Penetrating Brain Injury Research Articles

Penetrating knife injury to the skull: A case report in pediatric neurosurgical care

Isolated penetrating head injury in children is rare and is usually accidental. Each case is unique since the penetrating object and the trajectory through the brain parenchyma vary greatly among patients. We present a three-year-old girl who presented with a kitchen utility knife penetrating her left midface, skull, and brain abutting the anterior cerebral vasculature. Though the patient initially presented to a local trauma center, there were no pediatric nor vascular neurosurgeons on staff. Thus, she was transferred to our tertiary facility for definitive surgical management. A pediatric and vascular neurosurgeon worked together to remove the knife safely and the underlying vasculature remained intact. Postoperatively, the patient did well and was neurologically intact. Though penetrating cranial injury is rare in the pediatric population, such complex cases of brain injury can be properly managed with good outcome by an interdisciplinary team of specialists in tertiary care centers and can result in an excellent surgical and functional outcome for the patient.

Do EMS Providers Accurately Ascertain Anticoagulant and Antiplatelet Use in Older Adults with Head Trauma?

ABSTRACTObjective: Prehospital provider assessment of the use of anticoagulant or antiplatelet medications in older adults with head trauma is important. These patients are at increased risk for traumatic intracranial hemorrhage and therefore field triage guidelines recommend transporting these patients to centers capable of rapid evaluation and treatment. Our objective was to evaluate EMS ascertainment of anticoagulant and antiplatelet medication use in older adults with head trauma. Methods: A retrospective study of older adults with head trauma was conducted throughout Sacramento County. All 5 transporting EMS agencies and all 11 hospitals in the county were included in the study, which ran from January 2012 to December 2012. Patients ≥55 years who were transported to a hospital by EMS after head trauma were included. We excluded patients transferred between two facilities, patients with penetrating head trauma, prisoners, and patients with unmatched hospital data. Anticoagulant and antiplatelet use were categorized as: warfarin, direct oral anticoagulants (DOAC; dabigatran, rivaroxaban, and apixaban), aspirin, and other antiplatelet agents (e.g., clopidogrel and ticagrelor). We calculated the percent agreement and kappa statistic for binary variables between EMS and emergency department (ED)/hospital providers. A kappa statistic ≥0.60 was considered acceptable agreement. Results: After excluding 174 (7.6%) patients, 2,110 patients were included for analysis; median age was 73 years (interquartile range 62–85 years) and 1,259 (60%) were male. Per ED/hospital providers, the use of any anticoagulant or antiplatelet agent was identified in 595 (28.2%) patients. Kappa statistics between EMS and ED/hospital providers for the specific agents were: 0.76 (95% CI 0.71–0.82) for warfarin, 0.45 (95% CI 0.19–0.71) for DOAC agents, 0.33 (95% CI 0.28–0.39) for aspirin, and 0.51 (95% CI 0.42–0.60) for other antiplatelet agents. Conclusions: The use of antiplatelet or anticoagulant medications in older adults who are transported by EMS for head trauma is common. EMS and ED/hospital providers have acceptable agreement with preinjury warfarin use but not with DOAC, aspirin, and other antiplatelet use.

Poster 249 Remarkable Recovery of Function in a Young Adult Female after Low-Velocity Penetrating Head Injury and Arrival with Retained Foreign Body: A Case Report.

Poster 249 Remarkable Recovery of Function in a Young Adult Female after Low-Velocity Penetrating Head Injury and Arrival with Retained Foreign Body: A Case Report.

Surgical Resection for Epilepsy Following Cerebral Gunshot Wounds

The surgical management of epilepsy after penetrating gunshot wounds (GSWs) to the head has not been described in the modern era. Given the extensive damage to the cranium and cortex from such injuries, the safety and efficacy of surgical intervention are unclear. We report surgical strategy and outcomes after resection for medically refractory epilepsy following GSWs in 4 patients. A prospectively compiled database of 325 patients with epilepsy was used to identify patients undergoing surgery for medically refractory epilepsy after a GSW to the brain. Seizure frequency, scalp and intracranial electroencephalography evaluation, type of resection, and seizure outcomes were compiled. All 4 patients underwent direct electrocorticography recordings either with implanted electrodes or intraoperatively that were used to drive surgical decision making. All patients had intracranial shrapnel fragments and large areas of encephalomalacia on imaging. Intracranial electrodes were placed in 2 patients to localize seizure onsets. Two patients underwent frontal lobe resections, and the other 2 patients underwent multilobar resections. Latency between injury and epilepsy surgery was 12 years, and mean age at surgery was 28 years. In all cases, epilepsy surgery led to a significant improvement in seizure control (Engel class I, 2 patients; II, 1 patient; and III, 1 patient). Epilepsy is common after penetrating head injury, and the incidence is likely to increase given the growing numbers of armed conflicts in urban centers worldwide. In selected cases, intracranial monitoring and surgical resections may be safely performed and can lead to favorable seizure outcomes.

