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Cook R, Zima L, Khazaal J, Williams J. Low-velocity penetrating brain injury: a review of the literature and illustrative case. Brain Inj 2024; 38:668-674. [PMID: 38555515 DOI: 10.1080/02699052.2024.2336067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/22/2024] [Indexed: 04/02/2024]
Abstract
INTRODUCTION Low-velocity penetrating brain injury (LVPBI) is a class of brain injury where a foreign object violates the skull and damages the brain. Such injuries are rare and consequently understudied. CASE As such, we report an illustrative case of a 29-year-old female with a dense, plastic spike penetrating her right orbit and into her midbrain. After assessment with a CT scan and angiography, the object was removed with careful attention to possible vascular injury. The patient had an uncomplicated post-operative course and received antibiotic and antiepileptic prophylaxis. She was discharged on post-operative day 5, experiencing only mild left-sided weakness. DISCUSSION Common concerns regarding LVPBI include infection, post-traumatic epilepsy, and vascular injury. A review of published LVPBI cases over the past 20 years demonstrated that most cases (55.2%) are due to accidents. Of patients undergoing surgery, 43.4% underwent a craniotomy, and 22.8% underwent a craniectomy. Despite the grave nature of LVPBI, only 13.5% of the patients died. Additionally, 6.5% of patients developed an infection over their clinical course. CONCLUSION In all, more reported cases further paint a picture of the current state of management and outcomes regarding LVPBI, paving the way for more cohesive guidelines to ensure the best possible patient outcomes.
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Affiliation(s)
- Richard Cook
- Department of Neurosurgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Laura Zima
- Department of Neurosurgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jawad Khazaal
- Department of Neurosurgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - John Williams
- Department of Neurosurgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA
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Appelbaum RD, Farrell MS, Gelbard RB, Hoth JJ, Jawa RS, Kirsch JM, Mandell S, Nohra EA, Rinderknecht T, Rowell S, Cuschieri J, Stein DM. Antibiotic prophylaxis in injury: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document. Trauma Surg Acute Care Open 2024; 9:e001304. [PMID: 38835634 PMCID: PMC11149135 DOI: 10.1136/tsaco-2023-001304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/11/2024] [Indexed: 06/06/2024] Open
Affiliation(s)
- Rachel D Appelbaum
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael S Farrell
- Department of Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Rondi B Gelbard
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - J Jason Hoth
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Randeep S Jawa
- Department of Surgery, Stony Brook University, Stony Brook, New York, USA
| | - Jordan M Kirsch
- Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Samuel Mandell
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eden A Nohra
- Department of Surgery, University of Colorado, Denver, Colorado, USA
| | | | - Susan Rowell
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Joseph Cuschieri
- Department of Surgery at ZSFG, University of California San Francisco, San Francisco, California, USA
| | - Deborah M Stein
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
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Sharma M, Dhagat P, Kumar A. Delayed Cerebral abscess following a retained shrapnel. Med J Armed Forces India 2023; 79:117-120. [PMID: 36605354 PMCID: PMC9807653 DOI: 10.1016/j.mjafi.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/26/2020] [Indexed: 02/01/2023] Open
Abstract
Retained foreign bodies following penetrating brain injuries continue to pose therapeutic dilemmas. Previously used aggressive approach involving extensive wound debridement and removal of foreign bodies caused additional neurological deficit with higher mortality. Less aggressive approach used more recently involving decompressive craniectomy has lead to higher incidence of retained foreign bodies with potential of infective sequelae. We describe one such case where, in presence of a retained foreign body, an intracranial abscess formed after a gap of 17 yrs. The case has peculiar radiological and morphological findings.
