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Penetrating head injury by a stone: Case report and review of the literature
Clinical Neurology and Neurosurgery 112 (2010) 813–816
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Case report
Penetrating head injury by a stone: Case report and review of the literature Concetta Alafaci, Gerardo Caruso, Mariella Caffo ∗ , Alessandro A. Adorno, Daniele Cafarella, Francesco M. Salpietro, Francesco Tomasello Neurosurgical Clinic, Department of Neurosciences, Psychiatry and Anaesthesiology, University of Messina School of Medicine, Policlinico “G. Martino” via Consolare Valeria 1, 98124 Messina, Italy
a r t i c l e
i n f o
Article history: Received 31 October 2009 Received in revised form 15 April 2010 Accepted 10 June 2010 Available online 7 July 2010 Keywords: Foreign body Head trauma Intracranial stone Low velocity trauma
a b s t r a c t Traumatic intracranial penetration of foreign objects of non-missile intracranial nature rarely occurs. Haemorrhages, major vascular injury and contusions can be causes of death in early stage, epileptic seizures and infections are possible complications in later stages. Complete excision of the foreign body should be performed. Possible dural and vascular injuries should be repaired during surgical treatment. In the present study, we report a rare case of traumatic intracranial stone as a foreign object. A brief review of the literature is presented. © 2010 Elsevier B.V. All rights reserved.
1. Introduction Penetrating head injuries (PHIs) belong to the most severe traumatic brain injuries. Intracranial injuries most frequently encountered in the adult population are caused by armed weapons [1,2]. PHIs are fatal in 40% of cases because of damage to critical structures, vascular disruption, concussion blast injury, or meningitis [3,4]. Intracerebral haemorrhages, cerebral contusions and major vascular injuries are underlying factors causing death in early stages. In the present study, we report an unusual case of PHI caused by a stone, which is rarely encountered as a foreign object in intracranial traumatic injuries. 2. Case report A 19-year-old patient fell to the ground while driving his motorcycle. The boy was immediately transferred to our Department. The neurological examination revealed amnesia and psychomotor agitation with GCS 14. No other traumatic injuries were observed. A wide dermal cut was present in the right temporoparietal region. Skull X-ray showed, in right temporoparietal region, a comminuted depressed fracture with an entrapped foreign object. Cranial computed tomography (CT) with bone window and with 3D reconstructions revealed a right temporoparietal comminuted depressed fracture and the presence of a foreign object (Fig. 1A and B). A
cerebral contusion underneath the fracture was also seen (Fig. 1). Antibiotic ceftriaxone was administered daily at intravenous dose of 2 g for the first 3 days and 1 g for the remaining 3 days. In addition, we administered prophylactic anticonvulsant therapy with levitiracetam at daily dose of 1000 mg. Tetanus vaccine was also administered. The dermal cut was deeply cleansed with normal saline solution. The patient underwent immediate surgical intervention. The foreign object was visualized and identified as a stone (5 cm × 3 cm × 3 cm), embedded in a large comminuted depressed fracture (Fig. 2). The operative field was irrigated with saline and antibiotic solution. The stone was carefully removed. Comminute bone fragments were also totally removed. Through the lacerated dura layers, we observed an acute subdural haematoma that was evacuated. A cerebral contusion was evidenced and removed. The dura mater was closed with a water-tight suture. The postoperative course was uneventful and the patient recovered completely. The patient was discharged 10 days after surgery. In consideration of the large craniectomy (Fig. 3A), the patient was followed-up 3 months later for cranioplasty treatment (Fig. 3B). Cranioplasty was performed with biphasic calcium phosphate bone substitutes (Tricos® ) (Fig. 3A and B). TRICOS is constituted of 60% hydroxyapatite (HA) and 40%  tricalcium phosphate. The compound is a resorbable bioactive bone substitute, which enables the formation of new bone over time. 3. Discussion
∗ Corresponding author. Tel.: +39 090 2217167, fax: +39 090 693714. E-mail address: [email protected] (M. Caffo). 0303-8467/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.clineuro.2010.06.008
Injuries caused by objects with an impact velocity less than 100 m/s are known as non-missile injuries [5]. Penetrating head
814
C. Alafaci et al. / Clinical Neurology and Neurosurgery 112 (2010) 813–816
Fig. 1. (A) CT scan with 3D reconstructions with bone window reveals the presence of a foreign object embedded in the right temporoparietal depressed fracture. (B) Coronal CT scan with bone window shows the foreign body and the right temporoparietal comminuted depressed fracture. (C) Axial CT scan of the brain demonstrates a cerebral contusion underneath the fracture.
