Unusual penetrating cranio-cerebral injuries in children from mains plugs

Introduction Domestic accidents resulting in head injury are not uncommon. They mostly involve falls from high beds, tables or window seals. Rarely, children suffer penetrating skull injuries, often from unlikely objects. Materials We present two children, 2.5- and 1.5-year-old boys, respectively, who suffered penetrating wounds and compound depressed skull fractures when they fell from moderate height and landed on nearby electric mains plugs, which were driven into their heads. None of them lost consciousness or developed epilepsy. The first patient was brought with one plug pin firmly driven into the skull in the right frontal region. Parents had disassembled and removed the rest of the plug. The second patient was brought in with the whole plug attached and one pin embedded in the left parietal region. On plain radiographs and computed tomography (CT) scan, there was complete skull perforation, a compound depressed skull fracture, and the plug pin was embedded in the brain parenchyma in both patients. In the second patient, the injury site was near the motor cortex. In both cases, the plug was surgically removed, and the skull fracture was repaired. Discussion This type of injury from the protruding ends of mains plugs is uncommon and has to be borne in mind by parents, carers and any person dealing with childhood trauma because the plug could be removed at home and the child brought to the Emergency Department with only a small wound in the scalp, hiding a potentially serious underlying brain injury.     

An unusual case of cerebral penetrating injury by a driven bone fragment secondary to blunt head trauma

Temple trauma that appears initially localized to the skin might possess intracranial complications. Early diagnosis and management of such complications are important, to avoid neurologic sequelae. Non-penetrating head injuries with intracranial hemorrhage caused by a driven bone fragment are extremely rare. A 53-year-old male was referred to our hospital because of intracerebral hemorrhage. He was a mechanic and one day before admission to a local clinic, tip of metallic rod hit his right temple while cutting the rod. Initial brain computed tomography (CT) and magnetic resonance imaging demonstrated scanty subdural hematoma at right temporal lobe and left falx and intracerebral hematoma at both frontal lobes. Facial CT with 3-D reconstruction images showed a small bony defect at the right sphenoid bone's greater wing and a small bone fragment at the left frontal lobe, crossing the falx. We present the unusual case of a temple trauma patient in whom a sphenoid bone fragment migrated from its origin upward, to the contralateral frontal lobe, producing hematoma along its trajectory.     

Intrauterine penetrating direct fetal head trauma following gunshot injury

Case report An unusual case of an intrauterine penetrating head injury due to a pellet from an airgun is described. A 28-year-old pregnant woman, at term, shot herself intravaginally with a toy BB gun. Following a spontaneous precipitous vaginal delivery, the neonate presented with persistent seizure disorder, meningitis, cerebritis, and a right parietal region scalp swelling. Imaging studies revealed intracranial hemorrhage, and the metallic pellet was adjacent to the right lateral ventricle, which was removed through a parietal craniotomy. Computed tomography of the brain after 1 week demonstrated early abscess formation in the left frontal operculum and a subdural empyema in the posterior fossa. The abscesses were evacuated, and the meningitis was treated vigorously with broad-spectrum antibiotics. Although well for the past 6 years, the child demonstrates significant mental handicap and developmental delay.Discussion The pathogenesis, management, and medicolegal issues pertaining to the above case are discussed, and the relevant literature is briefly reviewed.     

Transorbital brain injury by a metallic fragment: a case report

Because of anatomical configuration of the orbit, the brain can be damaged by penetrating transorbital injuries. At first sight, this type of trauma can be thought of as a solitary eye trauma. In this paper, we report a case who suffered from brain injury by a metallic foreign body which passed into the brain through the orbit. He was operated on urgently at two stages and there was no complication after 14 months of follow-up. Any neurological deficit or deterioration of consciousness would be marked. These types of injuries have to be evaluated systemically. Finally, detailed history, neuroradiological investigations, early surgical exploration and multidisciplinary studies are very important to obtain a good outcome.     

Unusual penetrating head injury in children: personal experience and review of the literature

Introduction  A penetrating head injury belongs to the most severe traumatic brain injuries, in which communication can arise between the intracranial cavity and surrounding environment. Discussion  The authors present a literature review and typical case reports of a penetrating head injury in children. The list of patients treated at the neurosurgical department in the last 5 years for penetrating TBI is briefly referred. Rapid transfer to the specialized center with subsequent urgent surgical treatment is the important point in the treatment algorithm. It is essential to clean the wound very properly with all the foreign material during the surgery and to close the dura with a water-tight suture. Wide-spectrum antibiotics are of great use. In case of large-extent brain damage, the use of anticonvulsants is recommended. Conclusion  The prognosis of such severe trauma could be influenced very positively by a good medical care organization; obviously, the extent of brain tissue laceration is the limiting factor.     