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Affiliation(s)
- Manish Sharma
- Senior Adviser (Surgery & Neurosurgery), Army Hospital (R&R), Delhi Cantt, India
| | - P.K. Dhagat
- Brig/i/c Adm, Command Hospital (Northern Command), Udhampur, India
| | - Anil Kumar
- Senior Adviser (Surgery & Neurosurgery), Command Hospital (Northern Command), Udhampur, India
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Antibiotic prophylaxis in penetrating traumatic brain injury: analysis of a single-center series and systematic review of the literature. Acta Neurochir (Wien) 2023; 165:303-313. [PMID: 36529784 PMCID: PMC9922212 DOI: 10.1007/s00701-022-05432-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/19/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Penetrating traumatic brain injury (pTBI) is an acute medical emergency with a high rate of mortality. Patients with survivable injuries face a risk of infection stemming from foreign body transgression into the central nervous system (CNS). There is controversy regarding the utility of antimicrobial prophylaxis in managing such patients, and if so, which antimicrobial agent(s) to use. METHODS We reviewed patients with pTBI at our institution and performed a PRISMA systematic review to assess the impact of prophylactic antibiotics on reducing risk of CNS infection. RESULTS We identified 21 local patients and 327 cases in the literature. In our local series, 17 local patients received prophylactic antibiotics; four did not. Overall, five of these patients (24%) developed a CNS infection (four and one case of intraparenchymal brain abscess and meningitis, respectively). All four patients who did not receive prophylactic antibiotics developed an infection (three with CNS infections; one superficial wound infection) compared to two of 17 (12%) patients who did receive prophylactic antibiotics. Of the 327 pTBI cases reported in the literature, 216 (66%) received prophylactic antibiotics. Thirty-eight (17%) patients who received antibiotics developed a CNS infection compared to 21 (19%) who did not receive antibiotics (p = 0.76). CONCLUSIONS Although our review of the literature did not reveal any benefit, our institutional series suggested that patients with pTBI may benefit from prophylactic antibiotics. We propose a short antibiotic course with a regimen specific to cases with and without the presence of organic debris.
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Al-Alousi HM, Al-Kubaisi KT, Ismail M, Al-Ageely TA, Abdulameer AO, Aluaibi SA, Al-Taie RH, Hoz SS. Transbasal penetrating traumatic brain injury caused by a rifle rod: A case report. Surg Neurol Int 2022; 13:555. [PMID: 36600737 PMCID: PMC9805597 DOI: 10.25259/sni_695_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background Penetrating traumatic brain injury (TBI) caused by a low-velocity object is a rare entity with a potential range of critical complications. Case Description We report a unique case of a 30-year-old male presenting with penetrating TBI caused by a rifle's cleaning rod. The rod passes through the left nostril to reach the frontal lobe after transgressing the sella turcica. A cranial computed tomography scan shows the extension of brain damage and the trajectory of the rod with no evidence of an associated vascular injury. Surgical removal of the rifle rod was performed using a transnasal approach by a multidisciplinary with the postoperative course went uneventfully. Conclusion Transbasal penetrating TBI through the nose is an extremely rare entity. This type of head injury carries its own peculiarities that deviate from the classic treatment algorithms.
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Affiliation(s)
| | - Kamal T. Al-Kubaisi
- Departement of Neurosurgery, College of Dentistry, Al-Anbar University, Al-Anbar, Iraq
| | - Mustafa Ismail
- Departement of Neurosurgery, College of Medicine, University of Baghdad, Iraq,,Corresponding author: Mustafa Ismail, Department of Neurosurgery, College of Medicine, University of Baghdad, Baghdad, Iraq.