Fig. 2. Intraoperative image of the stone embedded in the right temporoparietal comminuted depressed fracture.
injuries by non-missile low velocity particles constitute a rare sub-group which have specific features. The primary pathology in these events is tissue laceration, whereas in missile injuries shock waves and cavitations contribute to additional tissue damage [5]. PHI in adult population usually occurs due to ballistic weapons and shrapnel fragments. PHI may also be a consequence of suicide attempts and in self-inflicted injuries. PHI may cause intra-
parenchymal and intracranial lesions during the early period and may lead to a high degree of morbidity and mortality. Miller et al. reported 42 cases with intracranial wooden pieces with a 25% of mortality rate [6]. Despite antibiotic treatment, the incidence of infectious complications was observed in 64% of cases of PHI and a brain abscess was showed in 48% [7]. Rapid debridement of these wounds is also recommended, based on both the extent of such injuries and likelihood of identifying bone fragments or intracranial residua of the projectile object. It is also necessary to take into account the risk of CSF leakage linked to the damage of the dura mater. A careful and water-tight suture can notably limit this event. The incidence of post-traumatic epilepsy in patients after PHI is estimated at about 3%. In particular, post-traumatic epilepsy represents a late sequelae in adults. Seizures are thought to occur secondary to direct traumatic injury to cerebral cortex with subsequent cerebral scarring. The presence of intraparenchymal lesions is thought to predict the highest risk of epilepsy. Anticonvulsant medication in the immediate post-injury period is thought to mitigate neuronal hyperexcitability and re-equilibrate seizure threshold [3]. In PHI, cranial bone CT is the most valuable study to detect foreign objects as small as 0.06 mm [4]. It is particularly useful in the initial evaluation of the traumatic event, because it can localize the foreign body, plot is trajectory, identify the bone defect and evaluate the extent of parenchymal injury. The foreign body penetrating the intracranial cavity is removed only by definite surgical treatment. It is crucial to prevent any involuntary movement of the foreign body which could enlarge the damaged area [8]. Surgery is also performed for the repair of cerebral or dural damage. Bony fragments must be excised. It is necessary to take into account the risk of CSF leakage or brain abscess
Fig. 3. (A) CT scan with 3D reconstructions with bone window shows the large craniectomy in the area of the depressed fracture. (B) CT scan with 3D reconstructions with bone window after the cranioplasty treatment.
C. Alafaci et al. / Clinical Neurology and Neurosurgery 112 (2010) 813–816
815
Table 1 Literature review patients. Author
Age and sex
Type of head injury
Location
Admission
Neuroradiological findings
Operative findings
Outcome
Cina
18, M
Left convex
Died
X-ray: radio-opacity on the left convex
No surgery
Victim of a gunshot
Bhootra
24, M
Penetrating stone due to felt into the ground Penetrating stone by the use of a slingshot
Left frontal
GCS 15
Died after 2 days (acute subdural haematoma, brain abscess)
Kiymaz
5, M
Left parietal
Sharma
M, age not reported
Right frontal
Unconscious patient, eye-opening in response to painful stimuli Not reported
7, F
Right temporal
Died
Balak
9, M
Penetrating stone struck to the head from a shapeless piece of marble
Midline
GCS 13, right hemiparesis
Stone embedded in the right frontal lobe Post mortem examination: right temporal depressed fracture, cerebral contusion Compression of the superior sagittal sinus
Not reported
Chattopadhyay
Penetrating stone due to vehicleexternal traffic accident Penetrating stone due to a fall off a running train Penetrating stone propelled from the rear wheel of a truck
Post mortem examination: left frontal comminuted fracture, acute subdural haematoma, brain abscess Intracranial stone in left parietal region
Satyarthee
28, M
Penetrating piece of knifesharpening stone broke during work
Right parietal
GCS 8
Enucleation of the right eyeball
GCS 15 at 6 months follow-up
Our case
19, M
