromonitoring as part of clinical management at our institution and review the existing literature on pediatric GSWH.

METHODS

We identified 3 patients ≤18 years of age who were admitted to a quaternary children's hospital from 2005 to 2021 with GSWH and received invasive intracranial pressure (ICP) and Pbto2 (brain tissue oxygenation) monitoring with or without noninvasive near-infrared spectroscopy (NIRS). We analyzed clinical and demographic characteristics, imaging findings, and ICP, Pbto2, cerebral perfusion pressure, and rSo2 (regional cerebral oxygen saturation) NIRS trends.

RESULTS

All patients were male with an average admission Glasgow Coma Scale score of 4. One patient received additional NIRS monitoring. Episodes of intracranial hypertension (ICP ≥20 mm Hg) and brain tissue hypoxia (Pbto2 <15 mm Hg) or hyperemia (Pbto2 >35 mm Hg) frequently occurred independently of each other, requiring unique targeted treatments. rSo2 did not consistently mirror Pbto2. All children survived, with favorable Glasgow Outcome Scale-Extended score at 6 months after injury.

CONCLUSIONS

Use of ICP and Pbto2 multimodality neuromonitoring enabled specific management for intracranial hypertension or brain tissue hypoxia episodes that occurred independently of one another. Multimodality neuromonitoring has not been studied extensively in pediatric GSWH; however, its use may provide a more complete picture of patient injury and prognosis without significant added procedural risk.

Diagnosis and management of occult non-missile penetrating brain injury

Penetrating brain injury (PBI) is a subtype of traumatic brain injury (TBI) that has been steadily increasing in prevalence and causing significant mortality in trauma patients. In an emergent setting, it is important to determine the mechanism of injury and decide whether a PBI or a blunt TBI has occurred in order to guide diagnostic imaging and subsequent treatment. In cases where a PBI has been likely or has occurred, it is important to initiate treatment expeditiously as rapid interventions have been shown to lead to better outcomes. However, in cases of unwitnessed pediatric trauma, it can be difficult to ascertain the specific method of injury due to a lack of reliable sources. In such cases of unwitnessed trauma, PBI should be included in the differential of any orbitocranial injury. In this series, we present two cases of unwitnessed pediatric orbitocranial injury that highlight the importance of gathering a detailed history, obtaining appropriate imaging studies, and using physician intuition.

Surviving a Self-inflicted Transorbital Pen Intrusion to the Cerebellum: Case Report

BACKGROUND

 Although intracranial traumas by penetrating foreign objects are not absolute rarities, the nature of trauma, the kind of object, and its trajectory make them a one of a kind case every time they occur. Whereas high-velocity traumas mostly result in fatalities, it is the low-velocity traumas that demand an individualized surgical strategy.

METHODS

 We present a case report of a 33-year-old patient who was admitted to our department with a self-inflicted transorbital pen injury to the brain. The authors recall the incident and the technique of the pen removal.

RESULTS

 Large surgical exposure of the pen trajectory was considered too traumatic. Therefore, we opted to remove the pen and have an immediate postoperative computed tomography (CT) scan. Due to its fragility, the pen case could only be removed with a screwdriver, inserted into the case. Post-op CT scan showed a small bleeding in the right peduncular region, which was treated conservatively. The patient was transferred back to intensive care unit and woken up the next day. She lost visual function on her right eye, but suffered from no further neurologic deficit.

CONCLUSION

 Surgical management of removal of intracranial foreign bodies is no routine procedure. Although some would favor a large surgical exposure, we could not think of an approach to do so without maximum surgical efforts. We opted for a minimal surgical procedure with immediate CT scan and achieved an optimal result. We find this case to be worth considering when deciding on a strategy in the future.

Successful resuscitation and multidisciplinary management of penetrating brain injury caused by tire explosion: A case report

RATIONALE

Penetrating brain injury (PBI) is a rare trauma that presents as a difficult and serious surgical emergency for neurosurgeons in clinical practice. Our patient was admitted with a PBI caused by a tire explosion, which is an extremely rare cause of injury.

PATIENT CONCERNS

We report a case of a 28-year-old male patient who suffered a PBI when a tire exploded while it was being inflated with a high-pressure air pump.