| | - Teeba A. Al-Ageely
- Departement of Neurosurgery, College of Medicine, University of Baghdad, Iraq
| | - Aanab O. Abdulameer
- Departement of Neurosurgery, College of Medicine, University of Baghdad, Iraq
| | - Sajjad A. Aluaibi
- Departement of Neurosurgery, College of Medicine, University of Mustansiriyah, Baghdad, Iraq
| | - Rania H. Al-Taie
- Departement of Neurosurgery, College of Medicine, University of Mustansiriyah, Baghdad, Iraq
| | - Samer S. Hoz
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, United States
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Surgical Antimicrobial Prophylaxis in Neonates and Children Undergoing Neurosurgery: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:antibiotics11070856. [PMID: 35884111 PMCID: PMC9311924 DOI: 10.3390/antibiotics11070856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/17/2022] [Accepted: 06/22/2022] [Indexed: 11/25/2022] Open
Abstract
Pediatric neurosurgery is a highly specialized branch of surgery in which surgical site infections (SSIs) are potentially serious complications that can also adversely affect a good surgical outcome, compromising functional recovery and, in some cases, even putting the patient’s life at risk. The main aim of this consensus document is to provide clinicians with a series of recommendations on antimicrobial prophylaxis for neonates and children undergoing neurosurgery. The following scenarios were considered: (1) craniotomy or cranial/cranio-facial approach to craniosynostosis; (2) neurosurgery with a trans-nasal-trans-sphenoidal approach; (3) non-penetrating head injuries; (4) penetrating head fracture; (5) spinal surgery (extradural and intradural); (6) shunt surgery or neuroendoscopy; (7) neuroendovascular procedures. Patients undergoing neurosurgery often undergo peri-operative antibiotic prophylaxis, with different schedules, not always supported by scientific evidence. This consensus provides clear and shared indications, based on the most updated literature. This work has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies, and represents, in our opinion, the most complete and up-to-date collection of recommendations on the behavior to be held in the peri-operative setting in this type of intervention, in order to guide physicians in the management of the patient, standardize approaches and avoid abuse and misuse of antibiotics.
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Schlag H, Neuhoff J, Castein J, Hoffmann C, Kandziora F. Rupture of the Superior Sagittal Sinus in Penetrating Head Injury-Management of a Rare Trauma Mechanism. J Neurol Surg Rep 2022; 83:e3-e7. [PMID: 35028277 PMCID: PMC8747896 DOI: 10.1055/s-0041-1742103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/19/2021] [Indexed: 11/13/2022] Open
Abstract
Civilian penetrating head injury caused by foreign objects is rare in Germany (Europe), but can result in complex neurovascular damage. We report on a patient who in suicidal intent inflicted on himself a penetrating brain injury near the vertex with a captive bolt gun. A laceration at the junction of the middle to the posterior third of the superior sinus occurred by bolt and bone fragments leading to critical stenosis and subsequent thrombosis. Upon surgery, the proximal and distal sinus openings were completely thrombosed. The sinus laceration was closed by suture and the intraparenchymal bone fragments were retrieved. Postoperative angiography disclosed persistent occlusion of the superior sagittal sinus. The patient did not develop any symptoms due to venous congestion (edema, hemorrhage), suggesting sufficient collateral venous outflow. The patient completely recovered despite the complexity of the lesion.
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Affiliation(s)
- Holger Schlag
- Centre for Spinal Surgery and Neurotraumatology, BG Unfallklinik Frankfurt am Main GmbH, Germany
| | - Jonathan Neuhoff
- Centre for Spinal Surgery and Neurotraumatology, BG Unfallklinik Frankfurt am Main GmbH, Germany
| | - Jens Castein
- Centre for Spinal Surgery and Neurotraumatology, BG Unfallklinik Frankfurt am Main GmbH, Germany
| | - Christoph Hoffmann
- Centre for Spinal Surgery and Neurotraumatology, BG Unfallklinik Frankfurt am Main GmbH, Germany
| | - Frank Kandziora
- Centre for Spinal Surgery and Neurotraumatology, BG Unfallklinik Frankfurt am Main GmbH, Germany
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Abstract
A 30-year-old man walked into the emergency department after a suicide attempt by firing a nail from a pneumatic nail gun directed at his left temple. He was haemodynamically stable and neurologically intact, able to recall all events and moving all extremities with a Glascow Coma Scale of 15. CT of the brain showed a 6.3 cm nail in the right frontal region without major intracerebral vessel disruption. He was taken to the operating room for left temporal wound washout, debridement of gross contamination and closure with titanium cranial fixation plate. The foreign body was not accessible on initial surgical intervention and was left in place to define anatomy and plan for subsequent removal. Thin slice CT images were used to create 3D reconstructions to facilitate stereotactic navigation and foreign body removal via right craniotomy the following day. The patient tolerated the procedures well and recovered with full neurological function.