眶颅穿通伤致开放性颈内动脉海绵窦瘘一例并文献复习

目的 结合病例并文献复习,探讨眶颅穿通伤后颈内动脉海绵窦瘘(CCF)的诊断及治疗策略.方法 1例19岁男性被长约12 cm的木质异物经左侧眼眶穿入对侧海绵窦区,在外院手术拔除异物失败.入院后最初的脑血管造影检查未发现CCF,但轻微触动异物后,可发现右侧隐匿存在的CCF.经充分术前准备后我们完整拔除异物,并在1min内对呈开放性的CCF进行了血管内栓塞治疗.结果 经过介入治疗后,CCF完全消失；尽管术后发生了脑积水、颅内感染、脑脊液鼻漏等一系列并发症,但经过合理治疗,患者出院时伤口愈合良好,未遗留神经功能缺损和视力障碍.结论 眶颅穿通伤常导致颅内血管损伤和颅内出血,强烈建议对这类患者常规进行脑血管造影术检查；一旦异物穿入海绵窦区,应高度怀疑CCF的发生,最好能在神经介入支持下取出异物；另外,需特别注意的是,对于有异物滞留的眶颅穿通伤,其并发的CCF可能不会表现出典型症状,易于漏诊,草率地拔除异物将导致隐匿的CCF呈开放性,导致大出血致患者迅速死亡.     

盲管性颅脑火器伤119例分析

目的分析盲管性颅脑火器伤的临床特点。方法对１１９例盲管性颅脑火器伤病例进行回顾性分析总结。结果男１０５例，女１４例；平均年龄２１岁。入院时ＧＣＳ９～１５分４８例；６～８分５９例，３～５分１２例。早期合并症主要为脑挫裂伤、颅内血肿、感染等。晚期合并症主要为异物存留及癫痫。死亡１４例，死亡率１１．７％。结论火器伤能产生较大的瞬时伤道，对颅脑造成严重而广泛的损伤，不能用一般颅脑外伤的致伤原理和经验来诊治火器性颅脑伤。准确判断伤情及伤道，早期彻底清创，注意手术方法的选择和手术要点的掌握，以及尽量减少脑组织的继发损伤，防止各种并发症，是降低死亡及残废率的关键。     

Ten self-inflicted intracranial penetrating nail gun injuries

Penetrating craniocerebral injuries from nail gun use are rare. We describe a case of 10 self-inflicted nail gun injuries with intracranial penetrations. We also review the literature and discuss management strategies of such craniocerebral trauma. A 33-year-old male with a long-standing history of severe depression took a nail gun and sustained 10 penetrating intracranial injuries. Initial neuroimaging revealed 10 penetrating nails, all sparing the major cerebral vasculature. Immediate surgical removal was undertaken in the surgical suite using a combination of craniotomies, craniectomies, and blind removal. Intracranial injuries from self-inflicted nail gun misuse is becoming increasingly more frequent. Initial appropriate clinical decision-making are critical in preventing further cortical or vascular damage.Intracranial nail gun injuries, although unusual, are a well-described form of penetrating cranial trauma. This mechanism of injury presents unique problems for the patient and the treating physician. The increasing availability and consequent use of compressed air driven nail guns has increased the likelihood of craniocerebral penetrating trauma associated with these devices. In the United States, the Centers for Disease Control report, on average, around 37,000 patients with injuries related to nail gun use treated annually in emergency departments between 2001 and 2005, with 40% involving home consumers.1 Overall, self-inflicted nail gun injuries are less common than accidental discharges, which occur mostly on the construction site and involve injury to an extremity. Treating these penetrating brain injuries presents a number of clinical challenges to the surgeon. Nonetheless, a sound rational management strategy should permit most of these patients to be discharged with no additional injury. In this case report, we report a unique case of self-inflicted craniocerebral penetrating injuries, due to a pneumatic nail gun, involving 10 nails. Based on a literature review, this is largest number of penetrating foreign objects removed from the cranium and cerebral parenchyma in a patient that survived and made a full complete recovery. Our objective in presenting this particular case is to demonstrate that although nail gun injuries are often impressive on radiographic imaging, they often produce a very limited local injury with very little neurologic devastation.     

Extracranial Extension of Intracranial Atypical Meningioma En Plaque with Osteoblastic Change of the Skull

Meningioma is a common primary tumor of central nervous system. However, extracranial extension of the intracranial meningioma is unusual, and mostly accompanied the osteolytic change of the skull. We herein describe an atypical meningioma having extracranial extension with hyperostotic change of the skull. The patient was a 72-year-old woman who presented a large mass in the right frontal scalp and left hemiparesis. Brain magnetic resonance imaging and computed tomography scans revealed an intracranial mass, diffuse meningeal thickening, hyperostotic change of the skull with focal extension into the right frontal scalp. She underwent total removal of extracranial tumor, bifrontal craniectomy, and partial removal of intracranial tumor followed by cranioplasty. Tumor pathology was confirmed as atypical meningioma, and she received adjuvant radiotherapy. In this report, we present and discuss a meningioma en plaque of atypical histopathology having an extracranial extension with diffuse intracranial growth and hyperostotic change of the skull.     

