Penetrating head and spine injuries due to artisanal Sahelian metal arrows: experience from a tertiary hospital in Niger.

BACKGROUND AND OBJECTIVE: Metal arrows are medieval weapons typically used for hunting and war. The incidence of metal arrow wounds has declined considerably since the 16th century. Different metal arrowheads exist, and the traditional Sahelian arrowhead is barbed. Extraction of this type of metal arrow is challenging because of the risk of extensive damage to surrounding structures. To the best of our knowledge, there are no guidelines in the literature for intracranial and spinal penetrating Sahelian arrow injuries and their surgical extraction. Most authors referred to the principles of common trauma injury. In this study, we aimed to share our experience with the surgical extraction of intracranial and spinal artisanal Sahelian arrows leading to penetrating injuries, and to propose some guidelines for such lesions. METHODS: We present a consecutive case series of 8 patients admitted to the Department of Neurosurgery of the National Hospital of Zinder for metal arrow injuries of the head and spine between November 2015 and June 2023. RESULTS: Eight patients with penetrating head and spine barbed-arrow injuries were admitted to our department. Mean age was 19.37 years (range, 15 to 25 years). Patients were all male, from a rural area. Trauma circumstances involved fighting between farmers and herders. All patients received antibiotics, analgesics and tetanus prophylaxis at admission before undergoing surgical extraction under general anesthesia. Successful extraction was achieved in all cases. CONCLUSION: Extraction of intracranial or spinal artisanal Sahelian arrows is a challenge, particularly in limited facility structures. The proposed guidelines may lead to good extraction outcomes.

Traumatic penetrating head injury by crossbow projectiles: A case report and literature review.

Background: Low-energy penetrating head injuries caused by arrows are relatively uncommon. The objective of this report is to describe a case presentation and management of self-inflicted intracranial injury using a crossbow and to provide a relevant literature review. Case Report: A 31-year-old man with a previous psychiatric history sustained a self-inflicted injury using a crossbow that he bought from a department store. The patient arrived neurologically intact at the hospital, fully awake and oriented. He was not able to verbalize due to immobilization of the jaw as well as fixation of his tongue to his hard palate secondary to the position of the arrow. The trajectory of the object showed an entry point at the floor of the oral cavity and an exit through the calvarium just off the midline. The oral and nasal cavity, along with the palate and, the skull base of the anterior cranial fossa, and the left frontal lobe, were all breached. No vascular injury was identified clinically or in imaging. The arrow was surgically removed in the operating room after establishing an elective surgical airway. The floor of the mouth, tongue, and palate was repaired next. A planned delayed cerebrospinal fluid leak repair was performed. The patient made a substantial recovery and was discharged home in good functional status. A systematic literature search was done using Medline for cases with intracranial injuries related to crossbows to review and appraise the available literature. Conclusion: A thorough assessment in a multidisciplinary trauma center and the availability of a subspecialty care team, including neurosurgery and otolaryngology, are paramount in such cases. The vascular imaging should be done before and after any planned surgical intervention. Emergent and elective surgical airway management should be considered and made available throughout the stabilization and care of the acute injury. Surgical management should be planned to remove the object with adequate exposure to facilitate visualization, removal, and the possible need for further intervention, including anticipating aerodigestive and vascular injuries on removal. Finally, access to weapons and the relation to psychiatric illness should not be overlooked, as many reported cases are self-harming in nature.

[Traumatic intracranial aneurysms following combat damage]. / Travmaticheskie anevrizmy golovnogo mozga pri boevykh povrezhdeniyakh.

OBJECTIVE: To develop the principles for the treatment of traumatic intracranial aneurysms after combat damage to skull and brain. MATERIAL AND METHODS: There were 18 patients with traumatic intracranial aneurysms from February 2022 to the present. Of these, 15 ones had gunshot penetrating wounds of the skull and brain. In 3 cases, aneurysms developed after explosive injury. All patients underwent computed tomography (CT) of the brain, CT angiography of brain vessels and selective cerebral angiography. We analyzed nature of brain damage, trajectory of the wounding projectile and aneurysm location to determine predictors of traumatic intracranial aneurysms. Surgical treatment was performed in all cases. RESULTS: Hemorrhagic manifestations were observed in 11 patients. In 4 cases, traumatic intracranial aneurysms were diagnosed before rupture. Blunt head injury was followed by subarachnoid hemorrhage in 2 cases and ischemic stroke in 1 case. Endovascular or microsurgical intervention was performed depending on location of aneurysm, clinical manifestations and severity of brain damage. In case of distal aneurysms, endovascular and microsurgical destructive interventions prevailed. At the same time, proximal aneurysms (within or below the circle of Willis) required reconstructive endovascular treatment. CONCLUSION: Traumatic aneurysms should be suspected in all patients with penetrating craniocerebral injuries. Follow-up is contraindicated for traumatic intracranial aneurysms due to high risk of hemorrhage.