Penetrating stone due to felt on the ground
Right temporoparietal
GCS 14
Fracture with embedded stone, acute subdural haematoma
Complete recovery. Cranioplasty 3 months after trauma
development, which is linked to the disruption of the dura mater barrier. In our research of relevant English medical literature in the Medline database we found only seven reported cases [9–15] (Table 1). Cina et al. described a patient with an intracranial stone which had pierced the scalp when the victim of a gunshot wound fell into the ground [9]. Bhootra and Bhana described an unusual case of a penetrating foreign body in which a piece of stone acted as a missile by the probable use of a slingshot. The patient was not admitted into the hospital and no neuroradiological studies were performed. The patient was sent home and died 2 days later. A
CT: left parietal depressed fracture, pneumocephalus CT: right frontal comminuted fracture
CT: midline depressed fracture, hypodense area on the left cerebral cortex surrounding a stone CT: right parietal depressed fracture and right orbital roof extending to right orbital wall and the ethmoid, frontotemporal acute subdural haematoma, bifrontal contusion, pneumocephalus CT: right temporoparietal comminuted depressed fracture, cerebral contusion
Complete recovery
Cerebral contusion and neurologic damage as a result of pressure changes Partial recovery
medical autopsy revealed a comminuted depressed fracture on the left frontal bone. There were bone fragments driven into the cranial cavity, with a lacerated tear underlying the dura. There was an acute subdural haematoma on the left cerebral hemisphere, a lacerated defect on the superior aspect of the left frontal lobe. There were yellowish exudates around the lacerated brain tissue, consistent with a local cerebral abscess with very focal purulent exudates over the meninges in this area only. Moreover, a black-coloured stone was found embedded in the lacerated defect in the left frontal lobe [10]. Kiymaz and Yilmaz reported a case of penetrating head injury by a stone in a 5-year-old boy due to a vehicle-external
816
C. Alafaci et al. / Clinical Neurology and Neurosurgery 112 (2010) 813–816
accident. The CT scan revealed a left parietal depression fracture and pneumocephalus. In the same region, an intracranial foreign object, identified as a stone, was seen [11]. Sharma et al. reported a case of a young male that sustained a head injury consequent to a fall off a running train. CT scan revealed an intracranial foreign body with a comminute skull fracture in the right frontal region. At surgery, a stone was found embedded in the right frontal lobe [12]. Chattopadhyay described the case of a 7-year-old girl that was suddenly struck on the right side of the head by a stone propelled from the rear wheel of a speeding truck. She immediately lost consciousness and died successively. Post mortem examination revealed a depressed fracture of the temporal bone with a cerebral contusion [13]. Balak et al. reported the case of a 9-yearold boy that was struck by a shapeless piece of marble. CT scan showed a midline depressed skull fracture. Surgical repair of the depressed skull fracture was performed. On the third day after the operation, the patient developed a paresis on the left side. A CT scan showed a hypodense edematous area on the left cerebral motor cortex surrounding a seemingly retained bone fragment. A magnetic resonance study revealed an incomplete obstruction of the venous flow in the superior sagittal sinus. At surgery, a marble-like stone was carefully removed [14]. Satyarthee et al. described the case of a 28-year-old man in which a piece of knife-sharpening stone penetrating into the head through right orbital roof. CT scan revealed a foreign body in right parietal region with depressed fracture of the right frontal bone and right orbital roof. There was an acute subdural haematoma and pneumoencephalus. At surgery the foreign body was removed [15]. Penetrating head injuries represent a very severe traumatic event with a high risk of complications. Rapid transportation directly to specialized centers is of the utmost urgency. Due to the high risk of infectious complications, a prophylactic wide-spectrum antibiotic treatment amenable to crossing the blood-brain barrier should be given early in patient management. The use of anticonvulsant prophylactic agents is recommended in those cases in which traumatic brain lesions are evident, such as intracerebral haemorrhage, subdural haematoma, depressed skull fracture
