Neurophilosophy

Unusual penetrating brain injuries

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Via Street Anatomy comes this recent case report from Acta Neurochirurgica, of a man who had a paintbrush stuck into his brain – bristly end first – during a fight, but didn’t realize until 6 hours later, when he went to hospital complaining of a headache! Even more remarkably, any brain damage that may have occurred was apparently insufficient to cause any behavioural or cognitive deficits.

Mandat, T. S., et al. (2005). Artistic assault: an unusual penetrating head injury reported as a trivial facial trauma. Acta Neurochir. 147: 331-333. [Summary]

The authors report a case of penetrating head injury that presented with a deceptively mild complaint. To our knowledge, it is the first report of a paintbrush penetrating the brain. The patient reported being punched in the left eye and presented with a minor headache, swelling around the left orbit, a small cut on the cheek and slightly reduced left eye abduction. After radiological evaluation, a penetrating head injury was diagnosed. Under general anesthesia, through a lateral eyelid incision a 10.5 cm long paintbrush, which had penetrated from the left orbit to the right thalamus, was removed. No post-operative infection was seen at six months follow-up. This brief report serves to highlight that penetrating brain injury can occur without neurological deficit and that a minimally invasive surgical approach was successful in avoiding any complications.

A lot of people seem to share my morbid fascination with this sort of thing: my recent post on prehistoric Inca neurosurgery brought about a dozen inbound links, and an illustrated history of trepanation is one of the most popular posts I’ve ever written. So, below are some of the more unusual penetrating brain injuries that I stumbled across while performing a quick search for the one above, starting with the least unusual, a self-inflicted nail gun injury.

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Testerman, G. M. & Dacks, L. M. (2007). Multiple self-inflicted nail gun head injury. South. Med. J. 100: 608-10. [Summary]

Penetrating brain injury resulting from nail-gun use is a well-characterized entity, one that is increasing in frequency as nail guns become more powerful and more readily available to the public. We present a case and offer management strategies for a 50-year-old male with two intracranial penetrating nail gun injuries. Nail gun brain injuries are commonly intentionally self-inflicted. Suicide should be considered when straight nails cause wounds to the chest, head, or abdomen. The primary preoperative concern is formation of a traumatic pseudoaneurism, which prompts both preoperative and follow-up cerebral angiography. Surgery for combined intracranial and extracranial injury may require the collaborative expertise of colleagues from the fields of ophthalmology, otolaryngology, and oral maxillofacial surgery. A rational management strategy should permit these patients to be discharged with no additional injury.

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Yilkudi, M. G., et al. (1985). Penetrating cranial nail injury. An unusual domestic assault: Case report. East Central Afr. J. Surg. 10: 60-62. [PDF]

A rare case of intracranial nail injury caused by domestic violence is presented. The 35-year old female patient was found unconscious with a 12cm nail almost completely buried into her skull. X-ray of the skull showed the nail in the cranial cavity. A burr hole was made and the nail removed. Immediate post-operative period showed a Glasgow coma score of 10/15 and right hemi paresis which improved with time. At six months after injury, her neurological status was normal. Despite the lack of a CT scan in some areas attempt must be made using clinical judgement and performance of burr holes to treat such patients who cannot afford transfer to a standard neurological centre. This report also highlights the fact that penetrating brain injuries of this nature without much neurological deficit and that a minimally invasive surgical approach can be used successfully to manage such cases while avoiding serious postoperative complications.

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James, G., et al. (2006). A case of self-inflicted craniocerebral penetrating injury. Emerg. Med. J. 23: e32. [Summary

A 44 year old man was referred to the accident and emergency department by the psychiatric services, having claimed to have hammered several nails through his skull over a three month period. The patient had a long history of depression, personality disorder, and previous deliberate self-harm. He had remained well throughout this period and had been cleaning the wounds with weak antiseptic on a regular basis. He had concealed the injuries by wearing a hat. Two days prior to admission he had inserted a much larger 12.7 cm (5 inch) masonry nail and had developed left sided weakness and unsteadiness of gait.

Examination showed that the patient remained well with no evidence of infection in the central nervous system. Neurological examination revealed a mild left sided weakness (4/5 Medical Research Council (MRC) scale) affecting both the arm and leg. The patient was fully alert and orientated and conversed normally. Inspection of the scalp revealed a large masonry nail protruding from the scalp with several other healed puncture wounds. Plain skull X-rays revealed a total of ten 5 cm nails and a larger, 12.7 cm masonry nail penetrating the skull. A computed tomography (CT) scan was performed, which despite considerable artefact confirmed that the nails had penetrated the brain substance. The patient was later transferred to the local neurosurgical unit for further management where, after angiography, all the nails were removed under general anaesthetic. He subsequently made an uneventful recovery.

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Karabatsou, K., et al. (2005). Self-Inflicted Penetrating Head Injury in a Patient With Manic-Depressive Disorder. Am. J.  Forensic Med. Pathol. 26: 174-7. [Summary]

A 32-year-old Caucasian male with a history of repeated self-injury drilled a hole in his skull using a power tool and subsequently introduced intracerebrally a binding wire from a sketchpad. An emergency craniotomy was performed around the site of cranial injury, and the foreign body was carefully extracted. The wire was located partially in the subdural space and partially in the right hemisphere of the brain. The patient made an excellent recovery and was referred to a psychiatrist for further treatment. This is a rare case of unusual and complex repetitive self-destructive behavior without apparent suicidal intent. The pertinent literature is reviewed and the surgical and psychiatric implications of such injuries are discussed.

