Penetrating trauma of the posterior fossa resulting in Vernet's syndrome and internuclear ophthalmoplegia

Brown-Sequard syndrome associated with a spinal cord injury caused by a retained screwdriver: A case report and literature review

Background:

Nonmissile penetrating spine injury (NMPSI) represents a small percent of spinal cord injuries (SCIs), estimated at 0.8% in Western countries. Regarding the causes, an NMPSI injury caused by a screwdriver is rare. This study reports a case of a retained double-headed screwdriver in a 37-year-old man who sustained a stab injury to the back of the neck, leaving the patient with a C4 Brown-Sequard syndrome (BSS). We discuss the intricacies of the surgical management of such cases with a literature review.

Methods:

PubMed database was searched by the following combined formula of medical subjects headings, (MESH) terms, and keywords: (((SCIs [MeSH Terms]) OR (nmpsi [Other Term]) OR (nonmissile penetrating spinal injury [Other Term]) OR (nonmissile penetrating spinal injury [Other Term])) AND (BSS [MeSH Terms])) OR (BSS [MeSH Terms]).

Results:

A total of 338 results were found; 258 were case reports. After excluding nonrelated cases, 16 cases were found of BSS induced by spinal cord injury by a retained object. The male-to-female ratio in these cases is 11:5, and ages ranged from 11 to 72. The causes of spinal cord injury included screwdrivers in three cases, knives in five cases, and glass in three cases. The extracted data were analyzed.

Conclusion:

Screwdriver stabs causing cervical SCIs are extremely rare. This is the first case from Iraq where the assault device is retained in situ at the time of presentation. Such cases should be managed immediately to carefully withdraw the object under direct vision and prevent further neurological deterioration.

Intracranial foreign material granulomas after cranial surgery

BACKGROUND

Various synthetic materials are used in neurosurgery and left in place intentionally during surgery for several purposes such as hemostasis, dural closure, or cranioplasty. Although leaving such substances in surgical sites is considered safe, in general, foreign body granuloma may occur months or years after intracranial surgery. Thus, far relatively little is known about treatment and outcome of such lesions.

METHODS

A systematic review of 3466 histopathological examinations after cranial surgeries achieved over a 13-year period was performed. After excluding patients with Teflon granulomas or infection, a total of 12 patients with foreign body granulomas induced by synthetic material used in a prior surgery were identified. Patient records, imaging studies, and histopathological data were analyzed. Furthermore, postoperative outcome was assessed.

RESULTS

Mean age at the second surgery was 51 years (range, 11-68 years). The median time between the primary and the secondary surgery was 13 months (range, 1-545 months). Eight patients (75%) presented with signs and symptoms related to the foreign body granulomas. Total resection of the foreign body granulomas was performed in all patients. The granulomas were induced by oxidized cellulose polymer (n = 6), suture material (n = 3), Gelfoam (n = 1), methylmethacrylate (n = 1), and bone wax (n = 1). The mean postoperative follow-up time was 54 months (range 1-137 months). There was symptomatic improvement in all instances. Imaging studies did not demonstrate any recurrence.

CONCLUSION

Despite its rarity, foreign body granuloma should be taken into consideration in the differential diagnosis of intracranial mass lesions especially in cases of suspected tumor recurrence after prior surgery. The pathogenesis of foreign body granuloma still needs further clarification. Our study demonstrates that they have good prognosis after surgical removal.

Traumatic Brain Injury Due to Screwdriver Assaults: Literature Review and Case Report

Penetrating head injuries due to the use of screwdrivers as wounding agents in acts of interpersonal violence seldom occur. The aim of this article is to update and summarize the relevant literature on penetrating craniocerebral screwdriver stab wounds and to report a new case of screwdriver assault. A number of studies were reviewed to investigate the incidence, distribution, common findings, mechanism of injury, differential diagnostic criteria, complications, treatment, and prognosis of craniocerebral screwdriver stab injuries. It was observed that the degree of traumatic severity depends on the cross-sectional area of the screwdriver and the anatomical region of injury. Craniocerebral screwdriver injuries are mainly cases of interpersonal violence and the mortality rate is approximately 47.6%. In 23.8% of the incidents, the trauma is overlooked on admission because of the small entry wound and, thus, the severity of the injury is not initially appreciated.

A stab in the back with a screwdriver: a case report

Background

Stabbings infrequently produce spinal injury. However, the use weapons other than blades can overcome this natural defence barrier.

Case Presentation

We present a spinal injury produced by a screwdriver, its management and a review of the literature.

Conclusion

This case highlights the need for clinical vigilance, including in those who appear stable and a senior multidisciplinary approach to each individual case.

Traumatic unilateral internuclear ophthalmoplegia

A 23-year-old man was admitted for a closed head injury following a fall from a height of 5 meters from a ladder. Because of a C-7 burst fracture, a halo and halo vest were applied approximately 9 hours following the fall. Approximately 21 hours after the accident, the patient complained of diplopia. On neuro-ophthalmology evaluation, a unilateral internuclear ophthalmoplegia was noted. MRI of the brain, performed 3 days after application of the halo and vest, showed a small infarct at the posterior aspect of the inferior midbrain, slightly left of midline. At 9.5 weeks there was 90% improvement of the internuclear ophthalmoplegia noted. Of the reported cases in the medical literature of traumatic internuclear ophthalmoplegia, 30 (83.33%) cases were male and 6 (16.67%) were female. The mean age was 31.7. 54% of the cases were bilateral; 46% unilateral. Mechanisms include: motor vehicle accident: 28 (41.79%), fall: 7 (10.45%), blunt trauma: 11 (16.42%), penetrating trauma 1: (1.49%), bike accident 3: (4.48%), other: 1 (1.49%), Unknown: 16 (23.88%).

Unrecognized Intracerebral Glass Particle Mimicking Cavernoma: Case Report

OBJECTIVE AND IMPORTANCE:

Although the presence of a foreign body in the cranium after a head injury is a well-known entity, cases of retained intracranial foreign bodies causing a delayed onset of neurological symptoms are rare. To our knowledge, an unrecognized intracerebral glass particle mimicking a cavernoma has not been previously reported in the literature.

CLINICAL PRESENTATION:

We report a unique case regarding an intracranial foreign body. A 39-year-old patient presented with new-onset epilepsy. The patient had no history of trauma. According to the magnetic resonance imaging findings and the patient's clinical course, the responsible lesion was considered to be a temporal cavernoma.

INTERVENTION:

During the operation, surprisingly, a glass particle was found within the temporal lobe. The glass had penetrated the cranium during a minor head injury and had remained undetected for 33 years. The patient was seizure-free without medication during 3 years of follow-up.

CONCLUSION:

Intracranial small foreign bodies can be difficult to diagnose, especially in patients with no history or a vague history of head trauma. Patients with long-standing retained foreign bodies may remain clinically well until complications arise. Intracranial foreign bodies may mimic other pathologies clinically and radiologically.