Right-to-Left Displacement of an Airgun Lead Bullet after Transorbital Entry into the Skull Complicated by Posttraumatic Epilepsy : A Case Report.

Penetrating head injury is a serious open cranial injury. In civilians, it is often caused by non-missile, low velocity flying objects that penetrate the skull through a weak cranial structure, forming intracranial foreign bodies. The intracranial foreign body can be displaced due to its special quality, shape, and location. In this paper, we report a rare case of right-to-left displacement of an airgun lead bullet after transorbital entry into the skull complicated by posttraumatic epilepsy, as a reminder to colleagues that intracranial metal foreign bodies maybe displaced intraoperatively. In addition, we have found that the presence of intracranial metallic foreign bodies may be a factor for the posttraumatic epilepsy, and their timely removal appears to be beneficial for epilepsy control.

Non-missile penetrating brain injury-surgical techniques for removing a long penetrating foreign body: a case report.

PURPOSE: Penetrating brain injury (PBI), a relatively uncommon injury, is associated with remarkable secondary complications such as vascular injury, intracranial haemorrhage, infection, and mortality. Non-missile PBI (NMPBI) due to sharp or blunt objects is usually treated surgically by removing the penetrating object, evacuating the associated haemorrhage, identifying possible bleeders along with haemostasis, and performing debridement. Various approaches are used for different scenarios of non-missile PBI according to the object's characteristics, penetrating site, depth, associated intracerebral haemorrhage (ICH), and presence of vascular injury along the penetrating tract. NMPBI cases are rarely reported among civilians. We herein describe a patient who was successfully treated for NMPBI, as well as frontal ICH, by simultaneously removing the heavy, metallic penetrating foreign body. METHODS: We performed corticotomy through a shorter tract instead of a deep penetrating trajectory, which minimizes the extent of damage to the brain and enables immediate management of vascular injury under direct vision while removing the foreign body, and intraoperative sonography, which provides real-time information of the penetrating object and the surrounding brain structure. We did not perform computed tomography angiography and digital subtraction angiography (DSA) because the stab location was at the frontal region, with low risk of vascular injury. Moreover, DSA is time-consuming, which may delay decompressive surgery. RESULTS: The patient was successfully treated through an alternative approach removing the long, heavy, metallic penetrating foreign body and eliminating the accompanying frontal ICH simultaneously. Focal brain abscess developed 8 days after the injury and resolved completely after antibiotics treatment. Dysphasia gradually improved but right distal limbs weakness with spasticity is still present. CONCLUSIONS: Our findings suggest prompt diagnosis by preoperative imaging, screening of vascular injury, decompression with debridement, and antibiotics treatment are important. The alternative surgical approach we proposed is exceptional and should be considered while treating patients with deep NMPBI.

A Case of a Penetrating Traumatic Head Injury Due to a Ceiling Fan.

A ceiling fan is a hidden enemy on the ceiling of a house. When the blunt blades rotate at a high speed, it has the capability to penetrate the skull bones. This case highlights the uncommon presentation of fan blade injury and the importance of compression bandage.

Unique Presentation and Novel Surgical Approach to a Transcribriform Penetrating Head Injury Caused by a Nail Gun.

A penetrating head injury caused by a nail gun is an infrequent clinically diverse condition that varies in severity by the neurovascular structures involved. The authors present the case of a patient whose frontal lobe was pierced by a nail that entered via a transnasal transcribriform trajectory without causing vascular injury or intracranial hemorrhage; the man was unaware of the nail's presence and presented with headache five days after the incident. The nail was extracted using a bifrontal craniotomy for direct visualization and for defect repair of the skull base combined with endoscopic endonasal extraction of the nail.

Glioblastoma 20 years after a nail gun trauma: A risk factor?