Lesión penetrante intracraneana transorbitaria,con compromiso de seno cavernoso en paciente pediátrico

Transorbitary intracranial penetrating traumatic injuries are uncommon in the pediatric population, and may occur in the context of domestic, sporting or school accidents. They can extend to skull base and compromise vascular structures such as cavernous sinus and internal carotid.We present a case of 6 years-old girl that suffered an intracranial transorbital penetrating injury with a wooden pencil that crossed from the medial edge of left orbit, transetmoidal and trans-sphenoidal, entering the right sellar region and leaving its end in contact with carotid artery (cavernous segment). After pre-surgical studies, foreign body removal was performed with endoscopic surgery + endovascular control in case of carotid injury. After removing the foreign body, a CSF fistula occurred and was repaired. Patient recovered adequately, without neurological deficit, without postoperative CSF fistula, without CNS infection or oculomotor alteration.     

Penetrating craniocerebral injury from an underwater fishing harpoon

Weapon injuries other than gunshot wounds or low-velocity stab wounds to the head are extremely rare. We report the case of a 6-year-old girl who sustained a penetrating craniocerebral injury after being accidentally shot with an underwater fishing harpoon. This mechanism of injury seems to share characteristics of both high- and low-velocity projectiles. We discuss the management of this unusual injury in a child, remarking that foreign body removal in these cases must be carried out following the original direction of the projectile trajectory. We review the current literature on craniocerebral injuries caused by similar objects, especially those occurring in children. Received: 18 December 1998     

Penetrating head injury in a paediatric patient caused by an electrical plug

Introduction Penetrating head injuries are rare especially in the paediatric age group. Relatively minor falls over common household objects can cause potentially life-threatening brain injuries.Case report We describe a penetrating head injury caused by a household electrical plug in a 6-month-old child. The two rounded pins of the plug were embedded in the posterior parietal area of her head, very close to the cranial midline. There was no neurological deterioration or bleeding. Radiological investigation showed a depressed skull fracture underneath the two pins. One of them came very close to the superior sagittal sinus but there was no evidence of intracranial bleeding. The electrical plug was extracted under general anaesthesia in the operating theatre. The penetrating fracture segments were removed. The sagittal venous sinus was fortunately undamaged.Conclusions Household objects like electrical plugs may constitute a risk for children. It may be worthwhile to reconsider the design of electrical plugs.     

Computed tomography and magnetic resonance angiography in cervicocranial vascular disease.

Although catheter angiography, or digital subtraction angiography (DSA), is still regarded as the gold standard for imaging of cervicocranial vascular disease, its morbidity, cost, and time-consuming features have prompted the development of noninvasive techniques based on computed tomography (CT) and magnetic resonance imaging. With the advent of powerful software, CT and magnetic resonance angiography are complementing and, in some cases, even replacing DSA in the diagnostic evaluation of carotid atherostenosis, unruptured aneurysms, dissections, stroke, penetrating trauma to the neck, and dural venous sinus occlusive disease. They offer advantages over DSA not only in reduced morbidity and time-saving but also in assessment of brain parenchyma, quantitative perfusion, and abnormalities of vessel walls. In the evaluation of blunt neck injuries and intracranial vascular malformations, fistulas, and vasculitis, CT and magnetic resonance angiography still do not provide as much information as DSA.     

Neurotrauma: the role of CT angiogram

Cerebrovascular injuries can occur in blunt or penetrating head and neck trauma. A high index of suspicion based on mechanism of injury and clinical assessment warrants screening for intracranial and extracranial vascular lesions. Conventional angiogram has been and remains the gold standard for diagnosis of these injuries, but computerized tomography angiography offers a fast, noninvasive method of imaging for neurotrauma patients. Advantages and disadvantages of each modality are discussed.     

The significance of skull fracture in mild head trauma differs between children and adults

Objective The objective was to determine whether the age of patients with mild head injury and skull fracture influences the level of risk for acute intracranial injuries.Method A study was conducted of 156 patients with skull fracture, 60 children (aged <14 years) and 96 adults, detected among 5,097 consecutive patients with mild head injury (Glasgow Coma Scale [GCS] score of 15–14 points) arriving at the Emergency Department of a Level I University Hospital Trauma Center during 1998. Acute intracranial injuries were defined as traumatic brain injuries identified by cranial computed tomography scan, excluding pneumocephalus.Results Compared with the children, this risk of intracranial injury was 13 times greater in the adults aged 14–54 years and 16 times greater in the over-54-year-olds. Besides age over 14 years (p<0.0001), compound skull fracture (p<0.001), and a GCS score of 14 (p<0.001) were factors significantly associated with intracranial injury in the logistic regression analysis.Conclusions Skull fracture in mild head injury implies a greater risk of intracranial injury in adults than in children.     