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Affiliation(s)
- Roger Chen Zhu
- Department of Surgery, New York-Presbyterian Queens, Flushing, New York, USA
| | | | - Miroslav Kopp
- Department of Surgery, New York-Presbyterian Queens, Flushing, New York, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Ning Lin
- Department of Surgery, New York-Presbyterian Queens, Flushing, New York, USA .,Department of Surgery, Weill Cornell Medical College, New York, New York, USA
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Marut D, Shammassian B, McKenzie C, Adamski J, Traeger J. Evaluation of prophylactic antibiotics in penetrating brain injuries at an academic level 1 trauma center. Clin Neurol Neurosurg 2020; 193:105777. [PMID: 32197146 DOI: 10.1016/j.clineuro.2020.105777] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Infections from penetrating brain injuries (PBI) lead to higher morbidity and mortality rates. The results of this research will be evaluated to develop institutional guideline for antibiotic prophylaxis in this patient population. The objective was to characterize the prophylactic antibiotic usage for patients presenting with PBI. PATIENTS AND METHODS This retrospective chart review included patients with a PBI identified through the institution's trauma center registry between December 2015 and July 2018. The primary outcome was the proportion of patients that received prophylactic antibiotics. Secondary outcomes included antibiotic administration timing, selection and duration of antibiotic regimens, infection rates and patient outcomes. RESULTS The study population included 33 patients, with 82 % males and an average age of 32 years. The most common mechanism of injury was a gunshot wound (94 %). Of the 33 patients, 24 (73 %) received at least one dose of prophylactic antibiotics. The median time to antibiotic administration was 52.8 min (IQR, 18-120), while the median duration of prophylaxis was 24 h (IQR, 7-84). The most common antibiotic regimen was a single cefazolin dose, with the next most common regimen included scheduled ceftriaxone and metronidazole. Overall, there were no documented central nervous system or skin and soft tissue infections during the initial admission, while 4 patients (12 %) were treated for pneumonia. Survivors (67 %) had a median hospital length of stay of 5.8 days. CONCLUSION The median duration of prophylaxis was shorter than the current data suggesting antibiotics for 5 days; however, there were no documented central nervous system infections, which is less than previously reported in the literature.
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Affiliation(s)
- Danielle Marut
- Department of Pharmacy, Cleveland Clinic Avon Hospital, Avon, OH, USA.
| | - Berje Shammassian
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christina McKenzie
- Department of Pharmacy, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John Adamski
- Department of Trauma Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jessica Traeger
- Department of Pharmacy, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Bolatkale M, Acara AC. The intracranial number of foreign bodies as a predictor of mortality after penetrating brain injury. Am J Emerg Med 2018; 37:433-438. [PMID: 29887193 DOI: 10.1016/j.ajem.2018.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/31/2018] [Accepted: 06/01/2018] [Indexed: 10/14/2022] Open
Abstract
INTRODUCTION Penetrating brain injury (PBI) is the most lethal form of traumatic brain injury, which is a leading cause of mortality. PBI has a mortality rate of 23%-93% and 87%-100% with poor neurological status. Despite the use of various prognostic factors there is still a need for a specific prognostic factor for early prediction of mortality in PBI to reduce mortality and provide good outcomes with cost-effective surgical treatments. The aim of this study was to investigate the predictive value of the number of intracranial foreign bodies (FBs) on mortality in PBI in the Emergency Department. METHODS The study included 95 patients admitted with PBI caused by barrel bomb explosion. The intracranial number of FB was examined by brain computed tomography. Logistic regression was used to assess the association of the intracranial number of FB on mortality. Correlation analyses were performed to investigate the association of Glasgow Coma Scale (GCS) with intracranial number of FB. RESULTS The optimal cut-off value of the intracranial number of FB calculated for mortality was 2, which was effective for predicting mortality (p < .001). In patients with >2 intracranial FB, the mortality rate was statistically significantly 51-fold higher than those with ≤2 (p < .001). A statistically significant negative correlation was determined between GCS and number FB (r = -0.697; p < .001). CONCLUSION When the intracranial number of FB was >2, mortality significantly increased in patients with PBI. The intracranial number of FBs may be considered as a novel prognostic factor for the prediction of mortality in PBI.