Neurological findings in pediatric penetrating head injury at a university teaching hospital in Durban, South Africa: a 23-year retrospective study.

OBJECTIVES Penetrating traumatic brain injuries (TBIs) can be divided into gunshot wounds or stab wounds based on the mechanisms of injury. Pediatric penetrating TBIs are of major concern as many parental and social factors may be involved in the causation. The authors describe the penetrating cranial injuries in pediatric patient subgroups at risk and presenting to the Department of Neurosurgery at the University of KwaZulu-Natal, by assessment of the Glasgow Coma Scale (GCS) score and review of the common neurological manifestations including cranial nerve abnormalities. METHODS The authors performed a retrospective chart review of children who presented with penetrating TBIs between 1985 and 2007 at a university teaching hospital. Descriptive statistical analysis with univariate and multivariate logistic regression was used to assess the variables. RESULTS Out of 223 children aged 16 years and younger with penetrating TBIs seen during the study period, stab wounds were causal in 127 (57%) of the patients, while gunshot injuries were causal in 96 (43%). Eighty-four percent of the patients were male. Apart from abnormal GCS scores, other neurological abnormalities were noted in 109 (48.9%) of the patients, the most common being cranial nerve deficits (22.4%) and hemiparesis. There was a strong correlation between left-sided stab wounds and development of seizures. The mean age of patients with neurological abnormalities was 11.72 years whereas that of patients with no neurological abnormalities was 8.96 years. CONCLUSIONS Penetrating head injuries in children are not as uncommon as previously thought. There was no correlation between the age group of the patients and the mechanism of injury, which implies that stab or gunshot injuries could occur in any of our pediatric population with the same frequency. While gunshot injuries accounted for 56% of the patient population, stab injuries still accounted for 44%. Following penetrating head injuries, neurological abnormalities tend to occur in the older subgroup of the pediatric patients. The most common neurological abnormalities were hemiparesis followed by cranial nerve deficits. Facial nerve deficits were the most commonly seen cranial nerve abnormality. Immediate convulsions were a significant feature in patients with stab injuries to the head compared to those with gunshot injuries.

Attempted Suicide with Needle Penetration through Cranial Defect: A Rare Case Report

Intracranial foreign bodies are usually secondary to penetrating injuries through the orbit, ear, or cranial bones. Nails, knives, screwdrivers, sewing needles, bullets, and shrapnel have been described related to penetrating brain injury (PBI). The majority of deaths from trauma reflect unintentional accidents, but a significant minority follow suicide and even a smaller proportion (less than 10%) reflect homicide. Self-inflicted injuries among psychiatric patients are not uncommon. We report a rare case of a 35-year-old woman who tried to commit suicide by inserting a needle in her brain through cranial defect. Needle was removed and patient recovered uneventfully. Awareness of the psychological condition and suicide precautionary measures should be kept in mind in all cases of self-inflicted PBI patients.

