Complications, outcomes, and management strategies of non-missile penetrating head injuries

Bradley M. Harrington MBBCh 1 , Armin Gretschel MBChB, MMed (Neurosurgery) 1 , Carl Lombard MSc, PhD 2 , Russell R. Lonser MD 3 , and Adriaan J. Vlok MBChB, MMed (Neurosurgery), PhD 1
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  • 1 Division of Neurosurgery, University of Stellenbosch; and
  • 2 Division of Epidemiology and Biostatistics, Department of Global Health, University of Stellenbosch, Western Cape, South Africa; and
  • 3 Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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OBJECTIVE

While high-velocity missile injury (gunshot) is associated with kinetic and thermal injuries, non-missile penetrating head injury (NMPHI) results in primary damage along the tract of the piercing object that can be associated with significant secondary complications. Despite the unique physical properties of NMPHI, factors associated with complications, expected outcomes, and optimal management have not been defined. In this study, the authors attempted to define those factors.

METHODS

Consecutive adult patients with NMPHI who presented to Tygerberg Academic Hospital (Cape Town, South Africa) in the period from August 1, 2011, through July 31, 2018, were enrolled in a prospective study using a defined treatment algorithm. Clinical, imaging, and laboratory data were analyzed.

RESULTS

One hundred ninety-two patients (185 males [96%], 7 females [4%]) with 192 NMPHIs were included in this analysis. The mean age at injury was 26.2 ± 1.1 years (range 18–58 years). Thirty-four patients (18%) presented with the weapon in situ. Seventy-one patients (37%) presented with a Glasgow Coma Scale (GCS) score of 15. Weapons included a knife (156 patients [81%]), screwdriver (18 [9%]), nail gun (1 [0.5%]), garden fork (1 [0.5%]), barbeque fork (1 [0.5%]), and unknown (15 [8%]). The most common wound locations were temporal (74 [39%]), frontal (65 [34%]), and parietal (30 [16%]). The most common secondary complications were vascular injury (37 patients [19%]) and infection (27 patients [14%]). Vascular injury was significantly associated with imaging evidence of deep subarachnoid hemorrhage and an injury tract crossing vascular territory (p ≤ 0.05). Infection was associated with delayed referral (> 24 hours), lack of prophylactic antibiotic administration, and weapon in situ (p ≤ 0.05). A poorer outcome was associated with a stab depth > 50 mm, a weapon removed by the assailant, vascular injury, and eloquent brain involvement (p ≤ 0.05). Nineteen patients (10%) died from their injuries. The Glasgow Outcome Scale (GOS) score was linearly related to the admission GCS score (p < 0.001). One hundred forty patients (73%) had a GOS score of 4 or better at discharge.

CONCLUSIONS

The most common NMPHI secondary complications are vascular injury and infection, which are associated with specific NMPHI imaging and clinical features. Identifying these features and using a systematic management paradigm can effectively treat the primary injury, as well as diagnose and manage NMPHI-related complications, leading to a good outcome in the majority of patients.

ABBREVIATIONS dSAH = deep SAH; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICH = intracerebral hematoma; NMPHI = non-missile penetrating head injury; SAH = subarachnoid hemorrhage.

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Contributor Notes

Correspondence Adriaan J. Vlok: University of Stellenbosch, Western Cape, South Africa. ianvlok@sun.ac.za.

INCLUDE WHEN CITING Published online June 19, 2020; DOI: 10.3171/2020.4.JNS20122.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Clark WC , Muhlbauer MS , Watridge CB , Ray MW . Analysis of 76 civilian craniocerebral gunshot wounds . J Neurosurg . 1986 ;65 (1 ):9 14 .

    • Search Google Scholar
    • Export Citation
  • 2

    Enicker B , Madiba TE . Cranial injuries secondary to assault with a machete . Injury . 2014 ;45 (9 ):1355 1358 .

  • 3

    Cychowska M , Bloch-Bogusławska E . Cases of non-fatal chop wounds to the head. Article in Polish . Arch Med Sadowej Kryminol . 2013 ;63 (4 ):283 287 .

    • Search Google Scholar
    • Export Citation
  • 4

    Del Castillo-Calcáneo JD , Bravo-Angel U , Mendez-Olan R , Traumatic brain injury with a machete penetrating the dura and brain: case report from southeast Mexico . Int J Surg Case Rep . 2016 ;23 :169 172 .

    • Search Google Scholar
    • Export Citation
  • 5

    Li XS , Yan J , Liu C , Nonmissile penetrating head injuries: surgical management and review of the literature . World Neurosurg . 2017 ;98 :873.e9 873.e25 .

    • Search Google Scholar
    • Export Citation
  • 6

    Chowdhury FH , Haque MR , Hossain Z , Nonmissile penetrating injury to the head: experience with 17 cases . World Neurosurg . 2016 ;94 :529 543 .

