Emergency surgery in a severe penetrating skull base injury by a screwdriver: case report and literature review

Penetrating Midface Trauma: A Case Report, Review of the Literature, and a Diagnostic and Management Protocol

PURPOSE

Penetrating facial trauma is an uncommon injury, but patients who present with these dramatic situations require special consideration. We describe the case of a young man who had been shot with an arrow that deeply penetrated his midface as well as report the results of a literature review of penetrating midface injuries. The information gathered was used to create a diagnostic protocol for patients who sustain such injuries.

METHODS

A PubMed search up to October 2019 using several key phrases was performed, and 623 unique articles were evaluated. Excluding firearm injuries to the midface, there were 57 unique cases that involved penetrating midface injuries. Clinical and imaging data were compiled and evaluated with descriptive statistical analysis.

RESULTS

The average patient age was 27 years, with a male predilection. The most common reported etiology was accidental trauma (54%), and a knife was the most common weapon of injury (30%). The most common (32%) specific location of trauma was within the orbital region, including the canthus or the eyelid. In all cases where the patient had not died immediately, surgery was used to remove the penetrating object. We found that computed tomography was the most commonly obtained imaging study (39% of cases). Radiographs were the sole imaging in 28% of the cases, with angiography (16%) and magnetic resonance imaging (10%) used less frequently in management. In 28% of the cases, deep structures, such as the carotid artery, sphenoid sinus, or skull base, were involved in the injury. In 25% of the cases, there was injury to the central nervous system. Death occurred in 8.8% of the cases. Postoperative complications occurred in at least 21% of the cases. Statistical analysis also revealed a significant correlation between antibiotic use and full recovery. Penetration of the object posterior to the maxillary sinus was correlated with incomplete recovery or death.

CONCLUSIONS

Based on all case reports collected, a Dartmouth Penetrating Midface Protocol was developed to aid the practitioner who may happen to be responsible for these dramatic life-threatening injuries. The Dartmouth Penetrating Midface Protocol is based on the type of imaging available at the treating facility, the neurologic and hemodynamic stability of the patient, and the depth of penetration beyond the posterior wall of the maxillary sinus.

Double Beveling on Imaging: A Characteristic Feature of Entry and Exit Penetrating Injury Wound

Beveling of the calvarial bone is reported in firearm exit wounds and stabbing injuries in forensic literature. Beveling in entry wounds is rare. We report a case of a 27-year-old man who sustained a nonfatal penetrating craniofacial injury due to motorbike brake handle, and completely recovered after conservative management. We describe the characteristic inward as well outward beveling on imaging due the penetrating trajectory of the motorbike break handle.

The cell-based approach in neurosurgery: ongoing trends and future perspectives

OBJECTIVE

Examination of the current trends and future perspectives of the cell-based therapies in neurosurgery.

METHODS

A PubMed/MEDLINE-based systematic review has been performed combining the main Medical Subject Headings (MeSH) regarding the cell- and tissue-based therapies with the "Brain", "Spinal Cord", "Spine" and "Skull" MeSH terms. Only articles in English published in the last 10 years and pertinent to neurosurgery have been selected.

RESULTS

A total of 1,173 relevant articles have been chosen. Somatic cells and gene-modification technologies have undergone the greatest development. Immunotherapies and gene therapies have been tested for the cure of glioblastoma, stem cells mainly for brain and spinal cord traumatic injuries. Stem cells have also found a rationale in the treatment of the cranial and spinal bony defects, and of the intervertebral disc degeneration, as well.Most of the completed or ongoing trials concerning the cell-based therapies in neurosurgery are on phase 2. Future perspectives involve the need to overcome issues related to immunogenicity, oncogenicity and routes for administration. Refinement and improvement of vector design and delivery are required within the gene therapies.

CONCLUSION

The last decade has been characterised by a progressive evolution of neurosurgery from a purely mechanical phase to a new biological one. This trend has followed the rapid and parallel development of translational medicine and nanotechnologies.The introduction of new technologies, the optimisation of the already existing ones, and the reduction of costs are among the main challenges of the foreseeable future.

Management of Penetrating Skull Base Injury: A Single Institutional Experience and Review of the Literature

BACKGROUND

Penetrating skull base injury (PSBI) is uncommon among head injuries, presenting unique diagnostic and therapeutic challenges. Although many cases of PSBIs have been reported, comprehensive understanding of its initial diagnosis, management, and outcome is still unavailable.

MATERIALS AND METHODS

A retrospective review was performed for patients treated in neurosurgical department of Changzheng Hospital for PSBIs. Presurgical three-dimensional (3D) Slicer-assisted reconstructions were conducted for each patient. Then we reviewed previous literature about all the published cases of PSBIs worldwide and discussed their common features.

RESULTS

A total of 5 patients suffering PSBIs were identified. Penetrating points as well as the surrounding neurovascular structures were clearly visualized, assisting in the presurgical planning of optimal surgical approach and avoiding unexpected vascular injury. Four patients underwent craniotomy with foreign bodies removed successfully and 1 patient received conservative treatment. All of them presented good outcomes after proper management.

CONCLUSION

Careful physical examination and radiological evaluation are essential before operation, and angiography is recommended for those with suspected vascular injuries. 3D modeling with 3D Slicer is practicable and reliable, facilitating the diagnosis and presurgical planning. Treatment decision should be made upon the comprehensive evaluation of patient's clinicoradiological features and characteristics of foreign bodies.

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.

Translucent three-dimensional CT is useful in considering the treatment strategy for the penetrating skull base injury with a metal rod: case report

An 18-year-old male suffered a penetrating skull base injury caused by a metal rod. We made translucent three-dimensional (3D) computed tomography (CT) for clearing the injury site. This method has revealed that right carotid artery was compressed directly by the foreign body, and internal carotid artery trapping was carried out based on hemodynamics as revealed by angiography. This patient achieved modified Rankin scale score of 1 at discharge. Cases of trauma involve a variety of circumstances and therefore require a case-by-case evaluation that depends on the patient's condition. Translucent 3D CT was useful in considering the treatment strategy of the penetrating skull base injury.

Intracranial penetrating injury by screw driver: a case report and review of literature

Penetrating injury to the head, with the exception of missile injuries is rare owing to thick calvarium. Orbital and temporal areas are comparatively vulnerable to penetrating injuries, due to their relative thinness. A case is presented in which a man killed his wife by forcefully thrusting a screw driver into her cranial cavity. The deceased presented to the hospital with the screw driver embedded in her head. She was declared as 'brought dead on arrival' at the emergency of the hospital. Pre-autopsy plain radiography and Computed Tomography (CT) of the head were done to assess the extent of brain damage. The peculiarity of this case lies in the fact that screw driver as a stabbing weapon in the head is very rarely used. In such cases, there is a need to perform radiography and CT with the weapon in-situ for better interpretation on injuries. In this paper role of radiography and CT in intra cranial penetration is discussed with review of literature.