Nonmissile Penetrating Injury to the Head: Experience with 17 Cases

Penetrating nonmissile injuries to the head are far less common than missile penetrating injuries. Here we describe our experience in managing 17 cases of nonmissile injury to the head, likely the largest such series reported to date. We also highlight the surgical steps and techniques used to remove in situ objects (including weapons) in the penetrating wounds that have not been described previously. We conducted a retrospective study of cases of nonmissile, low-velocity penetrating injuries of the head managed in our department. The recorded data of patients with penetrating head injuries were studied for the cause of the injury, type of object, type and extent of penetration, Glasgow Coma Scale score on admission, other clinical issues, evaluation and assessment, interval from penetration to operation, surgical steps and notes, difficulty during the operation, major and minor complications, follow-up, and ultimate outcome. Our 17 cases included 6 cases of accidental penetration and 11 cases of penetration as the result of violence. Weapons and other foreign objects causing injury included a teta (a pointed metal weapon with a wooden handle and a barb near the tip, used for hunting and fishing) in 4 cases, a dao (a sharp metal cutting instrument with a wooden handle used for cutting vegetables, fish, meat, bamboo, wood, etc.) in 3 cases, a bamboo stick in 3 cases, a metal rod in 2 cases, a knife in 2 cases, a sharp stone in 1 case, a metal steam chamber cover in 1 case, and a long peg in 1 case. GCS on admission was between 13 and 15 in 15 cases. Only 1 patient exhibited limb weakness. Four patients with an orbitocranial penetrating injury had 1-sided vision loss; 2 of these patients had orbital evisceration, and 1 of these patients died. In 14 patients, the foreign object was in situ at presentation and was removed surgically. Computed tomography scan and plain X-ray of the head were obtained in all patients. Postoperatively, 2 patients (11.7%) needed support in the intensive care unit but died early after surgery. One patient developed late osteomyelitis. The remaining patients were doing well at the most recent follow-up. The presenting picture of nonmissile penetrating injury to head may be daunting, but these cases can be managed with very good results with proper (clinical and radiologic) evaluation and simple neurosurgical techniques.

Early venous thromboembolism chemoprophylaxis in combat-related penetrating brain injury.

OBJECTIVE Traumatic brain injury (TBI) is independently associated with deep vein thrombosis (DVT) and pulmonary embolism (PE). Given the numerous studies of civilian closed-head injury, the Brain Trauma Foundation recommends venous thromboembolism chemoprophylaxis (VTC) after severe TBI. No studies have specifically examined this practice in penetrating brain injury (PBI). Therefore, the authors examined the safety and effectiveness of early VTC after PBI with respect to worsening intracranial hemorrhage and DVT or PE. METHODS The Kandahar Airfield neurosurgery service managed 908 consults between January 2010 and March 2013. Eighty of these were US active duty members with PBI, 13 of whom were excluded from analysis because they presented with frankly nonsurvivable CNS injury or they died during initial resuscitation. This is a retrospective analysis of the remaining 67 patients. RESULTS Thirty-two patients received early VTC and 35 did not. Mean time to the first dose was 24 hours. Fifty-two patients had blast-related PBI and 15 had gunshot wounds (GSWs) to the head. The incidence of worsened intracranial hemorrhage was 16% after early VTC and 17% when it was not given, with the relative risk approaching 1 (RR = 0.91). The incidence of DVT or PE was 12% after early VTC and 17% when it was not given (RR = 0.73), though this difference was not statistically significant. CONCLUSIONS Early VTC was safe with regard to the progression of intracranial hemorrhage in this cohort of combat-related PBI patients. Data in this study suggest that this intervention may have been effective for the prevention of DVT or PE but not statistically significantly so. More research is needed to clarify the safety and efficacy of this practice.

Management of penetrating abdominal and thoraco-abdominal wounds: A retrospective study of 186 patients

This is a single center retrospective review of abdominal or abdomino-thoracic penetrating wounds treated between 2004 and 2013 in the gastrointestinal and emergency unit of the university hospital of Grenoble, France. This study did not include patients who sustained blunt trauma or non-traumatic wounds, as well as patients with penetrating head and neck injury, limb injury, ano-perineal injury, or isolated thoracic injury above the fifth costal interspace. In addition, we also included cases that were reviewed in emergency department morbidity and mortality conferences during the same period. Mortality was 5.9% (11/186 patients). Mean age was 36 years (range: 13-87). Seventy-eight percent (145 patients) suffered stab wounds. Most patients were hemodynamically stable or stabilized upon arrival at the hospital (163 patients: 87.6%). Six resuscitative thoracotomies were performed, five for gunshot wounds, one for a stab wound. When abdominal exploration was necessary, laparotomy was chosen most often (78/186: 41.9%), while laparoscopy was performed in 46 cases (24.7%), with conversion to laparotomy in nine cases. Abdominal penetration was found in 103 cases (55.4%) and thoracic penetration in 44 patients (23.7%). Twenty-nine patients (15.6%) had both thoracic and abdominal penetration (with 16 diaphragmatic wounds). Suicide attempts were recorded in 43 patients (23.1%), 31 (72.1%) with peritoneal penetration. Two patients (1.1%) required operation for delayed peritonitis, one who had had a laparotomy qualified as "negative", and another who had undergone surgical exploration of his wound under general anesthesia. In conclusion, management of clear-cut or suspected penetrating injury represents a medico-surgical challenge and requires effective management protocols.