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This one is horrific, and I should warn you that the paper, which is written in Portugese by Brazilian neurosurgeons, contains a very graphic photograph of the patient’s external injuries.

de Andrade, G. C., et al. (2004). Penetrating brain injury due to a large asbestos fragment treated by decompressive craniotomy: case report. Arq. Neuropsiquiatr. 62: 1104-1107. [PDF]

We report the case of a 22-year-old man victim of penetrating brain injury due to a 15 x 12 [cm] asbestos fragment and a successfully treatment [sic] via decompressive craniotomy. Unlike gunshot wounds to the head, penetrating brain injury from low energy objects are unusual. Most reported involve cranio-orbitary injuries as well as self inflicted lesions in mentally ill patients. The reported case is noteworthy due to the large dimensions of the foreign body, the treatment via decompressive craniotomy and the good patient functional outcome.

And we can’t forget Phineas Gage, the first properly documented – not to mention best known – case of a penetrating brain injury, who was the subject of a BBC Radio 4 programme earlier this week.

Comments

  1. #1 B
    May 23, 2008

    You missed this one – don’t miss the photo gallery. Incredible!

    http://www.katu.com/news/specialreports/15296461.html

  2. #3 John S
    May 23, 2008

    I looked at the PDF for the asbestos case, and I couldn’t figure out how the picture of the damaged eye and the picture revealing the brain are linked. The man didn’t appear to have a huge hole in his skull, and I can’t read the PDF as it is in a foreign language. If you could enlighten me on how the pictures are related, if at all, that would be cool.

  3. #4 Alli
    May 24, 2008

    John S: I had the same problem initially. If you look back at the frontal face pic again, you’ll realize just under his eye is that big of piece of asbestos that is in the brain surgery pic; looks like it sorta came up thru his cheek/eye.

  4. #5 glorry22
    May 27, 2008

    I looked at the PDF for the asbestos case, and I couldn’t figure out how the picture of the damaged eye and the picture revealing the brain are linked. The man didn’t appear to have a huge hole in his skull, and I can’t read the PDF as it is in a foreign language. If you could enlighten me on how the pictures are related, if at all, that would be cool.

  5. #6 fireweaver
    May 27, 2008

    you’re quite right Mo, penetrating brain injury IS completely fascinating. and ANYTHING with amazing radiographs is doubly so. as a veterinarian, we basically only end up looking at creatures who ate something they shouldn’t have:

    http://www.shawnhogan.com/2005/09/dog-eats-13-inch-knife.html

    which is cool in its own regard, but wackiness + brain injury is utterly absorbing.

  6. #7 Lnk
    May 27, 2008

    The Brazilian man is a 22 years old artisan that had an accident while polishing “pedra sab´┐Żo” stones. A work accident. The disk he used for the polishing (or at least a big chunk of it, from the pictures I deduct it probably broke up) “escaped” and penetrated his skull from the eye/cheek point, going UP through his brain. He was therefore sent to the hospital in shock and underwent the emergency surgery. From what I read and see he must have been blinded by the accident but as far as neurological damage goes he just lost part of the left side response, similar to the 44 years old man case related above. There’s lots of medical terminology in the text and I’m not a doctor but I hope I could be of some help.

  7. #8 Mo
    May 27, 2008

    Thanks Lnk. He surely lost his right eye in this horrific accident, but perhaps his left eye was undamaged.

  8. #9 james severin
    May 29, 2008

    I don’t suppose anyone has run across such an injury caused by the heel of a woman’s high-heel or stiletto-heel shoe?

  9. #10 T. Dowling
    July 31, 2008

    While described as “asbestos” the object looks like a fragment of a thin reinforced grinding wheel as used in side grinders or cut-off wheel as used in tile, masonry & other abrasive saws.

    If that is the case, such “flywheel explosions” have amazing force. My 7″ angle grinder, for example, has a peripheral speed of about 260 feet per second, or over 175mph. I have had wire brush bristle fragments from this sort of tool penetrate my skin on occasion. This, despite the wire brush accessory having a smaller diameter and lower peripheral speed (c. 120mph) than the grinding disks!

    That is why such tools in the USA have guards, and users should: (1) Wear goggles, (2) Wear an additional face shield of polycarbonate i.e. Lexan ™,(3) Never be in a direct line with unguarded parts of the wheel and (4) Never remove or reduce the guards.

  10. #11 james pittman
    April 2, 2009

    I am a college student at Kaplan. I am doing a report on brain injuries and I can’t find any good information. I was hoping you could get back to me as soom as possible. And maybe you can send me some information on subdural haematomas?

  11. #12 Sam and Julia
    April 26, 2009

    Hello we think these images are extremely weird and vulgar, making us feel sick. But they are pretty interesting. Weird how people do these things. Thankyou for sharing them with the world and especially us!!!!!!

  12. #13 markayi
    September 8, 2009

    LOL,, its really weird picture and make me feel strange about my head. Hope its not my head and i dont want to know what is inside my head

  13. #14 Britta
    October 9, 2009

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  14. #15 Health
    September 8, 2010

    How can a nail into his head?
    Your pictures made me cringe

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