- Departament of Neurosurgery, Getúlio Vargas University Hospital - Federal University of Amazonas, Manaus, AM, Brazil,
- Department of Neurosurgery, Hospital Maradei - Clínica dos Acidentados, Belém, PA, Brazil,
- Department of Neurosurgery, Hospital Regional do Baixo Amazonas, Santarém, PA, Brazil,
- Department of Neurosurgery, University of São Paulo, São Paulo, SP, Brazil.
Daniel Buzaglo Gonçalves, Faculty of Medicine, Federal University of Amazonas, Manaus, Amazonas, Brazil.
DOI:10.25259/SNI_279_2021Copyright: © 2021 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, tweak, 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: Mylena Miki Lopes Ideta1, Louise Makarem Oliveira1, Gustavo Lopes de Castro1, Marco Antonio Leal Santos2, Erik Leonardo Jennings Simões3, Daniel Buzaglo Gonçalves1, Robson Luis Oliveira de Amorim1,4. Traumatic brain injury caused by Brazil-nut fruit in the Amazon: A case series. 09-Aug-2021;12:399
How to cite this URL: Mylena Miki Lopes Ideta1, Louise Makarem Oliveira1, Gustavo Lopes de Castro1, Marco Antonio Leal Santos2, Erik Leonardo Jennings Simões3, Daniel Buzaglo Gonçalves1, Robson Luis Oliveira de Amorim1,4. Traumatic brain injury caused by Brazil-nut fruit in the Amazon: A case series. 09-Aug-2021;12:399. Available from: https://surgicalneurologyint.com/surgicalint-articles/11029/
Background: Traumatic brain injury (TBI) represents one of the leading public health problems and a significant cause of neurological damage. Unintentional causes of TBI are the most frequent. However, fruit falling over the head causing TBI is extremely rare. In the Amazon region, accidents with ouriços, a coconut-like shell fruit, seem relatively common. However, to the best our knowledge, it has never been described in a scientific journal before. Therefore, we aim to evaluate a series of TBI caused by this tropical fruit.
Methods: This study is a retrospective review of 7 TBI cases due to the fall of ouriços admitted to two tertiary hospitals in the Amazon region from January 2017 to December 2018. The collected data included: age, Glasgow Coma Scale, skull fracture, venous sinus injury, hematoma, surgical treatment, and outcome.
Results: All patients were men, with an average age of 38, ranging from 8 to 77-years-old. Four out of seven had skull fractures. Five patients developed an epidural hematoma, and two of them had an associated subdural hematoma. Dura mater injury was observed in two patients, whereas four patients were operated. There was one related death.
Conclusion: This case series is the first to describe an unconventional but potentially fatal cause of TBI in the Amazon: the falling of the Brazil-nut fruit. Most patients were diagnosed with mild TBI. Nevertheless, patients may have cranial fractures and epidural hematomas, leading to death when there’s a delay in medical assistance.
Keywords: Amazon, Brazil nut tree, Epidemiology, Traumatic brain injury, Unintentional injury
Traumatic brain injury (TBI) represents one of the leading public health problems and an important cause of neurological damage, with high morbimortality rates. It occurs in all age groups, but it is more frequent in young men.[
The unintentional causes of TBI are far more common than the others. Accidentally being struck by or against an object, for instance, was responsible for 15.4% of all TBI emergency department visits, hospitalization, and deaths in the United States from 2007 to 2013, with most cases occurring among those aged 0–24-years-old.[
Grivna et al. (2013) have described that falling objects accounted for 6% of all trauma injuries and that the head was the third most commonly harmed anatomical site, representing 19.5% of the cases.[
In the Amazon Forest, there’s the Brazil-nut tree. Its fruit, a coconut-like shell called “ouriço,” is much heavier than the coconut from palm trees. Despite the recurrent news in local media,[
Although, lying in the middle of the Amazon forest and isolated from most of the country due to the lack of roads, Manaus is the only city providing specialized care for TBI patients to Amazonas state,[
This study is a retrospective review of TBI cases due to Brazil-nut fruit - ouriços - fall admitted in the main trauma hospital in Manaus (Hospital e Pronto-Socorro João Lúcio Pereira Machado) and Santarém (Hospital Municipal), from January 2017 to December 2018. The clinical data were collected through medical charts and included: age, Glasgow Coma Scale (GCS), skull fracture, venous sinus injury, hematoma, surgical treatment, and outcome. The tomographic findings were reviewed from the digital files of both hospitals. Due to a lack of information regarding skull fractures in the attending neurosurgeon’s operative report, the data “skull fracture” was collected only from the computed tomography (CT) findings. Informed consent was obtained from all individual participants included in the study.