A 48-year-old man presented with headaches and confusion. Imaging demonstrated a right frontal glioblastoma multiforme (GBM), twenty years after a nail gun injury to the same region. GBM in the same location as a previous injury points toward possible causation from the trauma in the development of a high-grade glioma.

Baron Larrey at the Dawn of Correlative Neuroanatomy.

In 1820, a young soldier was accidentally injured by a splinter of a fencing sword that penetrated through the right orbit into the brain. Examination by the French military surgeon Baron D.-J. Larrey revealed nominal aphasia, right hemiplegia, and monocular temporal hemianopia with an altitudinal component in the right eye only. In this paper, we aimed to reconstruct Larrey's contribution to neurology in the eve of correlative neuroanatomy. Larrey predicted that the blade passed from the roof of the right orbit to graze the root of the right optic nerve at the chiasm and from there, into the vicinity of the left Sylvian fissure. This course was verified posthumously 3 months later. Larrey's previous experience with galvanic currents enabled the adoption of Samuel von Sömmering's idea of regarding the brain as a telegraphing system made of a multitude of galvanic piles sending and receiving messages from distant points. Larrey's description is a very early diligent study of the tracks of penetrating head injuries. It correlates the symptoms with the injured cerebral tissues together with autopsy verification. Here are the beginnings of the construction of human correlative neuroanatomy, which lingered until flourishing in the first decades of the 20th century.

Importance of early recognition and management of delusional parasitosis.

Delusional parasitosis (DP) is a psychiatric condition characterized by an individual's persistent belief that she or he is infested with pathogens when no such infestation is medically present. Family education on safety is needed before discharge due to the high risk of self-injury when patients try to rid themselves of the parasite. We present the case of a woman who presented twice with self-inflicted injury with a foreign body to the head to eliminate supposed tapeworms in her brain; she declined antipsychotic medication and psychiatric referral after the first emergency department visit only to come back with a more serious injury requiring a frontoparietal craniotomy. This clinical situation underscores the importance of psychiatric assessment to ascertain a patient's risk to themselves. Neuroimaging should be considered in the evaluation of elderly patients presenting with new-onset psychiatric complaints.

Spontaneous migration of retained intracranial missiles: experience with 16 cases.

Spontaneous migration of retained intracranial missiles is uncommon but a potentially serious phenomenon. Our objective is to increase awareness of the risk of spontaneous migration of retained intracranial missiles by reporting our case series of 16 patients. We performed a retrospective single-center study on patients treated for intracranial missile injuries between 2000 and 2010 in Palestine with a particular focus on the migration of retained intracranial missiles. Detailed analyses were made of patients' age, sex, type of injurious agents (metallic bullets/rubber bullets/metallic shrapnel from bomb explosion), initial missile position, site to where the missile migrated, radiological and neurological manifestations, complications, treatment modalities (surgery vs. conservative) and functional outcome by Glasgow outcome scale-extended (GOSE) classification at last follow-up. In a cohort of 190 patients with retained intracranial missiles, we identified 16 (8.4%) patients with spontaneous migration. Patients' age ranged from 10 to 30 years (mean: 18.9 ± 6.4 years). There were only 2 female patients. The missiles that migrated intracranially were metallic bullets (n = 10), rubber bullets (n = 3), and metallic shrapnel from a bomb explosion (n = 3). Among the 16 patients, 10 patients experienced symptoms due to missile migration and were treated surgically, while six patients did not develop new symptoms after missile migration and were managed conservatively. In our case series, 16/190 (8.4%) patients with retained intracranial missiles developed spontaneous migration. Neurosurgeons performing delayed surgery on patients with retained intracranial missiles should be aware of the risk of spontaneous migration and verify the location of the missile after positioning the patient for surgery.

Rupture of the Superior Sagittal Sinus in Penetrating Head Injury-Management of a Rare Trauma Mechanism.

Civilian penetrating head injury caused by foreign objects is rare in Germany (Europe), but can result in complex neurovascular damage. We report on a patient who in suicidal intent inflicted on himself a penetrating brain injury near the vertex with a captive bolt gun. A laceration at the junction of the middle to the posterior third of the superior sinus occurred by bolt and bone fragments leading to critical stenosis and subsequent thrombosis. Upon surgery, the proximal and distal sinus openings were completely thrombosed. The sinus laceration was closed by suture and the intraparenchymal bone fragments were retrieved. Postoperative angiography disclosed persistent occlusion of the superior sagittal sinus. The patient did not develop any symptoms due to venous congestion (edema, hemorrhage), suggesting sufficient collateral venous outflow. The patient completely recovered despite the complexity of the lesion.