P.081 Penetrating brain injury, recent case series of a single institution and literature review

Background: Penetrating brain injury is a rare entity. Furthermore, clinical presentation can be highly variable and management difficult, especially when the foreign body is retain in the skull Methods: We present a serie of three recent cases of penetrating brain injury that happened at our institutionm including clinical and radiological data. We discuss management of those challenging cases and present a brief review of the literature. Results: Our cases (3) encompassed different mechanisms: bilateral nail gun injury, knife and aircraft propeller. All patients were male, with a median age of 37 years old. Work-up was negative for intracranial vascular injury. All patients were treated with initial craniectomy (bilateral in one case) and a course of antibiotics. Cranioplasty was later performed. All patients survived and evolved in favorable fashion. Conclusions: Penetrating brain injury is a rare injury, requiring individualized surgical and medical management. A few recommendations may be found in the literature but are often based on literature from blunt traumatic brain injury or war-related injuries.

Key in Brain: An Interesting Case of Civilian Penetrating Head Injury

Civilian penetrating head injuries are not common, and the occurrence of such injuries in the pediatric population is rare. Pediatric penetrating head injuries are low-velocity injuries, resulting from household objects. Presentation entirely depends on the area of the brain involved. There are several management dilemmas related to the nature, size, shape, and location of the object, but always warrants removal of the foreign body into the operation theater. The outcome depends on the presenting neurological status of the patient, which reflects underlying parenchymal injury. We are reporting an interesting case of civilian penetrating head injury in a 5-year-old female child with a key in the brain. Computed tomographic scan of the brain revealed a household key penetrated through the right temporal bone. The patient underwent a surgical procedure for the removal of the key. She recovered well without any neurological deficit.

Penetrating Brain Injury from Nail Guns: Epidemiological, Clinical and Forensic Features (P3.211)

Penetrating Brain Injury from Nail Guns: Epidemiological, Clinical and Forensic Features (P3.211)

Clinical Characteristics and Predictors of Adverse Outcome in Adult and Pediatric Patients With Healthcare-Associated Ventriculitis and Meningitis.

Background. Healthcare-associated meningitis or ventriculitis is a serious and life-threatening complication of invasive neurosurgical procedures or penetrating head trauma.Methods. We performed a retrospective study of adults and children with the diagnosis of healthcare-associated meningitis or ventriculitis, as defined by the 2015 Centers of Disease Control and Prevention case definition, at 2 large tertiary care hospitals in Houston, Texas from July 2003 to November 2014. Patients were identified by infection control practitioners and by screening cerebrospinal fluid samples sent to the central laboratory. We collected data on demographics, clinical presentations, laboratory results, imaging studies, treatments, and outcomes.Results. A total of 215 patients were included (166 adults and 49 children). A positive cerebrospinal fluid culture was seen in 106 (49%) patients, with the majority of the etiologies being Staphylococcus and Gram-negative rods. An adverse clinical outcome was seen in 167 patients (77.7%) and was defined as death in 20 patients (9.3%), persistent vegetative state in 31 patients (14.4%), severe disability in 77 patients (35.8%), or moderate disability in 39 patients (18.1%). On logistic regression analysis, age >45 years (adjusted odds ratio [OR], 6.47; 95% confidence interval [CI], 2.31–18.11; P ≤ .001), abnormal neurological exam (adjusted OR, 3.04; 95% CI, 1.27–7.29; P = .013), and mechanical ventilation (adjusted OR, 5.34; 95% CI, 1.51–18.92; P = .01) were associated with an adverse outcome.Conclusions. Healthcare-associated meningitis or ventriculitis is associated with significant morbidity and mortality.

Management and outcome of low velocity penetrating head injury caused by impacted foreign bodies.

