Elsevier

World Neurosurgery

Volume 94, October 2016, Pages 529-543
World Neurosurgery

Original Article
Nonmissile Penetrating Injury to the Head: Experience with 17 Cases

https://doi.org/10.1016/j.wneu.2016.06.062Get rights and content

Background

Penetrating nonmissile injuries to the head are far less common than missile penetrating injuries. Here we describe our experience in managing 17 cases of nonmissile injury to the head, likely the largest such series reported to date. We also highlight the surgical steps and techniques used to remove in situ objects (including weapons) in the penetrating wounds that have not been described previously.

Methods

We conducted a retrospective study of cases of nonmissile, low-velocity penetrating injuries of the head managed in our department. The recorded data of patients with penetrating head injuries were studied for the cause of the injury, type of object, type and extent of penetration, Glasgow Coma Scale score on admission, other clinical issues, evaluation and assessment, interval from penetration to operation, surgical steps and notes, difficulty during the operation, major and minor complications, follow-up, and ultimate outcome.

Results

Our 17 cases included 6 cases of accidental penetration and 11 cases of penetration as the result of violence. Weapons and other foreign objects causing injury included a teta (a pointed metal weapon with a wooden handle and a barb near the tip, used for hunting and fishing) in 4 cases, a dao (a sharp metal cutting instrument with a wooden handle used for cutting vegetables, fish, meat, bamboo, wood, etc.) in 3 cases, a bamboo stick in 3 cases, a metal rod in 2 cases, a knife in 2 cases, a sharp stone in 1 case, a metal steam chamber cover in 1 case, and a long peg in 1 case. GCS on admission was between 13 and 15 in 15 cases. Only 1 patient exhibited limb weakness. Four patients with an orbitocranial penetrating injury had 1-sided vision loss; 2 of these patients had orbital evisceration, and 1 of these patients died. In 14 patients, the foreign object was in situ at presentation and was removed surgically. Computed tomography scan and plain X-ray of the head were obtained in all patients. Postoperatively, 2 patients (11.7%) needed support in the intensive care unit but died early after surgery. One patient developed late osteomyelitis. The remaining patients were doing well at the most recent follow-up.

Conclusions

The presenting picture of nonmissile penetrating injury to head may be daunting, but these cases can be managed with very good results with proper (clinical and radiologic) evaluation and simple neurosurgical techniques.

Section snippets

Materials and Methods

We retrogradely studied patients with a nonmissile, low-velocity penetrating injury to head (brain, orbit, skull base, and face) who were admitted and managed in the Department of Neurosurgery, Dhaka Medical College Hospital, Dhaka, Bangladesh between July 2006 and July 2013. The recorded data of the patients with penetrating head injuries were carefully studied for cause of injury, type of object, type and extent of penetration, GCS on admission, other clinical issues, investigations, interval

Results

Management details of the 17 patients are presented in Table 1 and Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10, Figure 11, Figure 12, Figure 13, Figure 14. The male-female ratio was 2.4:1, and the average age was 29 years (range, 10–53 years). The average duration of follow-up was 6 years (range, 9 to 3.5 years). Causes of injury were accidental penetration in 6 cases, family violence in 2 cases, stabbing by a hijacker in 2 cases, and interpersonal

Discussion

Penetrating injuries of the skull and brain are relatively uncommon, representing only roughly 0.4% of all head injuries worldwide. Gunshot wounds account for the majority of penetrating skull and brain injuries in Western countries, but not in developing and third-world countries. These injuries are defined as wounds that involve a smaller area with relatively low-velocity impact. Regardless of the size of the penetrating object, penetrating skull injuries are rarely associated with major

Conclusion

Primary injury caused by a nonmissile penetrating object cannot be reversed and may cause death, but in most cases is not fatal. In such cases, secondary damage can be easily prevented with a very good ultimate outcome. The presenting picture of nonmissile penetrating injury to the head may be very daunting, but these cases can be managed with very good results by proper (clinical and radiologic) evaluation and simple neurosurgical techniques.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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