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Table of Contents    
LETTER TO EDITOR
Year : 2011  |  Volume : 59  |  Issue : 6  |  Page : 938-940

Traumatic calvarial stone: A rare case report and review of the literature


1 Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, India
2 Department of Neurosurgery, NRI Academy of Sciences, Guntur, India
3 Department of Neurosurgery, Krishna Institute of Medical Sciences, Hyderabad, India

Date of Submission02-Oct-2011
Date of Decision02-Oct-2011
Date of Acceptance10-Oct-2011
Date of Web Publication2-Jan-2012

Correspondence Address:
Manas K Panigrahi
Department of Neurosurgery, Krishna Institute of Medical Sciences, Hyderabad
India
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DOI: 10.4103/0028-3886.91397

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How to cite this article:
Patibandla MR, Thotakura AK, Panigrahi MK, Paniraj GL. Traumatic calvarial stone: A rare case report and review of the literature. Neurol India 2011;59:938-40

How to cite this URL:
Patibandla MR, Thotakura AK, Panigrahi MK, Paniraj GL. Traumatic calvarial stone: A rare case report and review of the literature. Neurol India [serial online] 2011 [cited 2014 Jul 30];59:938-40. Available from: http://www.neurologyindia.com/text.asp?2011/59/6/938/91397


Sir,

Non-missile intracranial traumatic penetration of a foreign body is very rare. We report a rare case of traumatic calvarial stone with review of the literature.

A 35-year-old male patient presented with alleged history of road traffic accident-while riding a two-wheeler without a helmet, he hit a divider and fell down. He had recurrent vomiting. Neurologic examination revealed amnesia for the event with Glasgow Coma Scale (GCS) score of 15/15. In addition he had left clavicle fracture and an irregular lacerated wound in the left parietal region. Skull X-ray [Figure 1] and cranial computed tomography (CT) [Figure 2]a and b showed left frontoparietal linear fracture and presence of a foreign object. Scalp wound was cleansed with normal saline solution, hydrogen peroxide and povidone iodine and an immediate surgical exploration, 5 × 4 cm craniectomy was done along with removal of comminuted depressed fracture fragments and the foreign object. The foreign object was visualized and identified as a stone (3 cm×3 cm×2 cm) embedded in the parietal fracture [Figure 3]. The inner layer of the dura was found intact. The operative field was irrigated with saline and antibiotic solution. He was put on injectable antibiotics for the first five days followed by oral antibiotic till suture removal. Postoperative course was uneventful and he was discharged on postoperative Day 7. After three months he had methyl methacrylate cranioplasty for the cranial defect.
Figure 1: X-ray skull lateral view showing linear fracture located in frontal and parietal bones along with well-defined hyperdensity at the parietal region

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Figure 2: (a and b) CT scan brain plain study with bone window axial view showing hyperdense foreign body (2400 HU) in the left parietal bone with underlying bone fragments

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Figure 3: Operative photo showing left parietal lacerated wound with stone embedded in the parietal bone

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Penetrating head injuries (PHIs) most commonly occur due to high-velocity ballistic weapons and firearms. Non-missile injury is the injury caused by objects with an impact velocity less than 100 m/s. [1] Penetrating head injuries by non-missile low-velocity particles constitute a rare subgroup with the primary pathology being tissue laceration, whereas in missile injuries cavitations and shock waves cause additional tissue damage. [1]

One of the consequences of penetrating is infectious complications. In the national survey of penetrating injuries by Kaufman et al., [2] the incidence of infectious complications was 64% and brain abscess was 48% despite treatment with antibiotics. Early debridement with complete removal of foreign body along with bony fragments was recommended. [3] PHIs can result in death in 40% of cases because of damage to important structures, major vascular injury, concussion, blast injury, or infection. [4],[5]

Incidence of post-traumatic seizures is higher with penetrating head injuries compared with closed head injuries. Seizures occur in 50% of patients with penetrating trauma in a study with a follow up period of 15 years. [6] Prophylactic antiepileptic drugs are recommended in those cases in which traumatic brain lesions are evident, such as intracerebral hemorrhage, subdural hematoma and depressed skull fracture. [7] Post-traumatic epilepsy occurs more likely in cases with injury to the parenchyma. [4] Prophylactic antiepileptic drug use has no effect on the development of late epilepsy. Most patients who have not had a seizure within three years of penetrating head injury will not develop seizures. [3]

Cranial bone CT is the most important study to detect foreign objects as small as 0.06 mm and is also useful in identifying hematoma, plotting the trajectory and identifying the calvarial defect. [5] There are eight similar reports of PHI by a stone in the literature. [7] PHIs are severe traumatic injuries, have high risk of morbidity and mortality, particularly compared to closed head injuries. Immediate transport to a specialized trauma centre is mandatory. Early surgery is most important. Surgery includes complete removal of foreign body along with bone remnants, watertight dural closure and evacuation of hematoma. It is crucial to prevent any uncontrolled movement of the foreign body which could increase the damaged area. Failure to identify the foreign body early results in poor outcome. The outcome depends on the severity and location of the initial injury, the rapidity of operative exploration and debridement, and the avoidance of delayed secondary injury.

 
  References Top

1.Clark WC, Muhlbauer MS, Watridge CB, Ray MW. Analysis of 76 civilian craniocerebral gunshot wounds. J Neurosurg 1986;65:9-14.  Back to cited text no. 1
    
2.Kaufman HH, Schwab K, Salazar AM. A national survey of neurosurgical care for penetrating head injury. Surg Neurol 1991;36:370-7.  Back to cited text no. 2
    
3.Weiss GH, Salazar AM, Vance SC. Predicting post traumalic epilepsy in penetrating head injury. Arch Neurol 1986;43:771-3.  Back to cited text no. 3
    
4.Caldicott DG, Pearce A, Price R, Croser D, Brophy B. Not just another "head lac" low-velocity, penetrating intra cranial injuries: A case report and review of the literature. Injury. Int J Care Injured 2004;35:1044-54.   Back to cited text no. 4
    
5.Musa BS, Simpson BA, Hatfield RH. Recurrent self-inflicted craniocerebral injury: case report and review of the literature. Br J Neurosurg 1997;11:564-9.   Back to cited text no. 5
    
6.Temkin NR. Dikmen SS, Winn HR. Posttraumatic seizures. Neurosurg Clin North Am 1991;2:425-35.  Back to cited text no. 6
    
7.Alafaci C, Caruso G, Caffo M, Adorno AA, Cafarella D, Salpietro FM, et al. Penetrating head injury by a stone: Case report and review of the literature. Clin Neurol Neurosurg 2010;112:813-6.  Back to cited text no. 7
    


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