Penetrating head injuries with impacted foreign bodies are rare, associated with a high incidence of morbidity and potentially life-threatening. In this study, we aimed at investigating the outcome of these cases as well as analyzing the factors affecting the prognosis. A retrospective study in which the records of 16 patients who had penetrating head injuries caused by low-velocity impacted foreign bodies were revised. All patients were males with a mean age of 28.9 years (range, 18 to 50 years). The follow-up period ranged from 4 to 13 months with a mean of 8.1 months. Causes of injury were construction accidents in 6 (37.5 %) patients, assault in 6 (37.5 %) and road traffic accidents in 4 (25 %). The impacted objects included a bar of iron, a piece of wood, a nail, a sickle and a piece of glass. Diagnostic computerized tomography (CT) of the brain was carried out on admission in all patients. Thirteen (81.3 %) patients were submitted to surgery, and all had the appropriate management in the form of antibiotics and dehydrating measures as required. The primary outcome measure was the Glasgow Outcome Scale (GOS) at the end of follow-up. At the end of follow-up, ten (62.5 %) patients had a GOS score of 5, two (12.5 %) patients had a score of 4, and four (25 %) patients had a score of 1. Low-velocity penetrating head injuries are most common in young adult males. With the appropriate management, a majority of even the most severe cases can have a favorable outcome.

Centrally Synthesized Estradiol Is a Potent Anti-Inflammatory in the Injured Zebra Finch Brain.

In homeotherms, injury to the brain, such as a penetrating wound, increases microglial cytokine expression and astroglial aromatase (estrogen synthase). In songbirds, injury-induced synthesis of estrogens is neuroprotective as aromatase inhibition and replacement with estradiol (E2) exacerbates and mitigates the extent of damage, respectively. The influence of induced aromatization on inflammation, however, remains unstudied. We hypothesized that injury-induced aromatization, via E2 synthesis, may affect neuroinflammation after a penetrating brain injury. Using adult zebra finches, we first documented an increase in the transcription of cytokines but not aromatase, 2 hours after the injury. Twenty-four hours after the injury, however, aromatase was dramatically elevated and cytokine expression had returned to baseline, suggesting that aromatization may be involved in the decrease of cytokines and neuroinflammation. In two subsequent experiments, we tested the influence of the inhibition of induced aromatization and aromatase inhibition with concomitant central E2 replacement on the transcription of the cytokines TNF-α, IL-1β, and IL-6, the enzyme cyclooxygenase-2 (cox-2), and its product prostaglandin E2 (PGE2). Administration of fadrozole, an aromatase inhibitor, caused a sustained elevation of IL-1β in females and TNF-α, cox-2, and PGE2 in both sexes. This prolonged neuroinflammation appears to be due to a failure to synthesize E2 locally because intracranial E2 replacement lowered IL-1β in females, TNF-α in males, and cox-2 and PGE2 in both sexes. IL-6 was not affected by injury, aromatase inhibition, or E2 replacement in either sex. These data suggest that E2 synthesis after a penetrating brain injury is a potent and inducible anti-inflammatory signal, with specific modulation of discrete cytokine signaling.

Distinct roles for metalloproteinases during traumatic brain injury

BackgroundSignificant protease activations have been reported after traumatic brain injury (TBI). These proteases are responsible for cleavage of transmembrane proteins in neurons, glial, and endothelial cells and this results in the release of their extracellular domains (ectodomains). MethodsTwo TBI models were employed here, representing both closed head injury (CHI) and open head injury (OHI). In situ zymography, immunohistochemistry, bright field and confocal microscopy, quantification of immunopositive cells and statistical analysis were applied. ResultsWe found, using in situ zymography, that gelatinase activity of matrix metalloproteinases (MMP)-2 and MMP-9 was upregulated in cortex of both injury models. Using immunohistochemistry for several MPPs (Matrix metalloproteinases) and ADAMs (disintegrin and metalloproteinases), including MMP-2, -9, ADAM-10, -17, distinct patterns of induction were observed in the two TBI models. In closed head injury, an early increase in protein expression of MMP-2, -9 and ADAM-17 was found as early as 10 min post injury in cortex and peaked at 1 h for all 4 proteases examined. In contrast, after OHI the maximal expression was observed locally neighboring the impact site, at a later time-point, as long as 24 h after the injury for MMP-2 and MMP-9. Confocal microscopy revealed colocalization of the 4 proteases with the neuronal marker NeuN in CHI, but only MMP2 colocalized with NeuN in OHI. ConclusionsThe findings may lead to a trauma-induced therapeutic strategy triggered soon after a primary insult to improve survival and to reduce brain damage following TBI.

