Worm-like shapes in the brain

Clinical History

Complications following nasogastric tube (NGT) insertion in patients with complex craniofacial trauma are infrequent. This report is of a rare case of inadvertent intracranial placement of a NGT in a young man after car accident but without obvious craniofacial fracture.

Imaging Findings

A 33 year old male patient was admitted to the hospital after a car accident. The patient was confused to some extent but cooperative and suffered from headache, nausea and vomiting. His GCS was 12-13 and his vital parametres stable, except for subcutaneous soft tissue swelling in the occipital and temporoparital regions. Following primary management such as IV-line fixation and nasogastric intubation, the patient was referred to the CT scan unit for evaluation of possible acute intracranial hematoma.
Plain axial brain CT scan showed no obvious skull base fracture or intracranial hemorrhage or hematoma. But surprisingly multiple worm-like shapes which coiled in different levels of the brain parenchyma were seen. The mentioned finding originated from the right inferior frontal lobe, extended to the right temporal region and ended in the left parietal lobe. Also a subgaleal hematoma at occipital and right temporoparietal regions was seen.
Regarding the CT scan finding, the possibility of iatrogenically placed material was suspected. Then, plain skull radiographs were obtained in anterior-posterior and lateral projections. The radiographs clearly depicted iatrogenically mal-positioned nasogastric tube which crossed over cribriform plate and visualized in intracranial. After this diagnosis by the radiologist, the patient was immediately transferred to the neurosurgical unit to NGT removal by neurosurgery. However, it was pulled by a young new staff member before arriving at the neurosurgeon. The person thought the NGT in the patient's stomach is blocked and does not drain properly. Thus, the patient taking full dose antibiotic coverage and closed follow up.

Discussion

NGT placement is a simple and a routine procedure that in some cases (especially emergencies) may is not performed carefully. Numerous complications associated with the displacement of NGTs have been reported including migration into the lungs, trachea and distal airways [1], or nasopharyngeal, duodenal, and gastric perforation, as well as pneumothorax, pneumomediastinum, pneumonia, laryngeal injuries, ventilatory failure, massive aspiration, and death [2,3]. Cribriform plate defect which is predisposing factor of intracranially mal-positioned nasogastric intubation could be traumatic [4,5] or non-traumatic [6] in origin. Several cases of intracranially mal-positioned nasogastric intubation have been reported throughout the world. Near all of them were seen in the deeply comatose patients with complex craniofacial fractures. On the other hand, our case was a conscious patient without obvious skull fracture. So, the present case was exclusive in this regard. Our case report highlights that an improperly passed rigid nasogastric tube, in a patient with no complicated craniofacial fracture, can penetrate completely the thin (but without overt defect) cribriform plate. Conversely, obvious cribriform plate defect is not the only source of the intracranially mal-positioned nasogastric tube. Indeed, the rigidity of the tube may lead to fracture of this thin bony barrier [6]. In one study by Bhattacharyya and Gopal [7], on 12 fresh cadavers was performed to assess the safety of NGT placement after andoscopic sinus surgery, it was observed that intracranial displacement of the tube through the surgically altered lamina cribrosa and the roof of the sphenoid sinus is unlikely but possible.
The consequences of inadvertent NGT positioning within the cranial cavity are serious, with a reported mortality rate of 64%, and severe complications can occur, including hemiparesia, blindness, smell sense loss or persistent cerebrosoinal fluid fistula and rinorea [8]. Fortunately none of these were seen in our patient. A simple radiographic study is mandatory and serves to identify misplacement of the tube. Once such misplacement has been established, an emergency CT study is essential, with the provision of adequate antibiotic coverage.

Differential Diagnosis List

Final Diagnosis

Intracranially mal-positioned nasogastric tube

URL:	https://www.eurorad.org/case/7090
DOI:	10.1594/EURORAD/CASE.7090
ISSN:	1563-4086