Transbasal penetrating traumatic brain injury caused by a rifle rod: A case report.

Background: Penetrating traumatic brain injury (TBI) caused by a low-velocity object is a rare entity with a potential range of critical complications. Case Description: We report a unique case of a 30-year-old male presenting with penetrating TBI caused by a rifle's cleaning rod. The rod passes through the left nostril to reach the frontal lobe after transgressing the sella turcica. A cranial computed tomography scan shows the extension of brain damage and the trajectory of the rod with no evidence of an associated vascular injury. Surgical removal of the rifle rod was performed using a transnasal approach by a multidisciplinary with the postoperative course went uneventfully. Conclusion: Transbasal penetrating TBI through the nose is an extremely rare entity. This type of head injury carries its own peculiarities that deviate from the classic treatment algorithms.

A Metal Badge Embedded in the Forehead: A Case Report of Military Uniform Safety.

Foreign body (FB) injury to the head is not uncommon in medical practice. Various objects have been reported in penetrating head injuries. Depth and location of penetration determine the expected complications and management approach. Here, we describe a case of FB injury to the head by the metal badge of a uniform hat and discuss the medical implications of such injuries among a large population of workers at risk. A 23-year-old male presented to the emergency room with the metal badge of his uniform hat embedded in the left side of his forehead after a physical altercation at work. Imaging revealed FB penetrating the soft tissue and minimally embedded in the outer table of the left frontal bone. The FB was removed in the emergency room with no complications. The wound was then cleaned and sutured, and the patient was discharged home with oral antibiotics for one week. Penetrating FB to the head can present significant morbidity to military personnel, and thus a safer design of work uniforms is warranted.

A case of transpetrosal penetrating head injury near the sigmoid sinus.

BACKGROUND: Penetrating brain injury is relatively rare, which occurs in 0.4% of all head trauma. In past reports, the orbit, nasal cavity, and oral cavity are the most common routes of entry of foreign substances into the skull. In this case report, we experienced a rare case of head trauma who injury through the petrosal bone. To the best of our knowledge, there is no similar literature. CASE DESCRIPTION: A 69-year-old man accidentally fell from a stepladder with a height of 3 m. There was a sprinkler on the ground, and it went through his posterior part of the right auricle at the collision. He was alert on admission. However, neurological examination showed right trigeminal, abducens, and facial nerve palsy. Computed tomography was performed, and it revealed that the objects penetrated the petrosal bone. Furthermore, it caused traumatic subarachnoid hemorrhage and acute subdural hemorrhage. Fortunately, it did not reach any cerebral artery and cerebral parenchyma. Immediately it was surgically removed with a good outcome. CONCLUSION: When suspected sigmoid sinus injury in head penetrating injury, craniotomy should be considered with bleeding from the sigmoid sinus during surgery.

Penetrating Injury of Superior Sagittal Sinus.

Penetrating injury of superior sagittal sinus (SSS) is very rare yet serious which can lead to morbidity and mortality. Complications such as bleeding, thrombosis, and infection are possible and should be anticipated. We report a case of 3-year-old boy with penetrating injury caused by a nail at the middle third of SSS. The patient underwent the surgery for extraction and sinus repair and antibiotic treatment during the hospital stay. He was neurologically intact and recovered completely. Comprehensive treatment of both surgical and medical management is important in achieving the best possible outcome.

Nonmissile penetrating head injury with a wooden table leg: An illustrative case.

Penetrating head injuries are relatively uncommon and require a unique approach. This report highlights a previously unreported mechanism of injury with a table leg and the steps required to evaluate and promptly treat the patient.

Traumatic Cerebrovascular Injuries Associated with Gunshot Wounds to the Head: A Single-Institution Ten-Year Experience.

