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|LETTER TO EDITOR
|Year : 2016 | Volume
| Issue : 5 | Page : 1081-1082
Penetrating injury of the posterior cranial fossa by a stone
Anand K Jha, Jayendra Kumar, Virat Harsh, Anil Kumar
Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
|Date of Web Publication||12-Sep-2016|
Anand K Jha
Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand
Source of Support: None, Conflict of Interest: None
|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
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 ,,,,,, 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. 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.,,,,,, 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  and Ishikawa et al. 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.,,,,,, 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.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]