    • Search Google Scholar
    • Export Citation
  • 7

    Taylor AG , Peter JC . Patients with retained transcranial knife blades: a high-risk group . J Neurosurg . 1997 ;87 (4 ):512 515 .

    • Search Google Scholar
    • Export Citation
  • 8

    de Holanda LF , Pereira BJA , Holanda RR , Neurosurgical management of nonmissile penetrating cranial lesions . World Neurosurg . 2016 ;90 :420 429 .

    • Search Google Scholar
    • Export Citation
  • 9

    de Villiers JC . Stab wounds of the brain and skull . In: Vinken PJ , Bruyn GW , eds. Handbook of Clinical Neurology . Elsevier ; 1975 :477 503 .

    • Search Google Scholar
    • Export Citation
  • 10

    Kieck CF , de Villiers JC . Vascular lesions due to transcranial stab wounds . J Neurosurg . 1984 ;60 (1 ):42 46 .

  • 11

    van Dellen JR , Lipschitz R . Stab wounds of the skull . Surg Neurol . 1978 ;10 (2 ):110 114 .

  • 12

    Estebanez G , Garavito D , López L , Penetrating orbital-cranial injuries management in a limited resource hospital in Latin America . Craniomaxillofac Trauma Reconstr . 2015 ;8 (4 ):356 362 .

    • Search Google Scholar
    • Export Citation
  • 13

    du Trevou M , Bullock R , Teasdale E , Quin RO . False aneurysms of the carotid tree due to unsuspected penetrating injury of the head and neck . Injury . 1991 ;22 (3 ):237 239 .

    • Search Google Scholar
    • Export Citation
  • 14

    Ijaz L , Nadeem MM . Transorbital penetrating brain injury to frontal lobe by a wheel spoke . J Pediatr Neurosci . 2014 ;9 (3 ):267 269 .

    • Search Google Scholar
    • Export Citation
  • 15

    Kataria R , Singh D , Chopra S , Sinha VD . Low velocity penetrating head injury with impacted foreign bodies in situ . Asian J Neurosurg . 2011 ;6 (1 ):39 44 .

    • Search Google Scholar
    • Export Citation
  • 16

    Casler JD , Doolittle AM , Mair EA . Endoscopic surgery of the anterior skull base . Laryngoscope . 2005 ;115 (1 ):16 24 .

  • 17

    Nguyen R , Fiest KM , McChesney J , The international incidence of traumatic brain injury: a systematic review and meta-analysis . Can J Neurol Sci . 2016 ;43 (6 ):774 785 .

    • Search Google Scholar
    • Export Citation
  • 18

    Grossbach AJ , Abel TJ , Smietana J , Impalement brain injury from steel rod causing injury to jugular bulb: case report and review of the literature . Brain Inj . 2014 ;28 (12 ):1617 1621 .

    • Search Google Scholar
    • Export Citation
  • 19

    Chen PC , Tsai SH , Chen YL , Liao WI . Post-traumatic cerebral infarction following low-energy penetrating craniocerebral injury caused by a nail . J Korean Neurosurg Soc . 2014 ;55 (5 ):293 295 .

    • Search Google Scholar
    • Export Citation
  • 20

    Bullock R , van Dellen JR. Acute carotid-cavernous fistula with retained knife blade after transorbital stab wound . Surg Neurol . 1985 ;24 (5 ):555 558 .

    • Search Google Scholar
    • Export Citation
  • 21

    O’Shaughnessy BA , Getch CC , Bowman RM , Batjer HH . Ruptured traumatic vertebral artery pseudoaneurysm in a child treated with trapping and posterior inferior cerebellar artery reimplantation. Case report and review of the literature . J Neurosurg . 2005 ;102 (2 )(suppl):231 237 .

    • Search Google Scholar
    • Export Citation
  • 22

    Larson PS , Reisner A , Morassutti DJ , Traumatic intracranial aneurysms . Neurosurg Focus . 2000 ;8 (1 ):e4 .

  • 23

    Redekop G , Marotta T , Weill A . Treatment of traumatic aneurysms and arteriovenous fistulas of the skull base by using endovascular stents . J Neurosurg . 2001 ;95 (3 ):412 419 .

    • Search Google Scholar
    • Export Citation
  • 24

    Abdulbaki A , Al-Otaibi F , Almalki A , Transorbital craniocerebral occult penetrating injury with cerebral abscess complication . Case Rep Ophthalmol Med . 2012 ;2012 :742186 .

    • Search Google Scholar
    • Export Citation
  • 25

    Teasdale G , Jennett B . Assessment of coma and impaired consciousness. A practical scale . Lancet . 1974 ;2 (7872 ):81 84 .

  • 26

    Jennett B , Bond M . Assessment of outcome after severe brain damage. A practical scale . Lancet . 1975 ;1 (7905 ):480 484 .

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