Successful management of a penetrating iron-rod injury through the oral cavity involving the posterior cranial fossa
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/neuroindia.NI_870_16
Source of Support: None, Conflict of Interest: None
Craniocerebral penetrating injuries are infrequent and are always associated with a history of trauma such as falls or unexpected accidents. The front of the head, the convexity of the skull, and the anterior cranial fossa are the most common sites that may be involved. Foreign bodies including missiles, nails, and iron bars are the common causes of cranial penetrating injury., There are only a few studies reporting on cranial base penetrating injuries occurring through the oral cavity, especially where the penetrating object involved the posterior cranial fossa.
A 25-year old male patient fell from a 2-meter high platform with his face facing downwards; a protruding iron rod penetrated the deeper tissues of his oral cavity during the fall. The connected iron rod was cut off by firemen after approximately 2 hours, and the patient was sent to a local hospital. Emergent evaluation showed that there was no evidence of progressive neurological defect, cognitive dysfunction, or shock, and the airway was not obstructed. The Glasgow Coma Scale (GCS) score was 15. Plain X-ray of the head displayed an iron bar penetrating through the oral cavity and skull base [Figure 1]a and [Figure 1]b Four hours later, the patient was transferred to our department. Neurological examination revealed that there was a subcutaneous mass in his neck. The GCS at that time was 14, and the patient began to walk with instability but with stable vital signs. For a further assessment of the site of penetration, a three-dimensional reconstructed (TDR) computed tomographic (CT) scan of the head and neck was performed [Figure 1]c and [Figure 1]d. The digital subtraction angiography (DSA) demonstrated that there was no injury to the internal carotid artery or the vertebral artery [Figure 1]e and [Figure 1]f. There is neither pseudo-aneurysm formation nor was there injury to the vertebral or internal carotid artery.
Fifteen hours later, an emergent surgery was performed together by a neurosurgeon and an oral surgeon under general anesthesia. We chose the traditional midline posterior fossa approach for decompression, choosing to operate upon this patient in a lateral prone posture [Figure 2]a and [Figure 2]b. We exposed the operative field, and the iron rod and the plates surrounding the rod were taken out with a rongeur in a piecemeal manner. The size of the bone window was approximately 5 cm × 5 cm [Figure 2]b. After opening the dura, the existing subdural hematoma and part of the contused cerebellar tissue was removed for better decompression and exploration. We discovered that the iron rod was close to the vertebral artery; however, there were no signs of injury to the vertebral artery. Next, the 25-cm long iron bar was slowly pulled out from the front. there was no occurrence of hemorrhage during this process [Figure 2]c despite the presence of raised systemic blood pressure. Ultimately, a drainage tube was placed into the operative cavity after the removal of the rod, and the dissected layers were sutured.
Postoperatively, the patient was sent to the neurological intensive care unit. One day later, the computed tomography (CT) scan displayed slight edema of the cerebellar tissue [Figure 2]d. The patient woke up in a good physical condition, and was sent back to the general ward with continued broad-spectrum antibiotics and antiepileptic treatment. The volume of drainage gradually decreased from 320 to 30 ml, and hence, the tube was removed 4 days later. A repeat CT scan did not show any significantly abnormal findings and the edema had lessened [Figure 2]e. Five days later, the patient recovered without complications and was sent back to a local community hospital for rehabilitation. At a 3-month follow-up appointment, he had no neurological defects and had recovered well; a review magnetic resonance imaging (MRI) showed that there a gliotic focus at the site of injury in the right cerebellum [Figure 2]f. A cranioplasty at the surgical site was performed 3 months later.
We present the case of a severe craniocerebral penetrating injury successfully management at our centre. In this study, the plain X-rays, three dimension reconstructed CT images and a DSA adequately demonstrated the neurovascular structures surrounding the penetrating rod. In 2004, Peter et al., used a three dimension reconstructed CT scan to reconstruct a scenario similar to that seen in the case of Phineas Gage, who had been wounded one and a half centuries ago. Usually, DSA is necessary to locate the injured arteries or the site of the pseudoaneurysm. A previous study on penetrating head injury found that most patients (7/12) underwent a DSA, and one of the patients was discovered to be having a pseudoaneurysm. On the other hand, the CT or MRI findings could show image artifacts produced by the metal; they are often more useful in delineating wooden foreign bodies.
Rather than hastening the process of removal of the penetrating rod, an optimal timing of surgery is advisable so that the procedure is performed after a proper preoperative planning, deciding the interdisciplinary cooperation, and the postoperative steps required. A study on craniocerebral penetrating injuries found that patients with a Glasgow Coma Scale (GCS) score of 3–4 should be operated faster for attaining a better postoperative outcome; however, patients presenting with a GCS score of 14–15 should first be evaluated in detail prior to undertaking the actual procedure for removal of the penetrating object, in order to achieve better postoperative results and survival. Some patient with missile injures that involve non-eloquent areas are better off with a conservative treatment. In our study, the patient's GCS score was good, and therefore, surgery was undertaken only after his proper clinical and radiological evaluation.
During the surgery, we chose the Spennato's technique, which is also known as the 'double concentric' craniotomy. Moreover, the patient had an oral injury, and hence, the dental surgeon's help was sought. Many complicated craniocerebral penetrating injuries need a multidisciplinary approach and ophthalmological, otolaryngological, and maxillofacial surgeons should also join in the management of these patients. This cooperation can help to bring about a functionally useful recovery and also decreases the risk of complications, including cerebrospinal fluid leakage and intracranial infection.
Fortunately, there were no severe complications with continued supportive treatment. Infection was an intractable problem encountered during the management of a penetrating injury. The rate of infection is approximately 8% and might be the major cause of death. The removal of injured tissue and institution of an adequate drainage are critical steps in order to prevent a postoperative intracranial infection. The prolonged administration of broad-spectrum antibiotic treatment has been recommended.
The patient included in this study had a good postoperative outcome; however, the incidence of mortality associated with a penetrating head injury is quite high. A study reported that 70% of 110 patients with penetrating injury died in the hospital. An American study on craniocerebral gunshot wounds demonstrated that only 30.4% of the patients survived. Another study on nail gun-related head injury showed a lower rate of death; however, the mortality was still much higher than that observed in the more commonly encountered blunt head trauma.
To conclude, a comprehensive preoperative examination, an emergent surgery, interdisciplinary cooperation, and postoperative supportive treatment are helpful to achieve a good outcome in the presence of a craniocerebral penetrating injury.
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[Figure 1], [Figure 2]