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.

[Expert consensus on the penetrating brain injury].

Penetrating brain injury can be devastating to the central nervous system, with extremely high mortality and disability rates. Survivors may also suffer long-term complications that severely affect their quality of life. Therefore, this writing group referred to the relevant guidelines and consensus at home and abroad and summarized the progress of clinical research in recent years. The modified Delphi method was used to solicit opinions from 50 experts of the Neurosurgery Professional Committee of the PLA, and 46 experts responded to the opinions, forming 52 recommendations in the areas of classification, early recognition, diagnosis, emergency treatment, advanced monitoring, surgical methods, management of complications, and prognosis prediction of penetrating brain injury. These recommendations were formed to provide reference for the standardized diagnosis, treatment and scientific management of patients with penetrating brain injury.

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.

Ethical Issues Regarding Neurosurgical Management of Penetrating Brain Injury in the French Armed Forces.

Combat penetrating brain injury (PBI) differs significantly from PBI in civilian environments. Differences include technical factors such as the weapons involved, strained resource environments, and limited medical materials and human resources available. Ethical issues regarding the management of PBI in military settings may occur. This case study examines the case of a 20-year-old member of the French Armed Forces that suffered a penetrating brain injury in a combat situation. The four-quadrant method along with the four principles of medical ethics (respect for autonomy, beneficence, nonmaleficence, and justice) was used to analyze this case and to apply ethics to the practice of military medicine. Nowadays, we possess the medical and surgical resources as well as the aeromedical evacuation capability to save the life of a soldier with a penetrating craniocerebral wound. Nonetheless, the functional outcome of this type of wound places military doctors in an ethical dilemma. The line of conduct and clinical protocol established by the French Medical Health Service is to manage all PBIs when the patient's life can be saved and to provide all available financial and social support for the rehabilitation of patients and their family.

Comparative Effectiveness of Early Neurosurgical Intervention in Civilian Penetrating Brain Injury Management.

BACKGROUND AND OBJECTIVES: To compare the outcomes of early vs no-neurosurgical intervention in civilians with penetrating brain injury (PBI). METHODS: We collected data from the National Trauma Data Bank for PBI between 2017 and 2019. A total of 10 607 cases were identified; 1276 cases met the following criteria: age 16-60 years, an intensive care unit (ICU) length of stay (LOS) of >2 days, a Glasgow Coma Scale of 3-12, and at least one reactive pupil on presentation. Patients with withdrawal of life-sustaining treatments within 72 hours were excluded, leaving 1231 patients for analysis. Neurosurgical intervention was defined as an open-approach cranial procedure involving release, drainage, or extirpation of brain matter performed within 24 hours. Outcomes of interest were mortality, withdrawal of life-sustaining treatments, ICU LOS, and dispositional outcome. RESULTS: The target population was 1231 patients (84.4% male; median [IQR] age, 29 [18] years); 267 (21.7%) died, and 364 (29.6%) had a neurosurgical intervention within the first 24 hours. 1:1 matching yielded 704 patients (352 in each arm). In the matched cohort (mortality 22.6%), 64 patients who received surgery (18.2%) died compared with 95 (27%) in the nonsurgical group. Survival was more likely in the surgical group (odds ratio [OR] 1.66, CI 1.16-2.38, P < .01; number needed to treat 11). Dispositional outcome was not different. Overlap propensity score-weighted analysis (1231 patients) resulted in higher odds of survival in the surgical group (OR 1.8, CI 1.16-2.80, P < .01). The E-value for the OR calculated from the matched data set was 2.83. Early neurosurgical intervention was associated with longer ICU LOS (median 12 days [7.0, 19.0 IQR] vs 8 days [4.0, 15.0 IQR], P < .05). CONCLUSION: Management including early neurosurgical intervention is associated with decreased mortality and increased ICU LOS in matched cohorts of PBI.

Microglial CD300f immune receptor contributes to the maintenance of neuron viability in vitro and after a penetrating brain injury.