A 13-year-old with emesis, dizziness, dysarthria, right paresis, and paresthesia was admitted to our service with the initial GCS of 13. He was initially evaluated at a local hospital in the countryside, where he received analgesics, mannitol, and corticosteroids. After being transferred to Manaus, he underwent a cranial CT which revealed a left parietal epidural hematoma [
A 15-year-old boy struck by brazil-nut fruit in the occipital region presented with intense headache, emesis, and visual turbidity. At the first evaluation in a local hospital, the patient received analgesics and corticosteroids. He was transferred to Manaus and arrived at our service with a GCS of 15. The cranial CT findings were pneumocephalus and occipital fracture associated with epidural hematoma [
A 68-year-old Brazil-nut collector suffered from TBI due to a falling ouriço over the right parietal region. He presented at the local emergency department with confusion, headache, dizziness, dysarthria, paresis, and blurred vision. The referral to our hospital occurred only after 3 days, with a GCS of 15. Head CT showed a frontal-occipital subarachnoid hemorrhage and right temporoparietal intracerebral hemorrhage [
In this case series, all patients were men and from the countryside, among which two were agriculturists. The average age was 38, ranging from 8 to 77-years-old.
Four patients had skull fractures - half of which were in the frontoparietal region. The most common intracranial finding was extradural hematoma, seen in five patients, and one of them had an associated acute subdural hematoma. Furthermore, two patients had dura mater injury and subarachnoid hemorrhage – and one of them also had an intracerebral hemorrhage. Surgical treatment was performed in four patients. In all of them, we performed craniotomy with hematoma evacuation. Finally, the only death occurred in a child admitted lately in the emergency department, with a GCS of 3 and no brain stem function signs. Head CT revealed a large epidural hematoma that was not evacuated. Details are summarized in [
This case series is the first about TBI caused by ouriços falling. Clinical manifestations may vary, but most patients evolve with total recovery. Epileptic seizures, paresis, and paresthesia are some of the most frequently observed symptoms. It is vital to highlight that resulting lesions can lead to unfavorable outcomes that include death,[
Brazil-Nut Tree (Bertholletia excelsa) reaches from 30 m to 50 m[
Aiming to assess ouriços’ damage when hitting the human’s head, it is imperative to consider some variables, such as fall velocity and angle, fruit density, and diameter. If an ouriços weighting 0.75 kg falls from 50 m, the impact velocity is 31.32 m/s – about 1.4 times greater than the impact velocity of a coconut fruit, as described by Barss et al. (1984).[
Children seem to be a risk group for severe and fatal lesions since their skull’s resistance to fractures is considerably lower than adults’. For example, the fracture resistance for an adult is 11 times greater than that of a neonate.[
Due to the nature of the injury - an impact on the head’s top – it was expected that the prominent cranial abnormalities were fractures and extradural hematomas. Although most patients were admitted with few clinical manifestations, the presence of an epidural hematoma without any focal neurological symptom is not rare. We must remember that these injuries are associated with a lucid interval, after which the neurological condition may deteriorate.
Thus, in patients with a GCS lower than 15 or with a high-impact trauma history, head CT is mandatory, as well as in children with irritability, subgaleal hematoma, and a history of loss of consciousness after TBI.[
A paramount issue is that Amazon comprises a large territorial extent without homogeneously distributed health services and efficient transportation. Moreover, primary care may be flawed as many patients receive corticosteroids, not indicated for TBI patients.[
Manaus is the only city of the Amazonas state,[
This case series has some limitations, mainly due to its retrospective nature, as the epidemiological data were not seldomly missing or incomplete. However, most critical clinical data were collected, and the CT scans could be reviewed from the digital records.
Implementation of public health measures is essential to prevent these accidents, such as encouraging personal protective equipment whenever collecting ouriços. Furthermore, family orientation programs in at-risk regions should be established. Finally, centers with a prepared team and head CT scans should be implemented in countryside cities, and rapid transportation to Manaus and Santarém should be guaranteed whenever necessary.
These case series is the first to describe an unconventional but potentially fatal cause of TBI in the Amazon: the falling of the Brazil-nut fruit. Although most cases are considered “mild TBI,” patients may have cranial fractures and extradural hematomas, responsible for a significant morbimortality if proper medical assistance is delayed.
The patient history, radiology, and other imaging, ECG, histology and morphology, and other types of data used to support the findings of this study are available from the corresponding author on request.
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