DIAGNOSES

The patient was diagnosed with PBI presenting with multiple comminuted skull fractures, massive bone fragments with foreign bodies penetrating the underlying brain tissue of the top right frontal bone, multiple cerebral contusions, and intracranial hematoma.

INTERVENTIONS

Emergency combined multidisciplinary surgery was performed for the removal of the fragmented bone pieces, hematoma, and foreign bodies; decompression of the debridement flap; reconstruction of the anterior skull base; and repair of the dura mater.

OUTCOMES

The patient was successfully resuscitated and discharged 1 month later and is now recovering well.

LESSONS

Patients with PBI are critically ill. Therefore, timely, targeted examinations and appropriate multidisciplinary interventions through a green channel play a key role in assessing the condition, developing protocols, and preventing complications.

Trans-base and trans-vault low-velocity penetrating brain injury: A retrospective comparative study of characteristics, treatment, and outcomes

PURPOSE

Low-velocity penetrating brain injury (LVPBI) caused by foreign bodies can pose life-threatening emergencies. Their complexity and lack of validated classification data have prevented standardization of clinical management. We aimed to compare the trans-base and trans-vault phenotypes of LVPBI to help provide guidance for clinical decision-making of such injury type.

METHODS

A retrospective study on LVPBI patients managed at our institution from November 2013 to March 2020 was conducted. We included LVPBI patients admitted for the first time for surgery, and excluded those with multiple injuries, gunshot wounds, pregnancy, severe blunt head trauma, etc. Patients were categorized into trans-base and trans-vault LVPBI groups based on the penetration pathway. Discharged patients were followed up by outpatient visit or telephone. The data were entered into the Electronic Medical Record system by clinicians, and subsequently derived by researchers. The demography and injury characteristics, treatment protocols, complications, and outcomes were analyzed and compared between the two groups. A t-test was used for analysis of normally distributed data, and a Mann-Whitney U test for non-parametric data. A generalized linear model was further established to determine whether the factors length of stay and performance scale score were influenced by each factor.

RESULTS

A total of 27 LVPBI patients were included in this analysis, comprised of 13 (48.1%) trans-base cases and 14 (51.9%) trans-vault cases. Statistical analyses suggested that trans-base LVPBI was correlated with deeper wounds; while the trans-vault phenotype was correlated with injury by metal foreign bodies. There was no difference in Glasgow Coma Scale score and the risk of intracranial hemorrhage between the two groups. Surgical approaches in the trans-base LVPBI group included subfrontal (n = 5, 38.5%), subtemporal (n = 5, 38.5%), lateral fissure (n = 2, 15.4%), and distal lateral (n = 1, 7.7%). All patients in the trans-vault group underwent a brain convex approach using the foreign body as reference (n = 14, 100%). Moreover, the two groups differed in application prerequisites for intracranial pressure monitoring and vessel-related treatment. Trans-base LVPBI was associated with higher rates of cranial nerve and major vessel injuries; in contrast, trans-vault LVPBI was associated with lower functional outcome scores.

CONCLUSION

Our findings suggest that trans-base and trans-vault LVPBIs differ in terms of characteristics, treatment, and outcomes. Further understanding of these differences may help guide clinical decisions and contribute to a better management of LVPBIs.

Post-mortem analysis of gunshot wounds to the head and thorax in dogs by computed tomography, radiography and forensic necropsy

In view of the scarcity of literature data on the use of radiological imaging techniques in forensic veterinary medicine, while at the same time the number of reported crimes against animals involving the use of firearms is rising, this paper attempts to assess the usefulness of radiography and computed tomography (CT) in the post-mortem diagnosis of gunshot wounds (GSW) in comparison to classic necropsy. The design of the experiment was as follows: preparation of the research material (13 dog carcasses), shooting of the material from different distances (1.5 and 12 m, plus one contact shot to the head) and using different types of ammunition, followed by X-rays and CT scans in each case to examine the injuries resulting from the shot. The final steps of the experiment were photographic documentation and autopsy by the Virchow method. In the examined material, post-traumatic bone lesions and the presence of metallic foreign bodies were successfully imaged by both radiography and CT. GSW analysis using CT provided much better data quality and some additional information. Two general conclusions can be drawn from the results of the experiment. First, damage caused by gunshots is correlated with the calibre, initial velocity and kinetic energy of the projectile, as well as the distance from the muzzle of the gun to the object shot. Second, radiological examination is useful in preparing forensic veterinary opinions. Used as a complement to classic necropsy, they increase the possibility of an accurate post-mortem diagnosis of shooting victims.