Emerging evidences suggest that immune receptors participate in diverse microglial and macrophage functions by regulating their immunometabolism, inflammatory phenotype and phagocytosis. CD300f, a TREM2-like lipid sensing immune receptor, that integrates activating and inhibitory cell-signalling pathways, modulates inflammation, efferocytosis and microglial metabolic fitness. In particular, CD300f overexpression was described to be neuroprotective after an acute brain injury, suggesting a role for this immune receptor in neurotrophic interactions. Thus, we hypothesised that CD300f modulates neuronal survival through neuron-microglial interactions. In order to study its biological function, we used in vitro and in vivo approaches, CD300f-/- animals and rCD300f-Fc, a fusion protein that interrupts the endogen interaction between CD300f receptor-ligands. In hippocampal cocultures containing neurons and mixed glia, we observed that rCD300f-Fc, but not control IgGs induced neuronal death. In accordance, in vivo studies performed by injecting rCD300f-Fc or control IgGs into rat or WT or CD300 KO mice neocortex, showed an increased lesioned area after a penetrating brain injury. Interestingly, this neuronal death was dependent on glia, and the neurotoxic mechanism did not involve the increase of proinflammatory cytokines, the participation of NMDA receptors or ATP release. However, exogenous addition of glial cell line-derived neurotrophic factor (GDNF) prevented this process. Taken together, our results suggest that CD300f modulates neuronal survival in vitro and after a penetrating brain injury in vivo and that CD300f inhibition alters microglial phenotype generating a neurotoxic microenvironment.

Reversible cerebral vasospasm and cerebral infarction secondary to meningitis following penetrating head trauma with bamboo.

A man in the 70s fell on a bamboo and punctured his left upper eyelid. CT of the head showed fractures of the medial and superior walls of the left orbit, intracranial traumatic subarachnoid haemorrhage, intraventricular haematoma and left frontal cerebral contusion. He was treated conservatively. Despite prophylactic antibiotic therapy, he had prolonged loss of consciousness. A cerebrospinal fluid examination revealed bacterial meningitis. Imaging studies on day 15 showed extensive subacute cerebral infarction in the bilateral parieto-occipital lobes and main trunk artery stenosis. On day 31, MRA showed improvement of the main arteries, and cerebral vasospasm-induced cerebral infarction was diagnosed. He was transferred to rehabilitation with full assistance. The prognosis of bamboo perforation trauma is critical. Thus, preventing and treating central nervous system infection are considered the key to the prognosis. However, given the lack of established treatment for meningitis-associated cerebral vasospasm, case-specific treatment must be considered.

An unplanned complex suicide with 6 mm Flobert revolver and train crash: a case report.

A complex suicide defines a combination of multiple suicidal methods the victim successively or concurrently carries out. We present a case of a 72-year old man found dead on the railtrack, seemingly committing simple train-related suicide. Flobert revolver - a small caliber handgun was found nearby. Herein, we emphasize the significance of a thorough external examination, stress the fact that victim can act after low-energy projectile trauma and match our case to a similar complex suicide.

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.

EFFECTS OF TRANEXAMIC ACID ON NEUROPATHOLOGY, ELECTROENCEPHALOGRAPHY, AND CEREBRAL FIBRIN DEPOSITION IN A RAT MODEL OF POLYTRAUMA WITH CONCOMITANT PENETRATING TRAUMATIC BRAIN INJURY.

