- Department of Neurosurgery, Emergency Teaching Hospital, Duhok, Iraq,
- College of Medicine, University of Baghdad, Baghdad, Iraq,
- Department of Neurosurgery, Kasr Alainy School of Medicine, Research and Teaching Hospitals, Cairo University, Cairo, Egypt,
- Department of Neurological and Spinal Surgery Service, Security Forces Hospital, Dammam, Saudi Arabia,
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, United States.
Waeel O. Hamouda, Professor Assistant, Department of Neurosurgery, Kasr Alainy School of Medicine, Research, and Teaching Hospitals, Cairo University, Cairo, Egypt. Senior Consultant, Neurological and Spinal Surgery Service, Security Forces Hospital, Dammam, Saudi Arabia.
DOI:10.25259/SNI_350_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Reber S. Yousif1, Alend M. Omar1, Mustafa Ismail2, Waeel O. Hamouda3,4, Aktham O. Alkhafaji2, Samer S. Hoz5. Excellent recovery after nonmissile penetrating traumatic brain injury in a child: A case report. 26-Aug-2022;13:388
How to cite this URL: Reber S. Yousif1, Alend M. Omar1, Mustafa Ismail2, Waeel O. Hamouda3,4, Aktham O. Alkhafaji2, Samer S. Hoz5. Excellent recovery after nonmissile penetrating traumatic brain injury in a child: A case report. 26-Aug-2022;13:388. Available from: https://surgicalneurologyint.com/surgicalint-articles/11823/
Background: Nonmissile penetrating traumatic brain injuries (pTBIs) are low-velocity injuries which can be caused by a variety of inflicting tools and represent a rare entity in children. Poor outcome has been attributed with an initial admission Glasgow Coma Scale (GCS) of
Case Description: We report a case of an 11-year-old boy who presented to our ER with a GCS of 6 after being assaulted on his head by a 30 cm length metallic tent hook penetrating his forehead reaching down to the central skull base zone.
Conclusion: We demonstrated that following standard recommendations in the management of pTBI which include applying the advanced trauma life support protocol in ER, acquiring the needed preoperative neuroimaging studies, avoiding moving the penetrating object till patient shifted to OR, and finally performing a planned stepwise surgical intervention through craniotomy may yield an excellent functional recovery, especially in children despite an otherwise grave initial presentation and apparently profound brain injury.
Keywords: Nonmissile, Pediatric, Penetrating traumatic brain injury, Recovery
Nonmissile penetrating traumatic brain injuries (pTBIs) are rare entity in children with different reported mechanisms of occurrence.[
An otherwise healthy 11-year-old boy presented by his family to the ER department suffering from disturbance in the level of consciousness with Glasgow Coma Scale (GCS) of 6/15 (E2, V2, M2). There has been no history suggestive of seizures. On examination, a 10 cm open wound in the left side of his forehead was evident with a skull bone defect seen beneath it through which brain tissue can be visualized. A sort of a medium-sized metallic hook used to fix tents to the ground was penetrating and anchored to the wound and the skull defect [
The decision was to intervene surgically aiming for (1) evacuation of the injury tract hematoma with achieving hemostasis, (2) elevation of the depressed frontal bone fracture with removal of any scattered accessible bony spicules, (3) cleaning and debridement of the soft tissue wound, and (4) closure in layers with the best achievable cosmetic outcome. Therefore, intraoperatively, the scalp wound was extended to perform a craniotomy centered around the hook entry site, exposing the underlying dura which was lacerated at the site of hook penetration, this was followed by cautious retrieval of the hook from within the brain under direct vision where it has been found to have a trajectory from the paramedian right frontal lobe to the contralateral posterior basal left frontal lobe sliding over the medial part of the sphenoid ridge for few millimeters into the anterior left temporal lobe [
Nonmissile pTBI is rare and constitutes only 0.4% of all brain injuries, but carries the risk of a worse prognosis than closed brain injuries,[
The initial management for nonmissile pTBI depends on the (1) advanced trauma life support (ATLS) protocol activation, (2) availability of diagnostic tools such as CT scan and angiography, and (3) the presence of experienced medical personnel as primary responders [
Regarding neuroimaging, a plain skull radiograph presents valuable information regarding the shape of the penetrating object and the existence of skull fractures[
Although, there is no standardized approach for object removal in nonmissile pTBI because it is determined by many factors, including the object site, object trajectory, patient characteristics, and brain injury mechanism,[
In cases where mass effect is present, decompressive craniectomy is usually performed to relieve the associated intracranial hypertension.[
The complications of nonmissile pTBI are limited to the penetration trajectory pathway, unlike missile injuries which usually involve cavitation and thermal effects.[
The outcome of the patients after nonmissile pTBI is mainly dependent on initial admission GCS, pupil size, and the initial CT scan findings.[
Following standard recommendations in the management of pTBI which includes applying the ATLS protocol in ER, acquiring the needed preoperative neuroimaging studies, avoiding moving the penetrating object till patient shifted to OR, and finally performing a planned stepwise surgical intervention through craniotomy may yield an excellent functional recovery, especially in children despite an otherwise grave initial presentation and apparently profound brain injury.