Brain Regions Influencing Implicit Violent Attitudes: A Lesion-Mapping Study.

Maladaptive aggression and violence can lead to interpersonal conflict and criminal behavior. Surprisingly little is known about implicit attitudes toward violence and aggression. Here, we used a range of techniques, including voxel-based lesion-symptom mapping, to examine the causal role of brain structures underpinning implicit attitudes toward aggression in a unique sample of combat veterans with traumatic brain injury. We found that damage to the dorsolateral prefrontal cortex (dlPFC) led to a more positive implicit attitude toward violence that under most normal situations would be considered inappropriate. These results suggest that treatments aimed at increasing cognitive control using cognitive behavioral therapies dependent on the intact dlPFC could treat aggressive and violent behavior.

Safe management of paediatric penetrating head injury without a CT scanner: A strategy for humanitarian surgeons based on experience in southern Afghanistan.

In many parts of the world, access to a CT scanner remains almost non-existent, and patients with a head injury are managed expectantly, often with poor results. Recent military medical experience in southern Afghanistan using a well-equipped surgical facility with a CT scanner has provided new insights into safe surgical practice in resource-poor environments. All cases of children aged under 16 years with penetrating head injury who were treated in a trauma unit in southern Afghanistan by a single neurosurgeon between 2008 and 2010 were reviewed. Based on a previously published retrospective review, a clinical strategy aimed specifically at generalist surgeons is proposed for selecting children who can benefit from surgical intervention in environments with no access to CT scanners. Fourteen patients were reviewed, of whom three had a tangential wound, 10 had a penetrating wound with retained fragments and one had a perforating injury. Two operations for generalist surgeons are described in detail: limited wound excision; and simple decompression of the intra-cranial compartment without brain resection or dural repair. In resource-poor environments, clinically-based criteria may be used as a safe and appropriate strategy for selecting children who may benefit from relatively straightforward surgery after penetrating brain injury.

Tea Cup in the brain, a rare case of penetrating brain injury in pediatric patient

Abstract Head injuries are very common in children. All over the world, the most common mechanism is fall. These injuries are more prevalent in developing countries due to lack of education, poverty, lack of standard and scientific ways to child upbringing. Penetrating injuries in pediatric patients is extremely uncommon and usually occur due to sharp objects like knife, screw driver, drills, nails. We are reporting a rare case of a child with penetrating head injury due to tea cup, very commonly used crockery in every house hold. To the best of our knowledge, no similar case has ever been reported in world literature. Our case also emphasized the need for educating people about child care.

Dynamic finite element simulation of the gunshot injury to the human forehead protected by polyvinyl alcohol sponge.

Although there are some traditional models of the gunshot wounds, there is still a need for more modeling analyses due to the difficulties related to the gunshot wounds to the forehead region of the human skull. In this study, the degree of damage as a consequence of penetrating head injuries due to gunshot wounds was determined using a preliminary finite element (FE) model of the human skull. In addition, the role of polyvinyl alcohol (PVA) sponge, which can be used as an alternative to reinforce the kinetic energy absorption capacity of bulletproof vest and helmet materials, to minimize the amount of skull injury due to penetrating processes was investigated through the FE model. Digital computed tomography along with magnetic resonance imaging data of the human head were employed to launch a three-dimensional (3D) FE model of the skull. Two geometrical shapes of projectiles (steel ball and bullet) were simulated for penetrating with an initial impact velocity of 734 m/s using nonlinear dynamic modeling code, namely LS-DYNA. The role of the damaged/distorted elements were removed during computation when the stress or strain reached their thresholds. The stress distributions in various parts of the forehead and sponge after injury were also computed. The results revealed the same amount of stress for both the steel ball and bullet after hitting the skull. The modeling results also indicated the time that steel ball takes to penetrate into the skull is lower than that of the bullet. In addition, more than 21% of the steel ball's kinetic energy was absorbed by the PVA sponge and, subsequently, injury sternness of the forehead was considerably minimized. The findings advise the application of the PVA sponge as a substitute strengthening material to be able to diminish the energy of impact as well as the load transmitted to the object.