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Table of Contents    
LETTER TO EDITOR
Year : 2016  |  Volume : 64  |  Issue : 5  |  Page : 1081-1082

Penetrating injury of the posterior cranial fossa by a stone


Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

Date of Web Publication12-Sep-2016

Correspondence Address:
Anand K Jha
Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.190272

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How to cite this article:
Jha AK, Kumar J, Harsh V, Kumar A. Penetrating injury of the posterior cranial fossa by a stone. Neurol India 2016;64:1081-2

How to cite this URL:
Jha AK, Kumar J, Harsh V, Kumar A. Penetrating injury of the posterior cranial fossa by a stone. Neurol India [serial online] 2016 [cited 2019 Nov 19];64:1081-2. Available from: http://www.neurologyindia.com/text.asp?2016/64/5/1081/190272




Sir,

Trans-cranial penetration by a stone is relatively rare. Trans-cranial penetrating injuries by a stone, a wooden piece, or a metal chopstick are usually through the orbit, nose, ear, squamous part of the temporal bone, or the thin walled skull. Direct penetration of the foreign body into the posterior cranial fossa is rare because of the thickness of the surrounding bone. Few cases of penetrating posterior cranial fossa have been described in the literature [1],[2],[3],[4],[5],[6],[7] and none of them have direct penetration into the posterior cranial fossa. We present a case having a unique mode and site of injury.

A 22-year old female patient was admitted with a history of penetrating head injury due to a fall from a motor bike. She was admitted after 6 hours of the injury. Her attendant stated that she had a history of loss of consciousness, and repeated episodes of vomiting. There was no history of convulsions or ear bleed. The patient also complained of severe headache, and imbalance on walking. On examination, she was well oriented to time, place, and person. The Glasgow coma scale was E4V5M6 and the vitals were stable (pulse: 90/m, blood pressure: 100/70mm Hg, Respiratory rate: 18 cycle/m). The pupils were bilaterally equal in size and reacting normally to light. The brain stem reflexes were normal. On cerebellar examination, rapid alternating movement by the left hand was slow and clumsy; and, finger-to-finger and finger to-nose test by the left hand was slow and clumsy with past pointing. Signs of meningitis were absent. A stitched wound of 5cm over the left side of the suboccipital region was observed [Figure 1]. Computed tomography (CT) of the head and skull showed a hyperdense foreign body on the left side of the posterior fossa with the associated presence of left cerebellar contusion [Figure 2]a and [Figure 2]b. After taking antitetanus and antimeningitic measures, she underwent surgery under general anesthesia in prone position and a craniectomy was performed [Figure 3]a around the foreign body to free it from the bone. The foreign body was gently extracted keeping in line with its trajectory and the procedure was met with very little resistance. The wound was inspected under direct vision for any bleeding, or cerebrospinal fluid flow. The dura was found to be torn and contused with part of cerebellum herniating through it [Figure 3]a and [Figure 3]b. The brain was thoroughly irrigated, the dura was repaired and the wound was closed in layers. The patient was put on antimeningitic medication. The post-operative period was uneventful and the patient was discharged on the 12th post-operative day without any sequelae. The post-operative CT scan showed the left side of posterior fossa bony defect with the presence of normal brain parenchyma [Figure 4].
Figure 1: A stitched wound over the left side of the suboccipital region

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Figure 2: (a and b) A hyperdense foreign body penetrating into the left side of the posterior cranial fossa with left cerebellar contusion

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Figure 3: (a and b) Intraoperative figure shows the penetrated stone and its actual size and shape seen following its successful removal

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Figure 4: Postoperative CT scan of the brain and skull showing the left posterior fossa bony defect with a normal brain parenchyma

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Penetrating injuries of the skull and brain parenchyma are relatively rare, constituting about 0.4% of head injuries.[9] Trans-cranial penetrating injuries with a stone, wooden objects, or metal chopsticks are usually through the orbit, nose, ear, squamous part of the temporal bone, or thorugh the thin-walled skull.

Direct penetration of the foreign body into the posterior cranial fossa is rare because of the surrounding thick bone. Only a few cases of penetrating injury into the posterior cranial fossa by foreign bodies through the orbit, nose, ear, and the squamous part of the temporal bone have been reported in literature.[1],[2],[3],[4],[5],[6],[7] We compared our findings with other published reports in the literature. Posterior cranial fossa penetration by a foreign body occurred mainly in the pediatric male patients due to falls that occur in the foreign body penetration along a precise trajectory through thin bony areas such as the orbit, nostril, auditory canal, oral cavity, and temporal squamous bone to reach the posterior cranial fossa. However, in our report, posterior cranial fossa penetration by stone occurred in an adult female patient. It resulted from a fall from motor bike (road traffic accident), with a direct penetration into the posterior cranial fossa. All the cases reported in the literature had maximum neurological deterioration at the time of injury except in the case described by Amano and Kamano [1] and Ishikawa et al.[7] However, our case presented to us after 6h of the injury with feature of raised intracranial pressure and cerebellar dysfunctionThe computed tomographic scan findings in our case was the presence of a hyperdense foreign body on the left side of the posterior cranial fossa with an associated cerebellar contusion. The occurrence of a cerebellar abscess due to penetrating injury by foreign bodies have been reported.[1],[2],[3],[4],[5],[6],[7] In our case, after removal of the stony foreign body, no evidence of abscess were seen on the CT scan. Institution of broad spectrum antibiotic coverage to prevent infection in mandatory in penetrating injuries by stony foreign bodies. Prompt surgical intervention in a case of posterior cranial fossa penetrating injury, therefore, prevents undue morbidity and mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Amano K, Kamano S. Cerebellar abscess due to penetrating orbital wound. Case report. J Comput Assist Tomogr 1982:6:1163-6,  Back to cited text no. 1
    
2.
Yamamoto I, Yamada S, Sato O: Unusual craniocerebral penetrating injury by a chopstick. Surg Neurol 1985:23:96-8,  Back to cited text no. 2
    
3.
Ildan F, Bagdatoglu H, Boyar B, Doganay M, Cetinalp E, Karadayi A, The nonsurgical management of a penetratingorbitocranial injury reaching the brainstem: Case report. J Trauma 1994;36:116- 8,  Back to cited text no. 3
    
4.
Kuroiwa T, Tanabe H, Ogawa D. Chopstick penetration of the posterior cranial fossa: Case report. Surg Neurol 1995;43:68- 9  Back to cited text no. 4
    
5.
Mori Y, Shibata T, Kajita Y. Penetrating intracranial foreign bodies. Nihon Kyukyu Igakukai Zasshi 1996;7:191-6  Back to cited text no. 5
    
6.
Shigemori M, Tokutomi T, Kikuchi Y. Brain injury. In: Shigemori M, Katayama Y, Kobayashi S, editors, Head injury of the children. Tokyo, Igakushion; 1996, pp 95-7  Back to cited text no. 6
    
7.
Ishikawa E, Meguro K, Yanaka K, Murakami T, Narushima K, Aoki T, et al.: Intracerebellar penetrating injury and abscess due to a wooden foreign body: Case report. Neurol Med Chir 2000;40;458-462  Back to cited text no. 7
    
8.
Satyarthee GD, Borkar SA, Tripathi AK, Sharma BS. Transorbital penetrating cerebral injury with a ceramic stone: Report of an interesting case. Neurol India 2009;57:331-3  Back to cited text no. 8
    
9.
Gennarelli TA, Champion HR, Sacco WJ, Copes WS, Alves WM. Mortality of patients with head injury and extracranial injury treated in trauma centers. J Trauma 1989;29:1193-2019  Back to cited text no. 9
    


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