Penetrating brain injury due to a large asbestos fragment treated by decompressive craniectomy: case report

We report the case of a 22-year-old man victim of penetrating brain injury due to a 15 x 12 asbestos fragment and a successfully treatment via decompressive craniectomy. Unlike gunshot wounds to the head, penetrating brain injury from low energy objects are unusual. Most cases reported involve cranio-orbitary injuries as well as self inflicted lesions in mentally ill patients. The reported case is noteworthy due to the large dimensions of the foreign body, the treatment via decompressive craniectomy and the good patient functional outcome.     

异物经颈静脉孔致非火器性颅脑穿通伤1例报告并文献复习

目的 探讨异物经颈静脉孔致非火器性颅脑穿通伤(PBI)的诊断与治疗方式.方法 回顾分析1例异物颈静脉孔刺入左侧小脑患儿的临床资料;并对相关文献进行复习.结果 患儿女,3岁,进食时摔倒致筷子插入咽部,家人自行拔除大部分异物(不完整),伤后患儿出现咽痛、头痛、恶心、呕吐.颅脑CT、MRI、CTA检查示,左侧小脑局限水肿,筷...     

The usefulness of diffusion tensor imaging in detection of diffuse axonal injury in a patient with head trauma

Diffuse axonal injury is the predominant mechanism of injuries in patients with traumatic brain injury. Neither conventional brain computed tomography nor magnetic resonance imaging has shown sufficient sensitivity in the diagnosis of diffuse axonal injury. In the current study, we attempted to demonstrate the usefulness of diffusion tensor imaging in the detection of lesion sites of diffuse axonal injury in a patient with head trauma who had been misdiagnosed as having a stroke. A 44-year-old man fell from a height of about 2 m. Brain magnetic resonance imaging (32 months after onset) showed leukomalactic lesions in the isthmus of the corpus callosum and the left temporal lobe. He presented with mild quadriparesis, intentional tremor of both hands, and trunkal ataxia. From diffusion tensor imaging results of 33 months after traumatic brain injury onset, we found diffuse axonal injury in the right corticospinal tract (centrum semiovale, pons), both fornices (columns and crus), and both inferior cerebellar peduncles (cerebellar portions). We think that diffusion tensor imaging could be a useful tool in the detection of lesion sites of diffuse axonal injury in patients with head trauma.     

Pathology of head trauma

This article reviews the essential primary and secondary injuries attributable to traumatic brain injury (TBI) which causes one third of all injury deaths in the United States. Motor vehicle crashes, falls, assaults, guns, sports, and recreational activities are the major causes of TBI. Secondary peak incidences of TBI occur in infants and children and the elderly. Conditions that increase risk for accidents include alcoholism, prior head injury, prior meningitis, seizure disorders, mental retardation, and psychiatric disorders. However, gunshot wounds to the head are steadily increasing and since 1990 have caused more deaths each year than motor vehicle accidents. The incidence, severity, etiology, and specific types of injuries have been assessed in clinicopathologic studies of head injuries. The pathologic features of both the primary and secondary lesions attributed to TBI should be understood by anyone caring for head-injured patients. The computed tomography (CT) and magnetic resonance (MR) images mirror the pathologic abnormalities found in head trauma. Radiologists must accurately interpret the CT and MR images of injured patients. Forensic pathologists have long appreciated the characteristic focal lesions, such as coup and contracoup contusions, that occur in falls or vehicle accidents, but the understanding of diffuse injuries has been more elusive. Understanding the nature of the focal and diffuse injuries is critical to understanding the morbidity and mortality of brain injury.     

Computed Tomography Analysis of Head and Spinal Cord Injuries Inflicted by Missiles and Explosives

Cerebral and spinal column computed tomography (CT) was performed in 53 patients wounded during war in the Republic of Croatia from June through December 1992. Of these, 36 (67%) suffered craniocerebral injuries; 10 (18%) sustained facial, neck, and paranasal sinus wounds; and 7 (13%) had vertebral andjor paravertebral lesions. Twenty-five (70%) of the patients with craniocerebral injuries had penetrating wounds with diffuse and multiple, predominantly hemorrhagic lesions of cortical and subcortical structures, with basal ganglia lesions in 15 (43%) and brainstem lesions in 6 (20%). Of the 7 vertebral studies. 4 showed paravertebral tissue damage to the spinal column and cord.