Patient’s consent not required as patient’s identity is not disclosed or compromised.
There are no conflicts of interest.
1. Alafaci C, Caruso G, Caffo M, Adorno AA, Cafarella D, Salpietro FM. Penetrating head injury by a stone: Case report and review of the literature. Clin Neurol Neurosurg. 2010. 112: 813-6
2. Borkar SA, Garg K, Garg M, Sharma BS. Trans orbital penetrating cerebral injury caused by a wooden stick. Surgical nuances for removal of a foreign body lodged in cavernous sinus. Childs Nerv Syst. 2014. 30: 1441-4
3. Chen L, Bao Y, Liang Y, Wang Y, Jiang J. Surgical management and outcomes of non-missile open head injury: Report of 44 cases from a single trauma centre. Brain Inj. 2016. 30: 318-23
4. de Holanda LF, Pereira BJ, Holanda RR, Neto JT, de Holanda CV, Filho MG. Neurosurgical Management of Nonmissile Penetrating Cranial Lesions. World Neurosurg. 2016. 90: 420-9
5. Dore-Duffy P, Wang S, Mehedi A, Katyshev V, Cleary K, Tapper A. Pericyte-mediated vasoconstriction underlies TBI-induced hypoperfusion. Neurol Res. 2011. 33: 176-86
6. Drosos E, Giakoumettis D, Blionas A, Mitsios A, Sfakianos G, Themistocleous M. Pediatric nonmissile penetrating head injury: Case series and literature review. World Neurosurg. 2018. 110: 193-205
7. Esposito DP, Walker JP. Contemporary management of penetrating brain injury. Neurosurg Q. 2009. 19: 249-54
8. Gökçek C, Erdem Y, Köktekir E, Karatay M, Bayar MA, Edebali N. Intracranial foreign body. Turk Neurosurg. 2007. 17: 121-4
9. González AL, Marín AG, Garijo JA, Mengual MV. Penetrating head injury in a paediatric patient caused by an electrical plug. Childs Nerv Syst. 2006. 22: 197-200
10. Kazim SF, Shamim MS, Tahir MZ, Enam SA, Waheed S. Management of penetrating brain injury. J Emerg Trauma Shock. 2011. 4: 395-402
11. Kobayashi M, Seto A, Nomura T, Yoshida T, Yamamoto M. 3D-CT highly useful in diagnosing foreign bodies in the paraesophageal orifice. Nihon Jibiinkoka Gakkai Kaiho. 2004. 107: 800-3
12. Koné N, Souleymane I, Koné B, Sissoko D, Tokpa V, Kleib A. About an observation of a child penetrating brain injury by knife. Open J Mod Neurosurg. 2021. 11: 267-71
13. Li XS, Yan J, Lui C, Luo Y, Liao XS, Yu L. Nonmissile penetrating head injuries: Surgical management and review of the literature. World Neurosurg. 2017. 98: 873.e9-25
14. Mackerle Z, Gal P. Unusual penetrating head injury in children: Personal experience and review of the literature. Childs Nerv Syst. 2009. 25: 909-13
15. Mandavia DP, Qualls S, Rokos I. Emergency airway management in penetrating neck injury. Ann Emerg Med. 2000. 35: 221-5
16. Schreckinger M, Orringer D, Thompson BG, La Marca F, Sagher O. Transorbital penetrating injury: Case series, review of the literature, and proposed management algorithm. J Neurosurg. 2011. 114: 53-61
17. Vakil MT, Singh AK. A review of penetrating brain trauma: Epidemiology, pathophysiology, imaging assessment, complications, and treatment. Emerg Radiol. 2017. 24: 301-9
18. Zyck S, Toshkezi G, Krishnamurthy S, Carter DA, Siddiqui A, Hazama A. Treatment of penetrating nonmissile traumatic brain injury case series and review of the literature. World Neurosurg. 2016. 91: 297-307