ABSTRACT: Several studies have demonstrated the clinical utility of tranexamic acid (TXA) for use in trauma patients presenting with significant hemorrhage. Tranexamic acid is an antifibrinolytic that inhibits plasminogen activation, and plasmin activity has been shown to mitigate blood loss and reduce all-cause mortality in the absence of adverse vascular occlusive events. Recent clinical developments indicate TXA is safe to use in patients with concomitant traumatic brain injury (TBI); however, the prehospital effects are not well understood. Importantly, TXA has been associated with seizure activity. Therefore, this study sought to evaluate the effects of early administration of TXA on neurological recovery and electroencephalogram (EEG) abnormalities following penetrating TBI with concomitant hypoxemia and hemorrhagic shock. We hypothesized that early administration of TXA will provide hemodynamic stabilization and reduce intracerebral hemorrhage, which will result in improved neurological function. To test this hypothesis, Sprague-Dawley rats received a unilateral, frontal penetrating ballistic-like brain injury by inserting a probe into the frontal cortex of the anesthetized rat. Five minutes following brain injury, animals underwent 30 min of respiratory distress and 30 min of hemorrhage. Upon completion of the hemorrhage phase, animals received the initial dose of drug intravenously over 10 min after which the prehospital phase was initiated. During the prehospital phase, animals received autologous shed whole blood as needed to maintain a MAP of 65 mm Hg. After 90 min, "in-hospital" resuscitation was performed by administering the remaining shed whole blood providing 100% oxygen for 15 min. Upon recovery from surgery, animals were administered their second dose of vehicle or TXA intravenously over 8 h. Tranexamic acid induced an early improvement in neurologic deficit, which was statistically significant compared with vehicle at 24, 48, and 72 h at three doses tested. Analysis of cerebral hemoglobin content and intracerebral lesion progression revealed 100 mg/kg provided the optimal effects for improvement of neuropathology and was continued for determination of adverse treatment effects. We observed no exacerbation of cerebral thrombosis, but TXA treatment caused an increased risk of EEG abnormalities. These results suggest that TXA following polytrauma with concomitant brain injury may provide mild neuroprotective effects by preventing lesion progression, but this may be associated with an increased risk of abnormal EEG patterns. This risk may be associated with TXA inhibition of glycine receptors and may warrant additional considerations during the use of TXA in patients with severe TBI.

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.

Neurosurgical management of penetrating brain injury during World War I: A historical cohort.

During World War I, 25% of penetrating injuries were in the cephalic region. Major Henri Brodier described his surgical techniques in a book in which he reported every consecutive penetrating brain injury (PBI) that he operated on from August 1914 to July 1916. The aim was to collate his data and discuss significant differences in management between soldiers who survived and those who died. We conducted a retrospective survey that included every consecutive PBI patient operated on by Henri Brodier from August 1914 to April 1916 and recorded in his book. We reported medical and surgical management. Seventy-seven patients underwent trepanation by Henri Brodier for PBI. Regarding injury mechanism, 66 procedures (86%) were for shrapnel injury. Regarding location, 21 (30%) involved the whole convexity. Intracranial venous sinus wound was diagnosed intraoperatively in 11 patients (14%). Postoperatively, 7 patients (9%) had seizures, 5 (6%) had cerebral herniation, 3 (4%) had cerebral abscess, and 5 (6%) had meningitis. No patients with abscess or meningitis survived. No significant intergroup differences were found for injury mechanism or wound location, including the venous sinus. Extensive initial surgery with debridement must be prioritized. Infectious complications must not be neglected. We should not forget the lessons of the past when managing casualties in present-day and future conflicts.

Transorbital penetrating head injury by a wooden chopstick in the cavernous sinus: a case report and literature review.

Penetrating head injury is a relatively rare condition associated with high morbidity and mortality. Although the immediate treatment of penetrating head injury is needed, surgical strategies are varied based on the trajectory of the penetrating objects in the cranium. We present a case of 24-year-old man who sustained a transorbital penetrating injury caused by a wooden chopstick. Neuroimages revealed a linear lesion extending from the left intraorbital segment to the cavernous sinus passing through the superior orbital fissure. The foreign body was successfully removed via the transcranial approach without complications. A careful management based on the perioperative images and correct diagnosis is necessary to avoid unfavorable complications. Four cases of transorbital penetrating injuries have been previously reported, in which the foreign body penetrated through the superior orbital fissure and lodged in the cavernous sinus. The frontotemporal craniotomy with extradural approach can be a useful option to remove foreign bodies around the cavernous sinus regions.

Comparative Effectiveness of Intracranial Pressure Monitoring vs No Monitoring in Severe Penetrating Brain Injury Management.