and neurological deficits. Rapid removal of the foreign body and bone fragments along with focal debridement of the skull, dura mater and involved parenchyma are the goals of surgical treatment. Failure to identify these events can results in significant morbidity, mortality and legal ramifications. The application of a correct multidisciplinary approach can also reduce the risk of delayed complications, especially epileptic seizures and brain abscess. References [1] Ozkan U, Kemaloglu S, Ozates M, Aydin D. Analysis of 107 civilian craniocerebral gunshot wounds. Neurosurg Rev 2002;25:231–6. [2] Levi L, Borovich B, Giulburd JN, et al. Wartime neurosurgical experience in Lebanon, 1982–85. I. Penetrating craniocerebral injuries. Isr J Med Sci 1990;26:548–54. [3] Caldicott DGE, Pearce A, Price R, Croser D, Brophy B. Not just another “head lac” low-velocity, penetrating intra-cranial injuries: a case report and review of the literature. Injury, Int J Care Injured 2004;35:1044–54. [4] Musa BS, Simpson BA, Hatfield RH. Recurrent self-inflicted craniocerebral injury: case report and review of the literature. Br J Neurosurg 1997;11:564–9. [5] Clark WC, Muhlbauer MS, Watridge CB, Ray MW. Analysis of 76 civilian craniocerebral gunshot wounds. J Neurosurg 1986;65:9–14. [6] Miller CF, Brodkey JS, Columbi BJ. The danger of intracranial wood. Surg Neurol 1977;7:95–103. [7] Kaufman HH, Schwab K, Salazar AM. A national survey of neurosurgical care for penetrating head injury. Surg Neurol 1991;36:370–7. [8] Eckstein M. The prehospital and emergency department management of penetrating head injury. Neurosurg Clin N Am 1995;6:741–51. [9] Cina SJ, Gelven PL, Nichols CA. A rock in a hard place. A brief case report. Am J Forensic Med Pathol 1995;16:333–5. [10] Bhootra BL, Bhana BD. An unusual missile-type injury caused by a stone: case report and medicolegal perspectives. Am J Forensic Med Pathol 2004;25:355–7. [11] Kiymaz N, Yilmaz N. Penetrating intracranial stone. Pediatr Neurosurg 2005;41:145–7. [12] Sharma A, Diyora B, Shah S. Stone in the brain. Indian J Neurotrauma 2006;3(2):149. [13] Chattopadhyay S. Accidental low velocity atypical missile injury to the head. Am J Forensic Med Pathol 2008;29:334–6. [14] Balak N, Aslan B, Serephan A, Elmaci N. Intracranial retained stone after depressed skull fracture. Problems in the initial diagnosis. Am J Forensic Med Pathol 2009;30:198–200. [15] Satyarthee GD, Borkar SA, Tripathi AK, Sharma BS. Transorbital penetrating cerebral injury with a ceramic stone: report of an interesting case. Neurol India 2009;57:331–3.
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Case report
Penetrating head injury by a stone: Case report and review of the literature Concetta Alafaci, Gerardo Caruso, Mariella Caffo ∗ , Alessandro A. Adorno, Daniele Cafarella, Francesco M. Salpietro, Francesco Tomasello Neurosurgical Clinic, Department of Neurosciences, Psychiatry and Anaesthesiology, University of Messina School of Medicine, Policlinico “G. Martino” via Consolare Valeria 1, 98124 Messina, Italy
a r t i c l e
i n f o
Article history: Received 31 October 2009 Received in revised form 15 April 2010 Accepted 10 June 2010 Available online 7 July 2010 Keywords: Foreign body Head trauma Intracranial stone Low velocity trauma
a b s t r a c t Traumatic intracranial penetration of foreign objects of non-missile intracranial nature rarely occurs. Haemorrhages, major vascular injury and contusions can be causes of death in early stage, epileptic seizures and infections are possible complications in later stages. Complete excision of the foreign body should be performed. Possible dural and vascular injuries should be repaired during surgical treatment. In the present study, we report a rare case of traumatic intracranial stone as a foreign object. A brief review of the literature is presented. © 2010 Elsevier B.V. All rights reserved.
