unusual penetrating head injury. hazem h kuheil mourtaga. · hazem h kuheil *, basel s baker 1,...

Annals of Alquds Medicine Volume/Issue 9: 22-26 (1434, 2013)

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Case report

Unusual Penetrating Head Injury.

Hazem H Kuheil* , Basel S Baker1, Amjad Z2,Bassam M3, Shaban

Mourtaga. Neurosurgical Department, Shifa Compound Center,Gaza , Palestine.

Abstract

Introduction: Penetrating head injury (PHI) remains an important issue in our neurological work,

even in modern neurosurgery1. In Gaza PHI is a frequent type of head injury. We present some

interesting and unusual cases of PHI with very good surgical results.

Clinical histories: Two patients had PHI in form of knife and metallic sharp fork. They exhibited

signs of increased ICP (headache, vomiting, and deterioration in consciousness.). Brain CT revealed

evidence of FBs intracranially.

Management: craniotomy and successful removal of the FBs were done without complications.

Conclusion: PHI with such FBs needs urgent craniotomy and removal of the FBs with coverage of

antibiotics and antiepileptic drugs.

First Case : Male patient, 41 years old, presented to the ER in Shifa Hospital, Gaza , after 30 minutes

of stab injury to the head (assault). He was also suffering of vomiting , headache and was drowsy,

GCS 14. CT of head showed a knife penetrating into the left occipital lobe above the protuberance

and 1cm left to midLine and 4cm intracranially (figures 1, 2, 3). Intubation was done in the prone

position to prevent movement of the knife. The length of the knife was approximately 60cm.

Ceftriaxone 1 gram, Gentamycine 80mg and phenytoin was given preoperatively.

Surgical procedure: In the prone position, the operator area was shaved and sterilized with povidone

–iodine Sol. 10% (figure 4). Horse shoe incision was done, then craniotomy through 4 Burr holes and

removal of the bone flap with knife. The brain was contused and bleeding from the tract seen and

from a small laceration from the end of superior sagittal sinus, hemostasis was achieved using

bipolar, surgicel and gelfoam. Dural repair was performed after washing the field with NS and

H2O2. Banners drain and repositioning the bone flap was then carried out. The patient was

transferred to ICU and he kept under sedation for 24 hours. The patient has started to improve, after

24 hours of surgery, and gained full consciousness and no residual deficit was noted (figures 5-6).

The surgical wound healed without complications. A follows up head CT 3 days later was normal

and the patient was discharged on the 6th

day of surgery. Follow up after 1 week and 1,3, 6 and 12

months revealed that the patient has recovered fully.

*Neurosurgeon and corresponding author, 1

head of surgery department, 2&3

residents in surgery department.


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Figures 1-6: (1) The patient as seen during CT scanning. (2 -3) CT brain of the patient. (4) The patient on the

operative table in prone position. (5) The patient postoperative with incision and benrose drain. (6) The patient after

5 days post surgery.

.2 Figure .1 Figure

.3 Figure .4 Figure

.5 Figure .6 Figure


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Second Case : Male patient, 15 years old , presented to the ER in Shifa Hospital Gaza , after 20 min

of stab injury to the head (assault). He was suffering from repeated vomiting, headache, dizziness

and was drowsy with GCS 13 (figure 7). Head CT showed a fork in the left temporal retroauricular

area with its sharp end 5cm intracranially (figure 8). There was bleeding from the entrance wound

and left mastoid fracture was noted. The CT and intubation were done in a lateral supine position to

prevent movement of the fork. The length of the fork was approximately 20cm. Ceftriaxone500mg,

metronedazole200mg and phenytoin was given preoperatively.

Surgical procedure: patient was put in the right lateral position, the operative area was shaved and

sterilized with povidone –iodine sol. 10% (figure 9). Question mark incision was done and

craniotomy through 4 Burr holes was undertaken. The bone flap with the fork down was then

removed. The brain surface was contused and bleeding from the fork’s tract and from the right

sigmoid sinus was seen together with penetrated mastoid fracture. There was no otological lesion and

middle and inner ear was normal. Hemostasis was achieved using bipolar and surgicel, sinus and

dural repair was performed after washing the field with NS and H2O2. Hemovac drain and

repositioning the bone flap was done. Fracture of mastoid bone was treated conservatively. Patient

was then transferred to the ICU and kept under sedation for 24 hours. Following that, the patient has

improved and was fully conscious and well orientated on the second day after surgery and without

any neurological deficit (fig. 14). The surgical wound healed without complications.

Follows up head CT, after 3 days was normal. The patient was then discharged on the 7th

day

following surgery. Follow up after 1 week and 1,3, 6 and 12 months revealed that the patient has

fully recovered.

Figures 7-8: (7) The patient in ER. (8) The patient on the operating table.

.7 Figure .8 Figure


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Figures 9-11: (9) CT temporal bone with mastoid bone fracture. (10) The patient with introperative incision. (11) Assault

weapon showing degree of penetration.

.9 Figure

.10 Figure .11 Figure


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Discussion:

PHI remains an important issue in neurological work, even in modern neurosurgery1, and is still a

widespread problem that happens mainly among young individuals. According to the literature, more

stab wounds of the brain occur through the orbit or temporal region2, due to thinning of the bone in

these areas. This sort of injury appears to be commoner in males and due to male to male violence.

Force needed to penetrate the skull is believed to be about 5 times higher in the temporal region and

11 times higher in the parietal region than the force needed to perforate the skin3-4

. CT scans are the

most appropriate investigation tools in this sort of injuries5. Cerebral hemorrhage, meningitis and

abscess formation are the most common complications with their consquetive morbidity and

mortality6. Therefore, the use of broad spectrum antibiotics is essential in such cases. Prophylactic

antiepileptic drugs for 1 week was used. The size of the craniotomy depends on the need to evacuate

haematoma during surgery7. In some cases of PHI, venous sinus injury is present as is the case our

two cases.

These FBs should be removed immediately in a qualified Neurosurgical center. Patients treated in

this manner have less morbidity and short hospital stay.

Acknowledgments

Special appreciation for Ministry of Health, administration of Shifa Hospital and all staff members of

neurosurgery , anesthesia and ICU departments –Shifa Hospital .

References

1. A. Lordache , J. M. Kaya. J. R. allies. B. allies. A rare case of severe craniocerebral trauma with

penetrating head injury , Romanian Neurosurgery (2011)-18 -1 ;77-81 .

2. V. J. DiMaio .Forensic Pathology , 2nd

Ed., CRC Press , Boca Raton, 2001. p. 207.

3. W. Weber. quantitative investigation concerning penetrating wounds of the human skull.

Z.Rechtsmetd.74 (1974)111-116.

4. P.T.O, Callaghan M,D. Jones, D.S. James. S. Leadbatter, C. A. Holt, L.D.M. Nokes. Dynamics

of stab wounds, the force required for penetration of various cadaveric tissues, Forensic Sci. Int.

.1041 (1999) 173-178.

5. Naim-Ur Rahmanet et al. Orbitocranial injury .Case reports. International Ophalmolgy 21;1997.

6. Muyukan E, Fleck BW, Cullen JF, WhiteJR. Case of Penetrating orbito-cranial injury. BrJ

Ophalmol.1991; 75;374.

7. Gil, J.J.,Acosta, C..Proceder quirurgico aplicado a un paciente accidantado con arpon

intracranial. 1995;3:28-35.

unusual penetrating head injury. hazem h kuheil mourtaga. · hazem h kuheil *, basel s baker 1,...

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