Cerebrovascular Complications in Early Survivors of Civilian Penetrating Brain Injury

BACKGROUND

This study investigates the presence of cerebrovascular injuries in a large sample of civilian penetrating brain injury (PBI) patients, determining the prevalence, radiographic characteristics, and impact on short-term outcome.

METHODS

We retrospectively reviewed patients with PBI admitted to our institution over a 2-year period. Computed tomography head scans, computer tomography angiograms and venograms of the intracranial vessels were evaluated to determine the wound trajectory, intracranial injury characteristics, and presence of arterial (AI) and venous sinus (VSI) injuries. Demographics, clinical presentation, and treatment were also reviewed. Discharge disposition was used as surrogate of short-term outcome.

RESULTS

Seventy-two patients were included in the study. The mechanism of injury was gunshot wounds in 71 patients and stab wound in one. Forty-one of the 72 patients (60%) had at least one vascular injury. Twenty-six out of 72 patients suffered an AI (36%), mostly pseudoaneurysms and occlusions, involving the anterior and middle cerebral arteries. Of the 72 patients included, 45 had dedicated computed tomography venograms, and of those 22 had VSI (49%), mainly manifesting as superior sagittal sinus occlusion. In a multivariable regression model, intraventricular hemorrhage at presentation was associated with AI (OR 9.9, p = 0.004). The same was not true for VSI.

CONCLUSION

Acute traumatic cerebrovascular injury is a prevalent complication in civilian PBI, frequently involving both the arterial and venous sinus systems. Although some radiographic features might be associated with presence of vascular injury, assessment of the intracranial vasculature in the acute phase of all PBI is essential for early diagnosis. Treatment of vascular injury remains variable depending on local practice.

Penetrating traumatic brain injury resulting from a cockerel attack: case report and literature review

Traumatic brain injury is common in children and can lead to death or considerable, long-lasting morbidity. We present the case of a 10-month-old female child who presented after being attacked by a cockerel in a chicken coop. Following a seizure, an MRI scan revealed an intracerebral haemorrhage underlying a stab-type wound inflicted by the bird. Animal bite injuries are common worldwide but they rarely cause intracranial injuries. Domestic hens are rarely dangerous but can become defensive or aggressive during breeding periods or when protecting their territory. To date, only a handful of articles have reported on wounds inflicted by chicken beaks. Those reported were largely facial or ocular injuries. Infectious complications have also been encountered post-injury. This is to our knowledge the first report of a bird attack resulting in significant penetrating traumatic brain injury. Children should be cautioned by guardians to avoid unsupervised contact with chickens, particularly during breeding. Attacks to the neurocranium when they occur must be taken seriously and not treated as humorous or insignificant. Imaging appropriate to the child's clinical condition should be pursued and appropriate intervention and antibiotic treatment should be implemented.

Prognostic performance of computerized tomography scoring systems in civilian penetrating traumatic brain injury: an observational study

Background

The prognosis of penetrating traumatic brain injury (pTBI) is poor yet highly variable. Current computerized tomography (CT) severity scores are commonly not used for pTBI prognostication but may provide important clinical information in these cohorts.

Methods

All consecutive pTBI patients from two large neurotrauma databases (Helsinki 1999–2015, Stockholm 2005–2014) were included. Outcome measures were 6-month mortality and unfavorable outcome (Glasgow Outcome Scale 1–3). Admission head CT scans were assessed according to the following: Marshall CT classification, Rotterdam CT score, Stockholm CT score, and Helsinki CT score. The discrimination (area under the receiver operating curve, AUC) and explanatory variance (pseudo-R²) of the CT scores were assessed individually and in addition to a base model including age, motor response, and pupil responsiveness.