1. Introduction Penetrating head injuries (PHIs) belong to the most severe traumatic brain injuries. Intracranial injuries most frequently encountered in the adult population are caused by armed weapons [1,2]. PHIs are fatal in 40% of cases because of damage to critical structures, vascular disruption, concussion blast injury, or meningitis [3,4]. Intracerebral haemorrhages, cerebral contusions and major vascular injuries are underlying factors causing death in early stages. In the present study, we report an unusual case of PHI caused by a stone, which is rarely encountered as a foreign object in intracranial traumatic injuries. 2. Case report A 19-year-old patient fell to the ground while driving his motorcycle. The boy was immediately transferred to our Department. The neurological examination revealed amnesia and psychomotor agitation with GCS 14. No other traumatic injuries were observed. A wide dermal cut was present in the right temporoparietal region. Skull X-ray showed, in right temporoparietal region, a comminuted depressed fracture with an entrapped foreign object. Cranial computed tomography (CT) with bone window and with 3D reconstructions revealed a right temporoparietal comminuted depressed fracture and the presence of a foreign object (Fig. 1A and B). A
cerebral contusion underneath the fracture was also seen (Fig. 1). Antibiotic ceftriaxone was administered daily at intravenous dose of 2 g for the first 3 days and 1 g for the remaining 3 days. In addition, we administered prophylactic anticonvulsant therapy with levitiracetam at daily dose of 1000 mg. Tetanus vaccine was also administered. The dermal cut was deeply cleansed with normal saline solution. The patient underwent immediate surgical intervention. The foreign object was visualized and identified as a stone (5 cm × 3 cm × 3 cm), embedded in a large comminuted depressed fracture (Fig. 2). The operative field was irrigated with saline and antibiotic solution. The stone was carefully removed. Comminute bone fragments were also totally removed. Through the lacerated dura layers, we observed an acute subdural haematoma that was evacuated. A cerebral contusion was evidenced and removed. The dura mater was closed with a water-tight suture. The postoperative course was uneventful and the patient recovered completely. The patient was discharged 10 days after surgery. In consideration of the large craniectomy (Fig. 3A), the patient was followed-up 3 months later for cranioplasty treatment (Fig. 3B). Cranioplasty was performed with biphasic calcium phosphate bone substitutes (Tricos® ) (Fig. 3A and B). TRICOS is constituted of 60% hydroxyapatite (HA) and 40%  tricalcium phosphate. The compound is a resorbable bioactive bone substitute, which enables the formation of new bone over time. 3. Discussion
∗ Corresponding author. Tel.: +39 090 2217167, fax: +39 090 693714. E-mail address: [email protected] (M. Caffo). 0303-8467/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.clineuro.2010.06.008
Injuries caused by objects with an impact velocity less than 100 m/s are known as non-missile injuries [5]. Penetrating head
814
C. Alafaci et al. / Clinical Neurology and Neurosurgery 112 (2010) 813–816
Fig. 1. (A) CT scan with 3D reconstructions with bone window reveals the presence of a foreign object embedded in the right temporoparietal depressed fracture. (B) Coronal CT scan with bone window shows the foreign body and the right temporoparietal comminuted depressed fracture. (C) Axial CT scan of the brain demonstrates a cerebral contusion underneath the fracture.
Fig. 2. Intraoperative image of the stone embedded in the right temporoparietal comminuted depressed fracture.
injuries by non-missile low velocity particles constitute a rare sub-group which have specific features. The primary pathology in these events is tissue laceration, whereas in missile injuries shock waves and cavitations contribute to additional tissue damage [5]. PHI in adult population usually occurs due to ballistic weapons and shrapnel fragments. PHI may also be a consequence of suicide attempts and in self-inflicted injuries. PHI may cause intra-
parenchymal and intracranial lesions during the early period and may lead to a high degree of morbidity and mortality. Miller et al. reported 42 cases with intracranial wooden pieces with a 25% of mortality rate [6]. Despite antibiotic treatment, the incidence of infectious complications was observed in 64% of cases of PHI and a brain abscess was showed in 48% [7]. Rapid debridement of these wounds is also recommended, based on both the extent of such injuries and likelihood of identifying bone fragments or intracranial residua of the projectile object. It is also necessary to take into account the risk of CSF leakage linked to the damage of the dura mater. A careful and water-tight suture can notably limit this event. The incidence of post-traumatic epilepsy in patients after PHI is estimated at about 3%. In particular, post-traumatic epilepsy represents a late sequelae in adults. Seizures are thought to occur secondary to direct traumatic injury to cerebral cortex with subsequent cerebral scarring. The presence of intraparenchymal lesions is thought to predict the highest risk of epilepsy. Anticonvulsant medication in the immediate post-injury period is thought to mitigate neuronal hyperexcitability and re-equilibrate seizure threshold [3]. In PHI, cranial bone CT is the most valuable study to detect foreign objects as small as 0.06 mm [4]. It is particularly useful in the initial evaluation of the traumatic event, because it can localize the foreign body, plot is trajectory, identify the bone defect and evaluate the extent of parenchymal injury. The foreign body penetrating the intracranial cavity is removed only by definite surgical treatment. It is crucial to prevent any involuntary movement of the foreign body which could enlarge the damaged area [8]. Surgery is also performed for the repair of cerebral or dural damage. Bony fragments must be excised. It is necessary to take into account the risk of CSF leakage or brain abscess
Fig. 3. (A) CT scan with 3D reconstructions with bone window shows the large craniectomy in the area of the depressed fracture. (B) CT scan with 3D reconstructions with bone window after the cranioplasty treatment.
