Literature ReviewPediatric Nonmissile Penetrating Head Injury: Case Series and Literature Review
Introduction
Traumatic brain injury in children may occur as a result of various mechanisms. It could be periambulatory or an accident while playing, but it could also be a result of violence (e.g., child abuse or shaken baby syndrome). Central nervous system (CNS) injuries tend to be milder in children (1–15 years old) than in adults and are the leading cause of death in the 1-year to 40-year age-group.1 Penetrating head injuries are rare2 and fatal in 40% of cases.3 Although in the Western world, they usually occur as gunshot wounds, in the developing world they commonly appear as sharp nonmissile wounds because of strict rules concerning gun possession.4
Nonmissile injuries are defined as those caused by objects traveling at a speed <100 m/second.3 They represent 0.4% of overall head trauma.5 In children, they are usually a result of accidents while playing with sharp objects.2 The most common entrance site is the roof of the orbit because of its thinner wall, followed by the squamous part of the temporal bone.5 Several materials inserting the skull have been reported. The list includes nails, metallic screws, stones, metallic rods, wooden sticks, chopsticks, pencils, knives, scissors, arrows, and other objects with a sharp edge.6
The result of a penetrating injury to the head is direct damage to the brain or its vessels, resulting in high morbidity and mortality. Almost 40% of fatal cases do not reach hospital.5 Complications reported include hematoma formation, contusions, and subarachnoid hemorrhage (SAH) resulting in seizures and variable degree of neurologic damage, depending on their location. Moreover, vascular lacerations with aneurysms or arteriovenous fistula (AVF) formations have been reported, as well as infection with meningitis or abscess formation, especially with certain types of material such as wooden objects.6
In this article, we present 5 cases of children, 3–14 years old, with penetrating nonmissile head injuries treated in the neurosurgical department of the pediatric hospital “Aghia Sofia” in Athens from 2010 to 2016. The cases cover a broad spectrum of the types of injuries reported in various medical journals. We have performed a review of the literature with similar cases in an attempt to compare treatment selection and patient outcomes among similar cases.
There has been no consensus regarding the initial management, treatment and follow-up of these patients.7 However, with the availability of similar diagnostic tools such as computed tomography (CT), magnetic resonance, and angiography, and with the universal use of emergency protocols such as advanced trauma life support and definitive surgical trauma care, case reports and case series of the last decade tend to report similar management algorithms. Subsequently, the first reviews attempting to suggest an overall treatment for penetrating head injuries have recently been published.6, 8 Our review is the first concentrating on the pediatric population and an attempt is made to adopt previously suggested treatment modalities to this special population.
Section snippets
Case 1
A 4-year-old girl was brought to the emergency department by her parents because of an accident while playing. The parents reported that the wind blew a large glass door while the child was playing nearby. A piece of glass from the door hit the patient on the head. No loss of consciousness or vomiting was reported (Figure 1).
On admission to the emergency department, the patient had a Glasgow Coma Scale (GCS) score of 15/15. She was crying and was able to follow simple commands. Vital signs were
Discussion
Penetrating head injuries account for a small percentage of overall brain injuries in civilian populations,9 with a reported incidence of 0.4% of all brain injuries.8 Children, because of their softer skulls, are at higher risk for penetrating injuries.10 Parts of the skull such as the orbit or the temporal bone are the most commonly reported sites of entry, with orbitocranial penetrating injuries accounting for up to 45% of overall penetrating head injuries in children.11, 12 The injuries can
Conclusions
Pediatric NMPHI despite its rarity is a neurosurgical emergency that carries high morbidity and mortality, attributable mainly to the injury mechanics. Pediatric brains, because of their developing state and great plasticity, may have an advantage in terms of functional outcome. Therefore, an effective treatment algorithm is needed to achieve such outcomes. Recent suggestions have improved patient survival. However, no adequate data exist regarding long-term prognosis, and certain aspects of
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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.