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Affiliation(s)
- Mustafa Bolatkale
- Medipol University Hospital, Department of Emergency Medicine, Istanbul, Turkey.
| | - Ahmet Cagdas Acara
- Bozyaka Research and Training Hospital, Department of Emergency Medicine, Izmir, Turkey
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Singh BK, Dutta A, Ahmed S, Hussain Z, Hazarika R, Singh B. Traumatic Cerrebral Fungus: Experience From an Institution in North East India. J Neurosci Rural Pract 2017; 8:S37-S43. [PMID: 28936070 PMCID: PMC5602259 DOI: 10.4103/jnrp.jnrp_10_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Traumatic brain fungus is manifestation of neglected head injury. Although rare it is not uncommon. The patients are usually intact with good Glasgow coma (GCS) score inspite of complex injuries and exposed brain parenchyma but morbidity and mortality is very high with time if no proper and timely management is offered. There is very less study on traumatic brain fungus with no defined management protocols. So an attempt was made to explain in details the surgical strategies and other management techniques in patients with traumatic brain fungus. AIMS To study and evaluate the pattern of causation, clinical presentations, modalities of management of traumatic brain fungus and outcome after treatment. METHODS All patients with fungus cerebri, admitted to our centre from January 2012 to December 2015 were studied prospectively. All the patients were examined clinically and triaged urgently for surgery. CT head was done in all patients to look for any brain parenchymal injury. All patients were managed surgically. Outcome was assessed as per the Glassgow Outcome Score. RESULTS Total 10 patients were included in the study. 8 were men and 2 women. The patients' ages ranged from 3-48 years (mean 31.6 years). The interval between initial injury and protrusion ranged from 3 days to 6 days (mean 4.1 days). Mean GCS at the time of presentation was 13.2.60% of the patients (n = 6) sustained moderate head injury. (GCS-9-13). Size of the fungus ranged from 5cm×3cm to 8cm×10cm. CONCLUSION Early and proper local wound treatment prevents fungus formation. Pre-emptive antibiotics, AEDs and cerebral decongestants are recommended. Loose water-tight duroplasty prevents CSF leak. But mortality and morbidity can be reduced significantly if brain fungus is managed properly by applying basic surgical principles and antibiotic protocols combined with newer surgical modalities.
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Affiliation(s)
| | - Abinash Dutta
- Department of Neurosurgery, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Shameem Ahmed
- Apollo - International Hospital, Guwahati, Assam, India
| | - Zakir Hussain
- Department of Neurosurgery, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Rajib Hazarika
- Department of Neurosurgery, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Bineta Singh
- Apollo - International Hospital, Guwahati, Assam, India
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Abstract
Penetrating head and neck trauma could cause significant mortality because of many important structures located in the brain and neck. Although high-velocity penetrating brain injury is often reported, reports of low-velocity, combined head and neck penetrating injury are rare. Hereby, the authors present a case of an old man who had encountered a serious accident, a 29-cm iron fork penetrated into his neck, through the skull base and into brain. After treatment by multidisciplinary team, the patient was in rehabilitation. The multidisciplinary team assists rapid diagnosis and treatment of penetrating neck and head injury is the key to ensure a good outcome. Therefore, as the authors face such patients again, a multidisciplinary team is needed.
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Roberts SAG, Toman E, Belli A, Midwinter MJ. Decompressive craniectomy and cranioplasty: experience and outcomes in deployed UK military personnel. Br J Neurosurg 2016; 30:529-35. [DOI: 10.1080/02688697.2016.1208807] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Caporlingua A, Caporlingua F, Lenzi J. Good outcome after delayed surgery for orbitocranial non-missile penetrating brain injury. Asian J Neurosurg 2016; 11:309. [PMID: 27366265 PMCID: PMC4849307 DOI: 10.4103/1793-5482.179641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Nonmissile orbitocranial penetrating brain injuries are uncommonly dealt with in a civilian context. Surgical management is controversial, due to the lack of widely accepted guidelines. A 52-year-old man was hit in his left eye by a metallic foreign body (FB). Head computed tomography (CT) scan showed a left subcortical parietal FB with a considerable hemorrhagic trail originating from the left orbital roof. Surgical treatment was staged; an exenteratio oculi and a left parietal craniotomy to extract the FB under intraoperative CT guidance were performed at post trauma day third and sixth, respectively. A postoperative infectious complication was treated conservatively. The patient retained a right hemiparesis (3/5) and was transferred to rehabilitation in good clinical conditions at day 49th. He had suspended antiepilectic therapy at that time. A case-by-case tailored approach is mandatory to achieve the best outcome in such a heterogeneous nosological entity. Case reporting is crucial to further understand its mechanism and dynamics.