BACKGROUND: Cerebrovascular injury (CVI) is a potentially devastating complication of gunshot wounds to the head (GSWH), with yet unclear incidence and prognostic implications. Few studies have also attempted to define CVI risk factors and their role in patient outcomes. We aimed to describe 10 years of CVI from GSWH and characterize these injury patterns. METHODS: Single-institution data from 2009 to 2019 were queried to identify patients presenting with dural-penetrating GSWH. Patient records were reviewed for GSWH characteristics, CVI patterns, management, and follow-up. RESULTS: Overall, 63 of 297 patients with GSWH underwent computed tomography angiography (CTA) with 44.4% showing CVI. The middle cerebral artery (22.2%), dural venous sinuses (15.9%), and internal carotid artery (14.3%) were most frequently injured. Arterial occlusion was the most prominent injury type (22.2%) followed by sinus thrombosis (15.9%). One fifth of patients underwent delayed repeat CTA, with 20.1% showing new/previously unrecognized CVI. Bihemispheric bullet tracts were associated with CVI occurrence (P = 0.001) and mortality (P = 0.034). Dissection injuries (P = 0.013), injuries to the vertebrobasilar system (P = 0.036), or the presence of ≥2 concurrent CVIs (P = 0.024) were associated with increased risk of mortality. Of patients with CVI on initial CTA, 30% died within the first 24 hours. CONCLUSIONS: CVI was found in 44.4% of patients who underwent CTA. Dissection and vertebrobasilar injuries are associated with the highest mortality. CTA should be considered in any potentially survivable GSWH. Longitudinal study with consistent CTA use is necessary to determine the true prevalence of CVI and optimize the use of imaging modalities.

An Unusual Case of Penetrating Injury Skull with Metallic RCC Rod in A Child - A Rare Case Scenario with Review of Literature.

Penetrating head injuries can be the result of numerous intentional or unintentional events, including missile wounds, stab wounds, and motor vehicle or occupational accidents (nails, screw-drivers). Penetrating head injuries in children constitute even a smaller part of the total number of traumatic head injuries seen in casualty. We report a case of neuro-trauma who was operated in our institution. A 6-year-old female presented in casualty with an iron rod penetrating into the skull.

Complications, outcomes, and management strategies of non-missile penetrating head injuries.

OBJECTIVE: While high-velocity missile injury (gunshot) is associated with kinetic and thermal injuries, non-missile penetrating head injury (NMPHI) results in primary damage along the tract of the piercing object that can be associated with significant secondary complications. Despite the unique physical properties of NMPHI, factors associated with complications, expected outcomes, and optimal management have not been defined. In this study, the authors attempted to define those factors. METHODS: Consecutive adult patients with NMPHI who presented to Tygerberg Academic Hospital (Cape Town, South Africa) in the period from August 1, 2011, through July 31, 2018, were enrolled in a prospective study using a defined treatment algorithm. Clinical, imaging, and laboratory data were analyzed. RESULTS: One hundred ninety-two patients (185 males [96%], 7 females [4%]) with 192 NMPHIs were included in this analysis. The mean age at injury was 26.2 ± 1.1 years (range 18-58 years). Thirty-four patients (18%) presented with the weapon in situ. Seventy-one patients (37%) presented with a Glasgow Coma Scale (GCS) score of 15. Weapons included a knife (156 patients [81%]), screwdriver (18 [9%]), nail gun (1 [0.5%]), garden fork (1 [0.5%]), barbeque fork (1 [0.5%]), and unknown (15 [8%]). The most common wound locations were temporal (74 [39%]), frontal (65 [34%]), and parietal (30 [16%]). The most common secondary complications were vascular injury (37 patients [19%]) and infection (27 patients [14%]). Vascular injury was significantly associated with imaging evidence of deep subarachnoid hemorrhage and an injury tract crossing vascular territory (p ≤ 0.05). Infection was associated with delayed referral (> 24 hours), lack of prophylactic antibiotic administration, and weapon in situ (p ≤ 0.05). A poorer outcome was associated with a stab depth > 50 mm, a weapon removed by the assailant, vascular injury, and eloquent brain involvement (p ≤ 0.05). Nineteen patients (10%) died from their injuries. The Glasgow Outcome Scale (GOS) score was linearly related to the admission GCS score (p < 0.001). One hundred forty patients (73%) had a GOS score of 4 or better at discharge. CONCLUSIONS: The most common NMPHI secondary complications are vascular injury and infection, which are associated with specific NMPHI imaging and clinical features. Identifying these features and using a systematic management paradigm can effectively treat the primary injury, as well as diagnose and manage NMPHI-related complications, leading to a good outcome in the majority of patients.