C. Alafaci et al. / Clinical Neurology and Neurosurgery 112 (2010) 813–816
815
Table 1 Literature review patients. Author
Age and sex
Type of head injury
Location
Admission
Neuroradiological findings
Operative findings
Outcome
Cina
18, M
Left convex
Died
X-ray: radio-opacity on the left convex
No surgery
Victim of a gunshot
Bhootra
24, M
Penetrating stone due to felt into the ground Penetrating stone by the use of a slingshot
Left frontal
GCS 15
Died after 2 days (acute subdural haematoma, brain abscess)
Kiymaz
5, M
Left parietal
Sharma
M, age not reported
Right frontal
Unconscious patient, eye-opening in response to painful stimuli Not reported
7, F
Right temporal
Died
Balak
9, M
Penetrating stone struck to the head from a shapeless piece of marble
Midline
GCS 13, right hemiparesis
Stone embedded in the right frontal lobe Post mortem examination: right temporal depressed fracture, cerebral contusion Compression of the superior sagittal sinus
Not reported
Chattopadhyay
Penetrating stone due to vehicleexternal traffic accident Penetrating stone due to a fall off a running train Penetrating stone propelled from the rear wheel of a truck
Post mortem examination: left frontal comminuted fracture, acute subdural haematoma, brain abscess Intracranial stone in left parietal region
Satyarthee
28, M
Penetrating piece of knifesharpening stone broke during work
Right parietal
GCS 8
Enucleation of the right eyeball
GCS 15 at 6 months follow-up
Our case
19, M
Penetrating stone due to felt on the ground
Right temporoparietal
GCS 14
Fracture with embedded stone, acute subdural haematoma
Complete recovery. Cranioplasty 3 months after trauma
development, which is linked to the disruption of the dura mater barrier. In our research of relevant English medical literature in the Medline database we found only seven reported cases [9–15] (Table 1). Cina et al. described a patient with an intracranial stone which had pierced the scalp when the victim of a gunshot wound fell into the ground [9]. Bhootra and Bhana described an unusual case of a penetrating foreign body in which a piece of stone acted as a missile by the probable use of a slingshot. The patient was not admitted into the hospital and no neuroradiological studies were performed. The patient was sent home and died 2 days later. A
CT: left parietal depressed fracture, pneumocephalus CT: right frontal comminuted fracture
CT: midline depressed fracture, hypodense area on the left cerebral cortex surrounding a stone CT: right parietal depressed fracture and right orbital roof extending to right orbital wall and the ethmoid, frontotemporal acute subdural haematoma, bifrontal contusion, pneumocephalus CT: right temporoparietal comminuted depressed fracture, cerebral contusion
Complete recovery
Cerebral contusion and neurologic damage as a result of pressure changes Partial recovery
medical autopsy revealed a comminuted depressed fracture on the left frontal bone. There were bone fragments driven into the cranial cavity, with a lacerated tear underlying the dura. There was an acute subdural haematoma on the left cerebral hemisphere, a lacerated defect on the superior aspect of the left frontal lobe. There were yellowish exudates around the lacerated brain tissue, consistent with a local cerebral abscess with very focal purulent exudates over the meninges in this area only. Moreover, a black-coloured stone was found embedded in the lacerated defect in the left frontal lobe [10]. Kiymaz and Yilmaz reported a case of penetrating head injury by a stone in a 5-year-old boy due to a vehicle-external
816
C. Alafaci et al. / Clinical Neurology and Neurosurgery 112 (2010) 813–816