Importance: Civilian penetrating brain injury (PBI) is associated with high mortality. However, scant literature is available to guide neurocritical care monitoring and management of PBI. Objective: To examine the association of intracranial pressure (ICP) monitoring with mortality, intensive care unit (ICU) length of stay (LOS), and dispositional outcomes in patients with severe PBI. Design, Setting, and Participants: This comparative effectiveness research study analyzed data from the Trauma Quality Improvement Program of the National Trauma Data Bank in the US from January 1, 2017, to December 31, 2019. Patients with PBI were identified, and those aged 16 and 60 years who met these inclusion criteria were included: ICU LOS of more than 2 days, Glasgow Coma Scale (GCS) score lower than 9 on arrival and at 24 hours, and Abbreviated Injury Scale score of 3 to 5 for the head region and lower than 3 for other body regions. Patients with bilaterally fixed pupils or incomplete data were excluded. A 1:1 propensity score (PS) matching was used to create a subgroup of patients. Patients were divided into 2 groups: with vs without ICP monitoring. Data analysis was conducted between September and December 2022. Exposures: Intracranial pressure monitoring vs no monitoring. Main Outcomes and Measures: Outcomes were mortality, rate of withdrawal, ICU LOS, and dispositional outcome. Measures were age, initial systolic blood pressure, initial oxygen saturation level on a pulse oximeter, first-recorded GCS score, GCS score at 24 hours, Abbreviated Injury Scale score, midline shift, and pupillary reactivity. Results: A total of 596 patients (505 males [84.7%]; mean [SD] age, 32.2 [12.3] years) were included, among whom 220 (36.9%) died and 288 (48.3%) had ICP monitoring. The PS matching yielded 466 patients (233 in each group with vs without ICP monitoring). Overall mortality was 35.8%; 72 patients with ICP monitoring (30.9%) died compared with 95 patients (40.8%) without ICP monitoring . Patients with ICP monitoring were more likely to survive (odds ratio [OR], 1.54; 95% CI, 1.05-2.25; P = .03; number needed to treat, 10). No difference in favorable discharge disposition was observed. The PS-weighted analysis included all 596 patients and found that patients with ICP monitoring were more likely to survive than those without (OR, 1.40; 95% CI, 1.10-1.78; P = .005). The E-value for the OR calculated from the PS-matched data set was 1.79. In addition, ICP monitoring vs no monitoring was associated with an increase in median (IQR) ICU LOS (15.0 [8.0-21.0] days vs 7.0 [4.0-12.0] days; P < .001). Conclusions and Relevance: In this comparative effectiveness research study, PBI management guided by ICP monitoring was associated with decreased mortality and increased ICU LOS, challenging the notion of universally poor outcomes after civilian PBI. Randomized clinical trials that evaluate the efficacy of ICP monitoring in PBI are warranted.

The Origin of Surrealism: Rethinking Apollinaire's Penetrating Brain Injury with Current Knowledge Regarding White Matter Tracts.

The French poet Apollinaire enrolled in the French army during World War I. In 1916, he sustained a penetrating brain injury when a fragment of shrapnel pierced his helmet in the right temporal region. Neurosurgical techniques were at that time standardized to manage the significant number of war-related neurosurgical casualties. Apollinaire, who experienced transient fainting followed by left-sided hemiparesis 2 months after his trauma, underwent trepanation. The poet's personality and behavior changed dramatically after his trauma. These neurobehavioral changes, associated with preserved cognition and no other neurologic dysfunction, were later described as Apollinaire syndrome. These personality changes were accompanied by flourishing writing changes. Hence, 15 months after his penetrating brain injury, the poet introduced the term "surrealism" to the world in his play The Breasts of Tiresias, giving birth to a major movement that paved the way for the 20th century. Linguistic shifts such as phonologic and semantic word games were at the forefront of the narrative process of the play. Traumatic brain injury often leads to cognitive impairment. In the case of Apollinaire, if the ballistic trauma were also responsible for diffuse axonal injury, it could have also led to semantic and social cognition impairment, in addition to the neuropsychological disorders that had already been widely documented by his friends and family. The world will always remember Apollinaire's writing genius as deeply associated with the birth of surrealism. But what if the poet's new writing style was caused, at least in part, by the unexpected help of a lost shrapnel fragment?