Results

Altogether, 75 patients were included. Overall 6-month mortality and unfavorable outcome were 45% and 61% for all patients, and 31% and 51% for actively treated patients. The CT scores’ AUCs and pseudo-R²s varied between 0.77–0.90 and 0.35–0.60 for mortality prediction and between 0.85–0.89 and 0.50–0.57 for unfavorable outcome prediction. The base model showed excellent performance for mortality (AUC 0.94, pseudo-R² 0.71) and unfavorable outcome (AUC 0.89, pseudo-R² 0.53) prediction. None of the CT scores increased the base model’s AUC (p > 0.05) yet increased its pseudo-R² (0.09–0.15) for unfavorable outcome prediction.

Conclusion

Existing head CT scores demonstrate good-to-excellent performance in 6-month outcome prediction in pTBI patients. However, they do not add independent information to known outcome predictors, indicating that a unique score capturing the intracranial severity in pTBI may be warranted.

Electronic supplementary material

The online version of this article (10.1007/s00701-019-04074-1) contains supplementary material, which is available to authorized users.

How to Remove a Penetrating Intracranial Large Nail

BACKGROUND

The incidence of penetrating intracranial foreign bodies is rare, and to date, not many relevant studies have been published worldwide. In particular, a nail penetrating intracranially, just near the superior sagittal sinus (SSS), is extremely rare. We treated the case of a large nail that penetrated the middle of the head and strategized its removal.

CASE DESCRIPTION

A 70-year-old man had experienced headache lasting a day. Computed tomography of the brain revealed a nail penetrating the middle of his head; in particular, the tip of the nail had penetrated the right ventricle, causing a slight subarachnoid hemorrhage. Angiography showed that the nail was very close to the SSS and that the venous flow was normal. However, there was a risk of the nail penetrating through the SSS or injuring other arteries, and we removed the nail directly from the intracranial view to stop bleeding from the SSS or other vessels. Fortunately, there was no bleeding, and we washed the hole created by the nail penetration and concluded the surgery.

CONCLUSIONS

Our technique is useful and safe for removing large nails penetrating the head.

Management of a Steel Bar Injury Penetrating the Head and Neck: A Case Report and Review of the Literature

BACKGROUND

Nonmissile penetrating injuries to the head and neck caused by a steel bar are rare, and a standard management strategy is lacking.

CASE DESCRIPTION

A 42-year-old woman sustained a steel bar injury with penetration of the head and neck. Computed tomography and three-dimensional reconstruction were performed for preoperative evaluation. Digital subtraction angiography was performed to confirm potential vascular injury. The steel bar was successfully removed through an open surgical procedure by a multidisciplinary team.

CONCLUSIONS

Relevant literature regarding nonmissile penetrating injuries involving a steel bar was reviewed to propose appropriate management strategies. Comprehensive imaging evaluation and prompt surgery by a multidisciplinary team contributed to the successful removal of the steel bar.

Surviving a transfixing gunshot wound to the head 70 years ago

Surviving a gunshot wound to the head is a rare event, particularly in the past when medical treatment was much less advanced than it is today. Moreover, the finding of such a case as an identified specimen within a museum collection is even more uncommon. This led us to report on this unique case in this paper as it poses a challenge to forensic anthropology and provides a unique educational oppourtunity. The skull from the Collection at the Cranium Museum in the Department of Morphology and Genetic at the Federal University of São Paulo (UNIFESP) dates back to 1946. For trauma registration the bone location, severity, trauma aetiology, trauma classification, description, callus formation, periosteal reaction, degree and success of repair, and an estimate of the time elapsed since the trauma, were all assessed. To explore the case radiologically a CT scan of the skull was performed. Considering the survival of the patient and the morphology of the wound it is likely that the injury was caused by a small calibre, low-velocity gunshot. The bullet path shows an almost vertical direction on the right side of the individual's splanchno and neurocranium. The path of the projectile is consistent with a suicide attempt, although the possibility of a homicide simulating a suicide cannot be discarded. This case highlights how informative such cases can be to the practice of forensic anthropology.

[Successful treatment and rehabilitation of severe, penetrating brain injury]

Penetrating brain injuries due to gunshots are rare in Denmark. This is a case report of the successful treatment of a 31-year-old man who was shot in the right frontal region of the head. The bullet went through his brain without damaging the large intracranial vessels. On admission he had a GCS of 9. Haematoma removal and bifrontal craniectomy was performed to obtain lowering of the intracranial pressure. One year after the incidence the patient was able return to work. This case report illustrates the importance of early prehospital and neurointensive treatment with lowering of the intracranial pressure and highly specialised rehabilitation.

