Pyogenic granuloma of the scalp arising from a retained bullet fragment after a contralateral skull-penetrating gunshot wound.

Pyogenic granulomas are benign lesions commonly found on the skin and mucosal surfaces. Although the etiology of pyogenic granuloma is not well understood, some reports have suggested that PG may be caused by impaired wound healing following tissue injury. Rare cases of pyogenic granulomas in the setting of local foreign body have been reported in the literature. Although foreign body reactions have not been identified as a cause of pyogenic granuloma, these reports evidence the need to further investigate this association. We present a 33-year-old man who presented with a pyogenic granuloma on the scalp six years after a contralateral skull-penetrating gunshot wound that resulted in retained bullet fragments.

Remarkable Recovery After Severe Gunshot Brain Injury: A Comprehensive Case Study of Functional Rehabilitation.

BACKGROUND Penetrating traumatic brain injury (TBI) caused by gunshots is a rare type of TBI that leads to poor outcomes and high mortality rates. Conducting a formal neuropsychological evaluation concerning a patient's neurologic status during the chronic recovery phase can be challenging. Furthermore, the clinical assessment of survivors of penetrating TBI has not been adequately documented in the available literature. Severe TBI in patients can provide valuable information about the functional significance of the damaged brain regions. This information can help inform our understanding of the brain's intricate neural network. CASE REPORT We present a case of a 29-year-old right-handed man who sustained a left-hemisphere TBI after a gunshot, causing extensive diffuse damage to the left cerebral and cerebellar hemispheres, mainly sparing the right hemisphere. The patient survived. The patient experienced spastic right-sided hemiplegia, facial hemiparesis, left hemiparesis, and right hemianopsia. Additionally, he had severe global aphasia, which caused difficulty comprehending verbal commands and recognizing printed letters or words within his visual field. However, his spontaneous facial expressions indicating emotions were preserved. The patient received a thorough neuropsychological assessment to evaluate his functional progress following a severe TBI and is deemed to have had a favorable outcome. CONCLUSIONS Research on cognitive function recovery following loss of the right cerebral hemisphere typically focuses on pediatric populations undergoing elective surgery to treat severe neurological disorders. In this rare instance of a favorable outcome, we assessed the capacity of the fully developed right hemisphere to sustain cognitive and emotional abilities, such as language.

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.

Cranial trauma in handgun executions: Circumferential delamination defect and its relationship with contact/close-range shooting.

Skeletal evidence usually constitutes the only source of information to interpret lesion patterns that help to clarify the circumstances surrounding death. The examination and interpretation of bone trauma are essential to the application and utility of anthropology as a forensic science. When discussing the effect of gunshot wounds in bone, it becomes imperative to differentiate between short and long-distance injuries based on clear, distinct, and observable signs. To contribute to the debate, our focus is directed toward the external analysis of the so-called circumferential delamination defect (CDD) as an observable proxy for close-range shooting (≤30 cm) and contact gunshot wounds in the skull. In the context of known extrajudicial killings, in which the perpetrators used short 9 × 19 FMJ ammunition in a close-range shooting, instances of CDD have been documented. Empirical evidence reinforcing the causal relationship between CDD and close-range shootings is presented. Elements' characteristics of firearm residues were also found in remains buried for up to 30 years. Primarily, this work shows that the concentrations of gunshot residues (Pb, Ba, and Sb) resemble those observed in fresh corpses with the same gunshot wound (GSW). Moreover, the correlation observed between CDD and gunshot residues, where the likelihood of CDD increases the closer to the head and the more perpendicular the shot angle is, reinforces CDD as a pivotal discriminatory factor in the skeletal evidence of short-range or contact shot. This research contributes to the field of forensic anthropology by providing fundamental insights into the etiology of CDD and its practical application.

Musket ball injuries to the head - Experimental CT-study.

A smoothbore musket firing a round ball was the primary weapon of the infantry from the 16th to mid 19th century. Musket ball injuries are thus relatively common when archaeological remains of battlefield victims from that period are studied. Several experimental studies have focused on terminal ballistics of a musket ball. In addition, there is a good supply of historical records directly from the battlefield and military hospitals. Studies and historical records have both concluded that head injuries are among the most lethal types of musket ball damage. In this study we utilized modern day research methods, including Synbone ballistic skull phantoms and computed tomography (CT) imaging, to examine more closely the head injuries and tissue damage caused by a musket ball. We were especially interested to observe how different musket ball velocities and shooting distances would influence bone and soft tissue defects. Our experiments clearly demonstrated that musket ball was a lethal projectile even from a longer distance. Already at low velocities, the musket ball perforated through the skull. Velocity also influenced the appearance of entrance and exit wounds. CT imaging provided us with a three-dimensional view of the wound channel, skull fragments and lead remnants inside the skull phantom. According to our findings, musket ball velocity influenced defect size and cavitation. In addition, velocity influenced the size and distribution of skull fragments and lead remnants in the wound channel. Combining all these aspects could aid us in studies of archaeological musket ball victims. In particular, they could help us to estimate the shooting distance and shed light on the potential course of events in the battlefield.