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Affiliation(s)
- Alessandro Caporlingua
- Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy
| | - Federico Caporlingua
- Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy
| | - Jacopo Lenzi
- Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy
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Mzimbiri JM, Li J, Bajawi MA, Lan S, Chen F, Liu J. Orbitocranial Low-Velocity Penetrating Injury: A Personal Experience, Case Series, Review of the literature, and Proposed Management Plan. World Neurosurg 2016; 87:26-34. [DOI: 10.1016/j.wneu.2015.12.063] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 12/13/2015] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
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16
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Chen L, Bao Y, Liang Y, Wang Y, Jiang J. Surgical management and outcomes of non-missile open head injury: Report of 44 cases from a single trauma centre. Brain Inj 2016; 30:318-23. [PMID: 26832968 DOI: 10.3109/02699052.2015.1113565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To retrospectively analyse the surgical management and outcomes of non-missile open head injuries (NMOHI). METHODS Forty-four patients who suffered from NMOHI were included. The Glasgow outcome score (GOS), computed tomography (CT), aetiology and outcomes and complications at discharge and during a 6-month follow-up were analysed. All patients underwent debridement. Intracranial haematoma evacuation, decompressive craniectomy (DC) or replacement were performed. RESULTS Motor vehicle accident and struck by/against were the most common causes (43.2% each). At admission, 33 patients had Glasgow coma scores (GCS) > 8 and 27 of them had a GCS score of > 13. Mean follow-up was 8.7 ± 4.3 months. All patients underwent debridement, 20 underwent bone fracture replacement and 27 underwent haematoma evacuation; 11 patients underwent haematoma evacuation and DC and one had bilateral DC. Twenty-seven patients showed good recovery; 11 patients had moderate disability; three patients had severe disability; and three patients died. After 6 months, 32 patients had good recovery and the morbidity of severe disability had decreased to 13.6%. Thirteen patients developed intracranial infection. Post-traumatic epilepsy and hydrocephalus was detected in three patients. Cerebrospinal fluid fistula was found in five patients. Only one patient developed a brain abscess after 6 months. CONCLUSIONS NMOHI yielded satisfactory recovery and achieved good outcomes.
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Affiliation(s)
- Lei Chen
- a Department of Neurosurgery , Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University , Shanghai , P.R. China
| | - Yinghui Bao
- a Department of Neurosurgery , Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University , Shanghai , P.R. China
| | - Yumin Liang
- a Department of Neurosurgery , Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University , Shanghai , P.R. China
| | - Yong Wang
- a Department of Neurosurgery , Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University , Shanghai , P.R. China
| | - Jiyao Jiang
- a Department of Neurosurgery , Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University , Shanghai , P.R. China
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McCague A, Shub E. Muriatic acid ingestion complicated by penetrating head injury: A case report and literature review. J Emerg Trauma Shock 2016; 9:86-8. [PMID: 27162442 PMCID: PMC4843573 DOI: 10.4103/0974-2700.179459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Rosenfeld JV, Bell RS, Armonda R. Current concepts in penetrating and blast injury to the central nervous system. World J Surg 2015; 39:1352-62. [PMID: 25446474 PMCID: PMC4422853 DOI: 10.1007/s00268-014-2874-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Aim To review the current management, prognostic factors and outcomes of penetrating and blast injuries to the central nervous system and highlight the differences between gunshot wound, blast injury and stabbing. Methods A review of the current literature was performed. Results Of patients with craniocerebral GSW, 66–90 % die before reaching hospital. Of those who are admitted to hospital, up to 51 % survive. The patient age, GCS, pupil size and reaction, ballistics and CT features are important factors in the decision to operate and in prognostication. Blast injury to the brain is a component of multisystem polytrauma and has become a common injury encountered in war zones and following urban terrorist events. GSW to the spine account for 13–17 % of all gunshot injuries. Conclusions Urgent resuscitation, correction of coagulopathy and early surgery with wide cranial decompression may improve the outcome in selected patients with severe craniocerebral GSW. More limited surgery is undertaken for focal brain injury due to GSW. A non-operative approach may be taken if the clinical status is very poor (GCS 3, fixed dilated pupils) or GCS 4–5 with adverse CT findings or where there is a high likelihood of death or poor outcome. Civilian spinal GSWs are usually stable neurologically and biomechanically and do not require exploration. The indications for exploration are as follows: (1) compressive lesions with partial spinal cord or cauda equina injury, (2) mechanical instability and (3) complications. The principles of management of blast injury to the head and spine are the same as for GSW. Multidisciplinary specialist management is required for these complex injuries.