[A foreign object in the frontal lobe]

In this case report a 77-year-old male tumbled in his lavatory and hit his head against a toilet roll holder. The holder penetrated his eye and orbita and left a 0.5 × 1 cm cylindrical piece of plastic inside his frontal lobe. He was admitted at a neurosurgical department, where the foreign object was removed. In this report, we summarise some of the basic principles of handling patients with a penetrating brain trauma, including risk of infection, control of bleeding and technical considerations before surgically removing a foreign object.

[Insufficient CT scan in visualizing an intracerebral parenchymal damage in a six-month-old boy]

A six-month-old boy fell over, and a crochet hook penetrated his skin underneath his left eye. The hook was removed, and an emergency physician found a Glasgow Coma Scale score of 6-7. A CT scan showed no cerebral or ophthalmic injury. However, the patient was persistently apathic with head- and gaze direction towards the left and a facial nerve palsy. An MRI showed a linear intracerebral lesion stretching through pons into the cerebellar vermis. The patient had neuropaediatric rehabilitation and recovered fully within months. The case is an example of CT scan being insufficient in visualizing intracerebral parenchymal damage.

Microembolism of single cortical arterioles can induce spreading depression and ischemic injury; a potential trigger for migraine and related MRI lesions

Increasing epidemiological evidence suggests an association between migraine with aura (MA) and cardiovascular events. There is experimental as well as clinical evidence implying cerebral microembolism as a potential trigger for MA attacks. Microembolism may also account for some of the ischemic MRI lesions more commonly observed in MA than in general population. Limited size of clinically-silent MRI lesions suggests isolated occlusion of a small vessel. However, it is not known whether selective thrombosis of a small arteriole (e.g. single mouse penetrating arteriole - PA), can induce cortical spreading depression (CSD), the putative cause of migraine aura and, hence, trigger an MA attack. For this, we mimiced thrombosis of a small vessel caused by microembolism by selectively occluding a PA just before diving into the cortex (radius; 10-25 µm) in the mouse. Clotting was induced with FeCl₃ applied focally over the PA by a glass micropipette for 3 min. DC potential changes were recorded and the alterations in cortical blood flow were monitored by laser speckle contrast imaging. Mice were kept alive for 1-4 weeks and brain sections were stained with H&E or luxol-fast blue to evaluate changes induced by PA occlusion. We found that single PA occlusion consistently triggered a CSD originating from the tissue around the PA soon after occlusion and induced delayed, small ischemic lesions within territory of the affected vessel a few weeks later. These findings suggest that cerebral microembolism can lead to MA attacks and may account for some of the silent brain lesions.

Radiological findings of transorbital penetrating intracranial injury in a child

In penetrating injuries, woods are known to be difficult to detect with radiological imaging studies, because the wood density are known to be extremely close to the value of air on CT. Adjustment of CT window and reconstruction of a 3D image from CT images allowed us to more accurately distinguish wood from air and to find the fragment of the wooden chopstick. It is particularly useful in transorbital penetrating injury.

Management of Through-and-Through Penetrating Skull Injury: A Railroad Spike That Transgressed the Anterior Skull Base

BACKGROUND

Penetrating injuries involving foreign objects that transgress the entirety of the human skull present challenges in the management of vascular injuries, infectious risk, cerebrospinal fluid leak, and cosmetic repair. Ultimately, effective management of these injuries requires a multidisciplinary team and judicious surgical planning.

CASE DESCRIPTION

Here we present the treatment of a patient who experienced a penetrating injury from a railroad spike, with entry and exit points involving the left and right anterior aspects of the temporal fossa, respectively.

CONCLUSIONS

The rationale for management decisions is reviewed in the context of the published literature.

Predicting survival after acute civilian penetrating brain injuries: The SPIN score

OBJECTIVE

To identify predictors associated with survival in civilian penetrating traumatic brain injury (pTBI) utilizing a contemporary, large, diverse 2-center cohort, and to develop a parsimonious survival prediction score for pTBI.

