Unusual penetrating brain injuries

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]

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.

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.

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.

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.

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.

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.