accident. The CT scan revealed a left parietal depression fracture and pneumocephalus. In the same region, an intracranial foreign object, identified as a stone, was seen [11]. Sharma et al. reported a case of a young male that sustained a head injury consequent to a fall off a running train. CT scan revealed an intracranial foreign body with a comminute skull fracture in the right frontal region. At surgery, a stone was found embedded in the right frontal lobe [12]. Chattopadhyay described the case of a 7-year-old girl that was suddenly struck on the right side of the head by a stone propelled from the rear wheel of a speeding truck. She immediately lost consciousness and died successively. Post mortem examination revealed a depressed fracture of the temporal bone with a cerebral contusion [13]. Balak et al. reported the case of a 9-yearold boy that was struck by a shapeless piece of marble. CT scan showed a midline depressed skull fracture. Surgical repair of the depressed skull fracture was performed. On the third day after the operation, the patient developed a paresis on the left side. A CT scan showed a hypodense edematous area on the left cerebral motor cortex surrounding a seemingly retained bone fragment. A magnetic resonance study revealed an incomplete obstruction of the venous flow in the superior sagittal sinus. At surgery, a marble-like stone was carefully removed [14]. Satyarthee et al. described the case of a 28-year-old man in which a piece of knife-sharpening stone penetrating into the head through right orbital roof. CT scan revealed a foreign body in right parietal region with depressed fracture of the right frontal bone and right orbital roof. There was an acute subdural haematoma and pneumoencephalus. At surgery the foreign body was removed [15]. Penetrating head injuries represent a very severe traumatic event with a high risk of complications. Rapid transportation directly to specialized centers is of the utmost urgency. Due to the high risk of infectious complications, a prophylactic wide-spectrum antibiotic treatment amenable to crossing the blood-brain barrier should be given early in patient management. The use of anticonvulsant prophylactic agents is recommended in those cases in which traumatic brain lesions are evident, such as intracerebral haemorrhage, subdural haematoma, depressed skull fracture
and neurological deficits. Rapid removal of the foreign body and bone fragments along with focal debridement of the skull, dura mater and involved parenchyma are the goals of surgical treatment. Failure to identify these events can results in significant morbidity, mortality and legal ramifications. The application of a correct multidisciplinary approach can also reduce the risk of delayed complications, especially epileptic seizures and brain abscess. References [1] Ozkan U, Kemaloglu S, Ozates M, Aydin D. Analysis of 107 civilian craniocerebral gunshot wounds. Neurosurg Rev 2002;25:231–6. [2] Levi L, Borovich B, Giulburd JN, et al. Wartime neurosurgical experience in Lebanon, 1982–85. I. Penetrating craniocerebral injuries. Isr J Med Sci 1990;26:548–54. [3] Caldicott DGE, Pearce A, Price R, Croser D, Brophy B. Not just another “head lac” low-velocity, penetrating intra-cranial injuries: a case report and review of the literature. Injury, Int J Care Injured 2004;35:1044–54. [4] Musa BS, Simpson BA, Hatfield RH. Recurrent self-inflicted craniocerebral injury: case report and review of the literature. Br J Neurosurg 1997;11:564–9. [5] Clark WC, Muhlbauer MS, Watridge CB, Ray MW. Analysis of 76 civilian craniocerebral gunshot wounds. J Neurosurg 1986;65:9–14. [6] Miller CF, Brodkey JS, Columbi BJ. The danger of intracranial wood. Surg Neurol 1977;7:95–103. [7] Kaufman HH, Schwab K, Salazar AM. A national survey of neurosurgical care for penetrating head injury. Surg Neurol 1991;36:370–7. [8] Eckstein M. The prehospital and emergency department management of penetrating head injury. Neurosurg Clin N Am 1995;6:741–51. [9] Cina SJ, Gelven PL, Nichols CA. A rock in a hard place. A brief case report. Am J Forensic Med Pathol 1995;16:333–5. [10] Bhootra BL, Bhana BD. An unusual missile-type injury caused by a stone: case report and medicolegal perspectives. Am J Forensic Med Pathol 2004;25:355–7. [11] Kiymaz N, Yilmaz N. Penetrating intracranial stone. Pediatr Neurosurg 2005;41:145–7. [12] Sharma A, Diyora B, Shah S. Stone in the brain. Indian J Neurotrauma 2006;3(2):149. [13] Chattopadhyay S. Accidental low velocity atypical missile injury to the head. Am J Forensic Med Pathol 2008;29:334–6. [14] Balak N, Aslan B, Serephan A, Elmaci N. Intracranial retained stone after depressed skull fracture. Problems in the initial diagnosis. Am J Forensic Med Pathol 2009;30:198–200. [15] Satyarthee GD, Borkar SA, Tripathi AK, Sharma BS. Transorbital penetrating cerebral injury with a ceramic stone: report of an interesting case. Neurol India 2009;57:331–3.