METHODS

Our cohort comprised 413 pTBI patients retrospectively identified from the local trauma registries at 2 US level 1 trauma centers, of which one was predominantly urban and the other predominantly rural. Predictors of in-hospital and 6-month survival identified in univariate and multivariable logistic regression were used to develop the simple Surviving Penetrating Injury to the Brain (SPIN) score.

RESULTS

The mean age was 33 ± 16 years and patients were predominantly male (87%). Survival at hospital discharge as well as 6 months post pTBI was 42.4%. Higher motor Glasgow Coma Scale subscore, pupillary reactivity, lack of self-inflicted injury, transfer from other hospital, female sex, lower Injury Severity Score, and lower international normalized ratio were independently associated with survival (all p < 0.001; model area under the curve 0.962). Important radiologic factors associated with survival were also identified but their addition to the full multivariable would have resulted in model overfitting without much gain in the area under the curve.

CONCLUSIONS

The SPIN score, a logistic regression-based clinical risk stratification scale estimating survival after pTBI, was developed in this large, diverse 2-center cohort. While this preliminary clinical survival prediction tool does not include radiologic factors, it may support clinical decision-making after civilian pTBI if external validation confirms the probability estimates.

Hearing Preservation After Penetrating Cochlear Injury

OBJECTIVES

To share results and recommendations for management of penetrating cochlear injury.

METHODS

A patient underwent repair of a penetrating cochlear injury after a projectile led to a traumatic cochleostomy with a narrow miss of the facial nerve and intracranial carotid artery.

RESULTS

Postoperatively, the patient's audiogram demonstrated a pure tone average of 47.5 dB for air conduction and 35 dB for bone conduction, worse in the high frequencies, with a Word Recognition Score of 76%.

CONCLUSIONS

Hearing loss from a penetrating cochlear injury can be mitigated with early repair, minimizing inner ear trauma, and steroid use to treat posttraumatic labyrinthitis.

[THE TREATMENT OF INJURED PERSONS WITH COMPLICATED PENETRATING THORACIC WOUNDINGS ON TERTIARY LEVEL OF THE MEDICAL CARE DELIVERY]

The results of examination and treatment of 36 injured persons with complicated penetrating thoracic woundings in tertiary centres were analyzed. Own experience of the pulmonary woundings surgical treatment, using application of videothoracoscopic and welding-coagulating equipment, was summarized.

Perimortem trauma in King Richard III: a skeletal analysis

BACKGROUND

Richard III was the last king of England to die in battle, but how he died is unknown. On Sept 4, 2012, a skeleton was excavated in Leicester that was identified as Richard. We investigated the trauma to the skeleton with modern forensic techniques, such as conventional CT and micro-CT scanning, to characterise the injuries and establish the probable cause of death.

METHODS

We assessed age and sex through direct analysis of the skeleton and from CT images. All bones were examined under direct light and multi-spectral illumination. We then scanned the skeleton with whole-body post-mortem CT. We subsequently examined bones with identified injuries with micro-CT. We deemed that trauma was perimortem when we recorded no evidence of healing and when breakage characteristics were typical of fresh bone. We used previous data to identify the weapons responsible for the recorded injuries.

FINDINGS

The skeleton was that of an adult man with a gracile build and severe scoliosis of the thoracic spine. Standard anthropological age estimation techniques based on dry bone analysis gave an age range between 20s and 30s. Standard post-mortem CT methods were used to assess rib end morphology, auricular surfaces, pubic symphyseal face, and cranial sutures, to produce a multifactorial narrower age range estimation of 30-34 years. We identified nine perimortem injuries to the skull and two to the postcranial skeleton. We identified no healed injuries. The injuries were consistent with those created by weapons from the later medieval period. We could not identify the specific order of the injuries, because they were all distinct, with no overlapping wounds. Three of the injuries-two to the inferior cranium and one to the pelvis-could have been fatal.

INTERPRETATION

The wounds to the skull suggest that Richard was not wearing a helmet, although the absence of defensive wounds on his arms and hands suggests he was still otherwise armoured. Therefore, the potentially fatal pelvis injury was probably received post mortem, meaning that the most likely injuries to have caused his death are the two to the inferior cranium.