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Isaacs AM, Yuh SJ, Hurlbert RJ, Mitha AP. Penetrating intracranial nail-gun injury to the middle cerebral artery: A successful primary repair. Surg Neurol Int 2015; 6:152. [PMID: 26500798 PMCID: PMC4596057 DOI: 10.4103/2152-7806.166168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 07/31/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Penetrating nail-gun injuries to the head are rare, however, the incidence has been gradually rising over the last decade. While there is a large volume of case reports in the literature, there are only a few incidences of cerebrovascular injury. We present a case of a patient with a nail-gun injury to the brain, which compromised the cerebral vasculature. In this article, we present the case, incidence, pathology, and a brief literature review of penetrating nail-gun injuries to highlight the principles of management pertaining to penetration of cerebrovascular structures. CASE DESCRIPTION A 26-year-old male presented with a penetrating nail-gun injury to his head. There were no neurological deficits. Initial imaging revealed that the nail had penetrated the cranium and suggested the vasculature to be intact. However, due to the proximity of the nail to the circle of Willis the operative approach was tailored in anticipation of a vascular injury. Intraoperatively removal of the foreign body demonstrated a laceration to the M1 branch of the middle cerebral artery (MCA), which was successfully repaired. CONCLUSION To our knowledge, this is the first reported case of a vascular arterial injury to the MCA from a nail-gun injury. It is imperative to have a high clinical suspicion for cerebrovascular compromise in penetrating nail-gun injuries even when conventional imaging suggests otherwise.
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Affiliation(s)
- Albert M Isaacs
- Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - Sung-Joo Yuh
- Department of Clinical Neurosciences, Calgary Spine Program, University of Calgary, Calgary, Alberta, Canada
| | - R John Hurlbert
- Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada ; Department of Clinical Neurosciences, Calgary Spine Program, University of Calgary, Calgary, Alberta, Canada
| | - Alim P Mitha
- Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada ; Department of Clinical Neurosciences, The Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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Neuroréanimation pédiatrique: l’expérience afghane. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0836-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society. ACTA ACUST UNITED AC 2011; 71:S210-34. [PMID: 21814089 DOI: 10.1097/ta.0b013e318227ac4b] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.
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Prevention of Infections Associated With Combat-Related Central Nervous System Injuries. ACTA ACUST UNITED AC 2011; 71:S258-63. [DOI: 10.1097/ta.0b013e318227ad86] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Talving P, DuBose J, Barmparas G, Inaba K, Demetriades D. Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents. Eur J Trauma Emerg Surg 2009; 35:225-39. [PMID: 26814899 DOI: 10.1007/s00068-008-8153-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2008] [Accepted: 12/08/2008] [Indexed: 12/19/2022]
Abstract
Terrorist violence has emerged as an increasingly common cause of mass casualty incidents (MCI) due to the sequelae of explosive devices and shooting massacres. A proper emergency medical system disaster plan for dealing with an MCI is of paramount importance to salvage lives. Because the number of casualties following a MCI is likely to exceed the medical resources of the receiving health care facilities, patients must be appropriately sorted to establish treatment priorities. By necessity, clinical signs are likely to prove cornerstones of triage during MCI. An appropriate and effective application of experiences learned from the use of selective nonoperative management (SNOM) techniques may prove essential in this triage process. The present appraisal of the available literature strongly supports that the appropriate utilization of these clinical indicators to identify patients appropriate for SNOM is essential, critical, and readily applicable. We also review the initial emergent triage priorities for penetrating injuries to the head, neck, torso, and extremities in a mass casualty setting.
