Injury: the British Journal of Accident Surgery (1990) Vol. 21/No.

414

6

Penetrating craniocerebral injury caused by a metal rod: an unusual case report E. Regev*, S. Constantim -1, S. Pornera&, Hadassah University

M. Selat and M. Shalitl

Hospital, Jerusalem, Israel

Itttfoduction Penetrating injuries of the cranium and the face are common occurrences in war but less common in civilian life. Usually they are caused by metallic fragments (bullets, car metal fragments, etc.) biological tissue fragments (bone, teeth), or by pencils and children’s toys (Mosberg et al., 1960; Sherman, 1960; Foy and Sharr, 1980). The majority of war injuries are high-velocity penetration wounds with their inherent complications, while most of the civilian injuries are of the low-velocity type. We encountered a patient who sustained a penetrating transfaciocranial injury. The treatment of this case illustrates the usefulness of the computed tomography scanning as an adjunct in the detection and localization of intracranial foreign bodies.

Case report A 15-year-old boy was brought to the Hadassah University Hospital emergency room after he had fallen from a tree. We were unable to elicit a full history of the injury. He had apparently fallen onto a rod that was stuck in the ground. Examination showed a metal rod which had entered his face in the left maxillary infraorbital region, crossed the midline and exited the skull in the right postauricular region above the mastoid process (Figure I). There were no further signs of trauma. He was fully conscious and the neurological examination was normal. The Glasgow Coma scale was 14. He was prepared for general anaesthesia and then taken to the CT (Elscint 2400) where the trajectory of the rod was demonstrated using an unenhanced study. The relationship to the major cerebral vessels was shown by an enhanced study (Figure 2). The rod entered the left side of the face between the maxilla and the orbit, and crossed the midline at the vomer. It passed through the right temporal lobe and exited the skull at the parietal-mastoid junction. The circle of Willis, the carotids and the brain stem were spared. There was no sign of bleeding in the brain tissue. In the CT room, under general anaesthesia via oral tracheal intubation, the irregular distal end of the rod was filed and smoothed using a low-speed dental drill and thereafter the rod was manually extracted via the entry wound. An immediate and 3 h

follow-up CT scans demonstrated a small contusion of the right temporal lobe. The patient was extubated the next morning and left the hospital after 3 days with no neurological sequelae. During the course of the hospital stay he received chloramphenicol 3 g/day and Dantoin 300 mg/day that was continued for a further 2 weeks.

‘Department of Oral and Maxillofacial Surgery. tDepartment of MaxillofaciaI Prosthetics. IDepartment of Neurosurgery. 0 1990 Butterworth-Heinemann 0020-1383/90/060414-G2

Ltd

Figure 1. The boy in the emergency room. The arrow points at the distal end above the right mastoid.

Discussion Head injuries sustained in war are usually characterized by a relatively high-velocity penetration of metal objects (bullets, hand grenade shrapnel, etc.), which cause massive destruction of brain tissue. The extent of the destruction is greater than the diameter of the foreign body. Most of the penetrating head injuries occurring in civilian life are caused by low-velocity foreign bodies acting as ‘missiles’. Many children and young adults have been injured by innocent objects, such as toys, by scissors, nails, fishing harpoons and construction materials (Mosberg and Sharett, 1960; Dooling et al., 1967; Ljunggren and Stroemblad, 1977; Chaeghulam and Ojukwa, 1980; Doran et al., 1982; Haworth and Villiers, 1988). These types of injuries can lead to meningitis, brain abscesses, intracranial hematoma and neurological deficit (Fey and Sham 7980). The neurological deficit is dependent on the location of the injury and can be variable. It may be non-existent as in our case and in a similar case described by Doron et al. (1982). It may even manifest 20 years later as reported by Ashkenazi et al. (1961). In our case, as in that described by Doron et al. (1982), no complications have developed during 5 months of follow-up. Our patient arrived fully conscious and was discharged with no apparent neurological deficit, probably because the location of the brain injury was in the inferior portion of the right temporal lobe, a relatively ‘innocent’ area. The use of the CT scan was most advantageous in demonstrating the trajectory of the rod before its extraction and in verifying the lack of haematoma immediately after the procedure. A multidisciplinary team approach (neurosurgeons,

Case reports

Figure 2. Serial, high resolution

CT scans demonstrating

the precise trajectory

anaesthetists, oral and rnaxillofacial surgeons) helped to expedite the treatment rendered to the patient. The child was anaesthetized in the CT room and both the neurosur-

geons and oral and maxillofacial surgeons were able to carry on with the extraction of the rod.

References Ashkenzi H. M., Kozary 2. Z. and B&am J. (1961) Sewing needle in the brain with delayed neurological manifestations. 1. Neurosurg. 18, 554. Chaeghulam S. C. and Ojukwu J. 0. (1980) Unusual craniocerebral injuries from nailing. Sttrg. Neural. 14,393. Dooling J. A., Bell W. E. and Whitehurst W. R. (1967) Penetrating skull wound from a pair of scissors. 1. Neurosurg. 26, 636. Doron Y., Gruszkiewicz and Peyser E. (1982) Penetrating craniocerebral injuries due to unusual foreign bodies. Neurosurg. Rev. 5, 35.

of the metal rod.

Foy P. and Sharr M. (1980) Cerebral abscesses in children after pencil-tip injuries. Lancet 2, 662. Haworth C. S. and Villiers J. C. (1988) Stab wound to the temporal fossa. Nearosurg. 23 (4), 431. Ljunggren B. and Stroemblad J. G. (1977) The good old method of the nail. Surg. Neural. 7, 288. Mosberg W. H. Jr and Sharett J. 0. (1960) Penetrating wounds of skull due to metal axle of collapsible toy cars. ]AMA 173,804. Sherman I. J. (1960) Brass foreign body in the brain stem. 1. Neurosurg. 17.483.

Paper accepted

7 February

1990.

Requests for reprints should be &resd to: Dr Eran Regev, Department of Oral and Maxillofacial Surgery, Hadassah Medical Center, Jerusalem 91120, Israel.

Penetrating craniocerebral injury caused by a metal rod: an unusual case report.

Injury: the British Journal of Accident Surgery (1990) Vol. 21/No. 414 6 Penetrating craniocerebral injury caused by a metal rod: an unusual case r...
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