FUNDING

The University of Leicester.

An unusual case of "dyadic-death" with a single gunshot

The terms "dyadic death" or "murder-suicide" refer to an incident where an individual commits homicide and then takes his or her own life. These events are generally committed by men within the family network, using firearms or sharp force instruments, and make up a relatively small proportion of homicides overall. Herein, we present the application of post-mortem multislice computed tomography (CT) and micro-CT analysis to an unusual case of dyadic death, where a 38-year-old man fired a single gunshot to his own right temple, killing himself and his 50-year-old wife, lying on the bed beside him. The integration of radiological, autoptic and histological data allowed us to reconstruct the trajectory of the gunshot, the most probable dynamics of the event, and to classify the incident as a "suicide-homicide", because the female victim died a few minutes later than her husband and murderer.

Does brain volume loss predict cognitive and narrative discourse performance following traumatic brain injury?

PURPOSE

In this study, the authors investigated the relationship between brain volume loss and performance on cognitive measures, including working memory, immediate memory, executive functions, and intelligence, and a narrative discourse production task. An underlying goal was to examine the prognostic potential of a brain lesion metric for discourse outcomes. It was hypothesized that brain volume loss would correlate with and predict cognitive and narrative discourse measures and have prognostic value for discourse outcomes.

METHOD

One hundred sixty-seven individuals with penetrating head injury participated. Correlational and regression analyses were performed for the percentages of total brain and hemispheric volume loss and scores on 4 cognitive measures (WMS-III Working Memory and Immediate Memory primary indexes, D-KEFS Sorting Test, and WAIS-III Full Scale IQ) and 7 narrative discourse measures (T-units, grammatical complexity, cohesion, local and global coherence, story completeness, and story grammar).

RESULTS

The volumetric measures had significant small-to-moderate correlations with all cognitive measures but only one significant correlation with the discourse measures. Findings from regression analyses were analogous but revealed several models that approached significance.

CONCLUSION

Findings suggest that an overall measure of brain damage may be more predictive of general cognitive status than of narrative discourse ability. Atrophy measures in specific brain regions may be more informative.

Radiological evidence of a modern 'martyr's crown': suicide by multiple self-inflicted nail gun shots

A man attempted suicide by shooting seven nails into his head with a nail gun; five in the right temporal region and two in the left. He subsequently presented at the emergency department with complaints of headache. He was found to be oriented in space and time, with no focal neurological deficits. The patient handed the nail gun to the doctors and informed them that he had earlier attempted suicide. Radiological studies showed the presence of nails arranged like a 'martyr's crown'. The man died six days after the surgical removal of the nails. Autopsy was refused by Italian authorities. We conclude that imaging techniques are an adjuvant to forensic medical diagnosis and forensic autopsies.

Ventromedial prefrontal cortex modulates fatigue after penetrating traumatic brain injury

BACKGROUND

Fatigue is a common and disabling symptom in neurologic disorders including traumatic penetrating brain injury (PBI). Despite fatigue's prevalence and impact on quality of life, its pathophysiology is not understood. Studies on effort perception in healthy subjects, animal behavioral paradigms, and recent evidence in different clinical populations suggest that ventromedial prefrontal cortex could play a significant role in fatigue pathophysiology in neurologic conditions.

METHODS

We enrolled 97 PBI patients and 37 control subjects drawn from the Vietnam Head Injury Study registry. Fatigue was assessed with a self-report questionnaire and a clinician-rated instrument; lesion location and volume were evaluated on CT scans. PBI patients were divided in 3 groups according to lesion location: a nonfrontal lesion group, a ventromedial prefrontal cortex lesion (vmPFC) group, and a dorso/lateral prefrontal cortex (d/lPFC) group. Fatigue scores were compared among the 3 PBI groups and the healthy controls.

RESULTS

Individuals with vmPFC lesions were significantly more fatigued than individuals with d/lPFC lesions, individuals with nonfrontal lesions, and healthy controls, while these 3 latter groups were equally fatigued. VmPFC volume was correlated with fatigue scores, showing that the larger the lesion volume, the higher the fatigue scores.