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Affiliation(s)
- Peep Talving
- Division of Trauma Surgery and Surgical Critical Care, University of Southern California, USC + LAC Medical Center, 1200 North State Street, Room 9900, Los Angeles, CA, 90033, USA.
| | | | | | | | - Demetrios Demetriades
- Division of Trauma Surgery and Surgical Critical Care, University of Southern California, USC + LAC Medical Center, Los Angeles, USA
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Prevention and management of infections associated with combat-related central nervous system injuries. ACTA ACUST UNITED AC 2008; 64:S252-6. [PMID: 18316969 DOI: 10.1097/ta.0b013e318163d2b7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Combat-related injuries to the central nervous system (CNS) are of critical importance because of potential catastrophic outcomes. Although the overall infection rate of combat-related CNS injuries is less than 5%, if an infection develops there is a very high associated morbidity and mortality. This review focuses on the management and prevention of infections related to injuries to the brain or the spinal cord. Management strategies emphasize the importance of expert evaluation and management by a neurosurgeon. This review provides evidence-based recommendations from military and civilian data to the management of combat-related CNS injuries. Areas of focus include bacteria cultures, antimicrobial therapy, irrigation and debridement, timing of surgical care, and wound coverage. Given these recommendations are not supported by randomized control trials or adequate cohorts studies in a military population, further efforts are needed to answer best treatment strategies.
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Winder MJ, Monteith SJ, Lightfoot N, Mee E. Penetrating head injury from nailguns: a case series from New Zealand. J Clin Neurosci 2007; 15:18-25. [PMID: 18032048 DOI: 10.1016/j.jocn.2007.06.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2007] [Revised: 06/19/2007] [Accepted: 06/21/2007] [Indexed: 11/26/2022]
Abstract
Penetrating head injury from nailguns has become increasingly recognised due to their frequent use in the construction industry and home. We report a New Zealand case series of 12 penetrating nailgun head injuries, the largest of its type, detailing presentation, management, risk factors and outcomes. Recommendations based on these factors are provided, suggesting a minimal surgical approach and an individually case-assessed need for antibiotic prophylaxis and anti-epileptic drugs. Prognostic factors on initial imaging are discussed. The majority of injuries, despite being visually impressive, are associated with minimal neurological impairment.
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Affiliation(s)
- Mark J Winder
- Department of Neurosurgery, Auckland City Hospital and Starship Children's Hospital, The University of Auckland, Auckland, New Zealand
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Selvanathan S, Goldschlager T, McMillen J, Campbell S. Penetrating craniocerebral injuries from nail-gun use. J Clin Neurosci 2007; 14:678-83. [PMID: 17452105 DOI: 10.1016/j.jocn.2006.02.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2005] [Revised: 02/05/2006] [Accepted: 02/07/2006] [Indexed: 11/23/2022]
Abstract
Three patients with penetrating craniocerebral nail-gun injuries are described. In the first patient the nail was impinging on the internal carotid artery (ICA) in the carotid canal. On removal of the nail, the patient developed a false aneurysm at the site. To our knowledge, this is the first reported case of nail-gun injury affecting the ICA and also the first case of penetrating head injury affecting the ICA in the carotid canal. The second patient had seven intracranial nails in the frontal area. Three nails penetrated the left orbit, one of which perforated the globe. One nail damaged the optic nerve resulting in optic neuropathy. In the third patient the nail extended through the squamous temporal bone into the temporal lobe. All three were managed successfully via closed gentle traction without craniotomy and/or endovascular intervention. The literature is reviewed and management options for penetrating head injuries are discussed.
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Affiliation(s)
- S Selvanathan
- Kenneth G. Jamieson Department of Neurosurgery, Level 7, Ned Hanlon Building, Royal Brisbane Hospital, Herston QLD 4029, Australia
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Heridas múltiples penetrantes intracraneales causadas por pistola de clavos: caso clínico. Neurocirugia (Astur) 2006. [DOI: 10.1016/s1130-1473(06)70320-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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