Neurologically Intact Survival after Bihemispheric Penetrating Head Trauma: A Case Report.

BACKGROUND: Patients with penetrating head trauma that crosses the midline of the brain have a high mortality rate; most die in the prehospital setting or during initial resuscitative efforts. However, surviving patients are often neurologically intact and several factors other than bullet path, including post-resuscitation Glasgow Coma Scale, age, and pupillary abnormalities, must be considered in aggregate when prognosticating patients. CASE REPORT: We present a case of an 18-year-old man who presented unresponsive after a single gunshot wound to the head that traversed the bilateral hemispheres. The patient was managed with standard care and without surgical intervention. He was discharged from the hospital neurologically intact 2 weeks after his injury. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with such apparently devastating injuries are at risk of premature termination of aggressive resuscitative efforts based on clinician bias that these efforts are futile and that patients cannot recover to a neurologically meaningful outcome. Our case reminds clinicians that patients with severe injury patterns with bihemispheric involvement can recover with good outcomes, and that bullet path is only one variable among multiple that must be considered to predict clinical outcome.

New surgical technique for non-missile trauma hemostasis as a result of sewing needle.

Traumas are the most important cause of mortality in the pediatric population. Bleeding is an important complication, especially in traumatic brain injuries with coagulation problem addition. Low-velocity penetrating brain injuries may be caused by sewing needles, nails, and knives. There are few studies in the literature for this injury type. This study presented a surgical technique and treatment to increase hemostasis in a 2-year-old patient after a sewing needle injury.

Antibiotic prophylaxis in penetrating traumatic brain injury: analysis of a single-center series and systematic review of the literature.

PURPOSE: Penetrating traumatic brain injury (pTBI) is an acute medical emergency with a high rate of mortality. Patients with survivable injuries face a risk of infection stemming from foreign body transgression into the central nervous system (CNS). There is controversy regarding the utility of antimicrobial prophylaxis in managing such patients, and if so, which antimicrobial agent(s) to use. METHODS: We reviewed patients with pTBI at our institution and performed a PRISMA systematic review to assess the impact of prophylactic antibiotics on reducing risk of CNS infection. RESULTS: We identified 21 local patients and 327 cases in the literature. In our local series, 17 local patients received prophylactic antibiotics; four did not. Overall, five of these patients (24%) developed a CNS infection (four and one case of intraparenchymal brain abscess and meningitis, respectively). All four patients who did not receive prophylactic antibiotics developed an infection (three with CNS infections; one superficial wound infection) compared to two of 17 (12%) patients who did receive prophylactic antibiotics. Of the 327 pTBI cases reported in the literature, 216 (66%) received prophylactic antibiotics. Thirty-eight (17%) patients who received antibiotics developed a CNS infection compared to 21 (19%) who did not receive antibiotics (p = 0.76). CONCLUSIONS: Although our review of the literature did not reveal any benefit, our institutional series suggested that patients with pTBI may benefit from prophylactic antibiotics. We propose a short antibiotic course with a regimen specific to cases with and without the presence of organic debris.

Intracranial penetrating injury by clothes fork in an infant: case report and review of the literature.

Nonmissile intracranial penetrating injury (IPI) in pediatric population is rare. Here, we report the exceedingly rare case of a 5-month-old infant sustained by a metallic clothes fork penetrating into his left forehead. The little baby was identified to carry a traumatic hemorrhagic shock, and a multidisciplinary team (MDT) was immediately established response for whole-course evaluation and decision-making. Computed tomography revealed that the clothes fork had impaled into the left frontal bone and brain parenchyma with about 3.2 cm inside the cranial vault. The infant underwent emergency surgery, and the clothes fork was removed jointly by MDT members under general anesthesia in the retrograde direction. His recovery was uneventful and was followed up 2 years without growth and developmental abnormality. As an extremely rare entity with distinct age-related characteristics, a MDT approach is a best choice and effective strategy to manage infant nonmissile IPI, including preoperative management, surgical treatment, and even following rehabilitation.