CONCLUSIONS

We demonstrated that ventromedial prefrontal cortex lesion (vmPFC) plays a critical role in penetrating brain injury-related fatigue, providing a rationale to link fatigue to different vmPFC functions such as effort and reward perception. The identification of the anatomic and cognitive basis of fatigue can contribute to developing pathophysiology-based treatments for this disabling symptom.

An arrow penetrating at base of the skull successfully removed

A 30-year-old male presented with accidental injury with an arrow which referred to us from a peripheral village hospital. It was found that the arrow was penetrating through the nasal bones. An xray skull lateral view showed the tip of the arrow penetrating into the posterior wall of the sphenoid sinus. As the patient had no clinical evidence of neurological or vascular injury, he was immediately operated upon and the arrow was removed. Patient was discharged in good condition and a 3-month follow-up was normal.

[Transnasal wounds of the base of the skull encountered in the practical work of the otorhinolaryngologist]

The authors describe rare clinical observations of patients suffering transnasal injuries to the base of the skull. Based on their own experience, they propose practical recommendations for the management of such cases.

Expect the unexpected: two cases of penetrating head and neck trauma from Operation Iraqi Freedom

The protocol for treating penetrating head and neck trauma in a war zone differs from the standard protocol. Rather than first securing an airway, as is standard in civilian trauma cases, the primary emphasis is on assessing and controlling hemorrhage because it is the leading cause of morbidity and mortality in a battlefield setting. Once that has been addressed, we shift to standard advanced-trauma life-support protocols. We describe two cases we encountered at our combined medical clinic in Western Baghdad--one involving a 4-year old Iraqi child with an ammunition round lodged in her neck and one involving a 38-year-old female U.S. soldier with a round lodged in her right superolateral orbit. Both cases were transferred to combat support hospitals for further treatment after our initial assessment and treatment, and both had successful outcomes.

Transorbital penetrating head injury by a toilet brush handle

BACKGROUND

Transorbital penetrating brain injuries are rare lesions without defined therapy standards.

CLINICAL PRESENTATION AND INTERVENTION

A male patient presented at our institution with a toilet brush handle in the right cerebral hemisphere. CT imaging identified the object entering the right orbit and having crossed the right hemisphere in the ventricular plane. After performing a medium-sized craniotomy, the object was removed step-by-step under monitoring with an intraoperative CT scan to ensure no involving major hemorrhage.

CONCLUSION

Transorbital penetrating brain injuries are treated best by utilizing all up-to-date technical developments such as intraoperative CT-scanning to increase the safety in the management of such exceptional lesions with increased risk of immediate life-threatening intracranial bleeding.

[Postmortem CT examination with 3D reconstruction in gunshot and post explosion injuries]

The authors presented the results of postmortem examinations of four cases related to gunfire and post explosion injuries. Prior to "classic" forensic autopsies, the corpses were examined using CT imaging. The findings (injuries and foreign bodies) are presented in the table and in images: 3D reconstructions contrasted with actual autopsy specimens. The enclosed CD includes 3D animations.

Unusual Delayed Presentation of a Nail Gun Injury Through the Skull Base

Published reports of nail gun injuries to the face are uncommon. We describe an unusual delayed presentation with injury through the infratemporal fossa and a literature review. A 55-year-old patient presented 2 weeks after an unrecognized injury with complaints of a headache. Imaging revealed a nail traversing the infratemporal fossa with intracranial extension. The nail was removed through a preauricular approach without sequelae. Nail gun missiles to the face are uncommon, dramatic, but often nonfatal because of their relative low velocity. Patients are usually diagnosed at the time of injury, evaluated with computed tomography and angiography, and treated with surgery.

[Using X-ray results in head gunshot wounds]

The authors draw attention to the importance of X-ray examinations in craniocerebral gunshot injuries. A life-saving neurosurgical operation of a victim resulted in changes occurring not only in the soft tissue, but also in the bony structures of the cranium, which practically rendered impossible any assessment of and differentiation between the location of entrance and exit wounds during autopsy. The assessment of preoperative head X-ray demonstrated the presence of characteristic crater-like bone defects, what allowed for determining the location of the entrance and exit wounds. The medico-legal examination of bone defects indicated that the entrance wound was situated on the left side, contrary to information provided by hospital medical records.