[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.

Suicide by a construction nail fired from a pistol.

Penetrating head injury to accomplish suicide by a non-ammunition-related projectile discharged from a nail-gun is a very rare entity. The authors describe even much rarer, and the first reported case of a suicide penetrating head injury by a construction nail discharged from a blank cartridge of a pistol. The absence of beveling and muzzle impression, the non-ejection of the discharged cartridge, and the exit of just the tip of the nail from the other side of wound were the atypical features in this firearm fatality sustained at a contact-range. The entry wound prototypes like abrasion and grease collar, and blackening were absent. An improvisation to insert a construction nail into the chamber of firearm, for utilization as a projectile was another unique highlight here. The deceased was a construction builder. Being debt-ridden, he probably could not manage to purchase even one live cartridge for his licensee pistol to bring suicidal ideation to culmination.

Low-velocity penetrating brain injury: a review of the literature and illustrative case.

INTRODUCTION: Low-velocity penetrating brain injury (LVPBI) is a class of brain injury where a foreign object violates the skull and damages the brain. Such injuries are rare and consequently understudied. CASE: As such, we report an illustrative case of a 29-year-old female with a dense, plastic spike penetrating her right orbit and into her midbrain. After assessment with a CT scan and angiography, the object was removed with careful attention to possible vascular injury. The patient had an uncomplicated post-operative course and received antibiotic and antiepileptic prophylaxis. She was discharged on post-operative day 5, experiencing only mild left-sided weakness. DISCUSSION: Common concerns regarding LVPBI include infection, post-traumatic epilepsy, and vascular injury. A review of published LVPBI cases over the past 20 years demonstrated that most cases (55.2%) are due to accidents. Of patients undergoing surgery, 43.4% underwent a craniotomy, and 22.8% underwent a craniectomy. Despite the grave nature of LVPBI, only 13.5% of the patients died. Additionally, 6.5% of patients developed an infection over their clinical course. CONCLUSION: In all, more reported cases further paint a picture of the current state of management and outcomes regarding LVPBI, paving the way for more cohesive guidelines to ensure the best possible patient outcomes.

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.

The role of emergency department thoracotomy in patients with cranial gunshot wounds.

BACKGROUND: Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low. METHODS: We used Pennsylvania Trauma Outcomes Study data, 2002 to 2021, and included EDTs for GSWs. We defined EDT by International Classification of Diseases codes for thoracotomy or procedures requiring one, with a location flagged as emergency department. We defined head injuries as any head Abbreviated Injury Scale (AIS) score of ≥1 and severe head injuries as head AIS score of ≥4. Head injuries were "isolated" if all other body regions have an AIS score of <2. Descriptive statistics were performed. Discharge functional status was measured in five domains. RESULTS: Over 20 years in Pennsylvania, 3,546 EDTs were performed; 2,771 (78.1%) were for penetrating injuries. Most penetrating EDTs (2,003 [72.3%]) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head injured (n = 94 of 1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound-0% (0 of 81) with a severe head injury ( p = 0.035 vs. no severe head injury) and 4.5% (5 of 110) with a nonsevere head injury. Of the five head-injured survivors, two were fully dependent for transfer mobility, and three were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation. CONCLUSION: Although there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

A comparison of computed tomography angiography and digital subtraction angiography for the diagnosis of penetrating cerebrovascular injury: a prospective multicenter study.

OBJECTIVE: In this research, the authors sought to characterize the incidence and extent of cerebrovascular lesions after penetrating brain injury in a civilian population and to compare the diagnostic value of head computed tomography angiography (CTA) and digital subtraction angiography (DSA) in their diagnosis. METHODS: This was a prospective multicenter cohort study of patients with penetrating brain injury due to any mechanism presenting at two academic medical centers over a 3-year period (May 2020 to May 2023). All patients underwent both CTA and DSA. The sensitivity and specificity of CTA was calculated, with DSA considered the gold standard. The number of DSA studies needed to identify a lesion requiring treatment that had not been identified on CTA was also calculated. RESULTS: A total of 73 patients were included in the study, 33 of whom had at least 1 penetrating cerebrovascular injury, for an incidence of 45.2%. The injuries included 13 pseudoaneurysms, 11 major arterial occlusions, 9 dural venous sinus occlusions, 8 dural arteriovenous fistulas, and 6 carotid cavernous fistulas. The sensitivity of CTA was 36.4%, and the specificity was 85.0%. Overall, 5.6 DSA studies were needed to identify a lesion requiring treatment that had not been identified with CTA. CONCLUSIONS: Cerebrovascular injury is common after penetrating brain injury, and CTA alone is insufficient to diagnosis these injuries. Patients with penetrating brain injuries should routinely undergo DSA.

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.

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.

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.

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.

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.

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.

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.