Figure 1
PRE-OPERATIVE CT SCAN IMAGES.
An unusual case of penetrating head injury by cutting plier
SectionHead & neck imaging
Case TypeClinical Cases
AuthorsNemsadze G, Hatti D, Biradar S, Shelia V, Jvarsheishvili A, Dzneladze Z, Lapiashvili E, Goletiani T
Connected authors
64 years, male
Clinical History
A male patient came with a foreign body penetrating the right eye and chief complaints of pain. The patient gave a history of accidental penetration of a cutting plier in the right eye. The patient was conscious, cooperative and well oriented to time, place and person with Glasgow Coma Scale 15.
Imaging Findings
Preoperative CT findings (Fig 1, 2): on the right side of the frontal lobe, periorbital space and intracranial space a high metallic density foreign body is seen. (Fig. 1a-d).
Due to strong metallic artefacts we were unable to identify the anterior and middle fossa of the brain and fractures. (Fig. 2).
Post-operative CT findings (Fig 3, 4): Intracranial haemorrhage is present extending from the right frontal lobe to the anterior limb of the internal capsule and putamen. (Fig. 3a). The haemorrhage appears hyperdens with surrounding edema and effacement of the right lateral ventricle and sylvian fissure as a sign of mass effect (Fig. 3b).
Intraorbital findings on the postoperative scan are bone fragments around the medial aspect of the sclera and within the retrobulbar space and soft tissues of the right orbit (Fig. 4a).
Increased attenuation in right frontal sinus is suggestive of hemorrhage ie hemosinus (Fig. 4b). Multiple bone fragments of the right orbital roof are seen (Fig. 4b).
Due to strong metallic artefacts we were unable to identify the anterior and middle fossa of the brain and fractures. (Fig. 2).
Post-operative CT findings (Fig 3, 4): Intracranial haemorrhage is present extending from the right frontal lobe to the anterior limb of the internal capsule and putamen. (Fig. 3a). The haemorrhage appears hyperdens with surrounding edema and effacement of the right lateral ventricle and sylvian fissure as a sign of mass effect (Fig. 3b).
Intraorbital findings on the postoperative scan are bone fragments around the medial aspect of the sclera and within the retrobulbar space and soft tissues of the right orbit (Fig. 4a).
Increased attenuation in right frontal sinus is suggestive of hemorrhage ie hemosinus (Fig. 4b). Multiple bone fragments of the right orbital roof are seen (Fig. 4b).
Discussion
Definition: A penetrating head injury is a type of head injury in which the dura mater and the outer layer of meninges is pierced by a projectile or objects.
Epidemiology: Annually 1.9 million people in United States experience skull fracture or intracranial injury [1].
Causes: Injuries maybe caused by gunshots (most common), unintentional falls (common), stab wounds (with knife, nails, metal-poles, keys, pencils, ice-packs. etc), motor vehicle or occupational accidents (nails, screwdrivers) [2]
Pathophysiology: In our case the penetrating head injury is caused by a cutting plier (stab wound) which is uncommon and causes injury of low-velocity type.
Damage caused by such low-velocity penetrating injury is restricted to the path of the (stab)wound and does not cause much cavitation. Predominantly it is more likely to cause infection, intracranial haemorrhage and increased intracranial pressure [2].
Clinical presentation: Patients present with pain, headache, loss of consciousness or may sometimes be asymptomatic.
Imaging Perspective: Diagnosistic evaluation is done by skull X-ray and CT. MRI is contraindicated because ferromagnetic objects experience a deflection in the presence of magnetic field. In our case X-Ray was not taken. As it is an emergency condition, CT is the investigation of choice.
Key Findings:Foreign body location and extension of intracranial injury can be seen.
Fractures can be seen, but in our case we were unable to identify them due to high metallic density artifact. Sub-arachnoid haemorrhage, intraventricular haemorrhage, diffuse oedema or pneumocephalus can be seen.
CT angiography: This examination is done in case of suspected blood vessel injury. In our case angiography was not performed because blood vessel injury was not suspected [3]. After confirming the location of the foreign body and extension of the intracranial injury and skull fracture, emergency operation was performed under GA. Operative Procedure: The foreign body was released by cutting the right medial orbital wall and was removed manually. Electrocoagulation and hemostatic sponge was used to stop minor bleeding. There was approximately 10ml of blood loss. No active bleeding was noticed. Postoperative consequences: the patient was on mechanical ventilator for 10days due to dyspnea and on 11th day tracheostomy was done. The patient developed chemosis in the right eye.
Prognosis: Prognosis of penetrating lesions mainly depends on the type and site of injury. As in this case the eyeball and vital structures were not involved leaving a good prognosis. The patient is doing well without ophthalmological and neurological complications. Possible causes for poor prognosis are injuries involving the temporal fossa or injury to vital structures such as th ediencephalon and mesencephalon or unilateral multilobe injury [3].
Complications:the course may be complicated by abscess formation, seizures , pneumocephalus , cerebrospinal fistula , neuro-endocrine dysfunction [3].
Epidemiology: Annually 1.9 million people in United States experience skull fracture or intracranial injury [1].
Causes: Injuries maybe caused by gunshots (most common), unintentional falls (common), stab wounds (with knife, nails, metal-poles, keys, pencils, ice-packs. etc), motor vehicle or occupational accidents (nails, screwdrivers) [2]
Pathophysiology: In our case the penetrating head injury is caused by a cutting plier (stab wound) which is uncommon and causes injury of low-velocity type.
Damage caused by such low-velocity penetrating injury is restricted to the path of the (stab)wound and does not cause much cavitation. Predominantly it is more likely to cause infection, intracranial haemorrhage and increased intracranial pressure [2].
Clinical presentation: Patients present with pain, headache, loss of consciousness or may sometimes be asymptomatic.
Imaging Perspective: Diagnosistic evaluation is done by skull X-ray and CT. MRI is contraindicated because ferromagnetic objects experience a deflection in the presence of magnetic field. In our case X-Ray was not taken. As it is an emergency condition, CT is the investigation of choice.
Key Findings:Foreign body location and extension of intracranial injury can be seen.
Fractures can be seen, but in our case we were unable to identify them due to high metallic density artifact. Sub-arachnoid haemorrhage, intraventricular haemorrhage, diffuse oedema or pneumocephalus can be seen.
CT angiography: This examination is done in case of suspected blood vessel injury. In our case angiography was not performed because blood vessel injury was not suspected [3]. After confirming the location of the foreign body and extension of the intracranial injury and skull fracture, emergency operation was performed under GA. Operative Procedure: The foreign body was released by cutting the right medial orbital wall and was removed manually. Electrocoagulation and hemostatic sponge was used to stop minor bleeding. There was approximately 10ml of blood loss. No active bleeding was noticed. Postoperative consequences: the patient was on mechanical ventilator for 10days due to dyspnea and on 11th day tracheostomy was done. The patient developed chemosis in the right eye.
Prognosis: Prognosis of penetrating lesions mainly depends on the type and site of injury. As in this case the eyeball and vital structures were not involved leaving a good prognosis. The patient is doing well without ophthalmological and neurological complications. Possible causes for poor prognosis are injuries involving the temporal fossa or injury to vital structures such as th ediencephalon and mesencephalon or unilateral multilobe injury [3].
Complications:the course may be complicated by abscess formation, seizures , pneumocephalus , cerebrospinal fistula , neuro-endocrine dysfunction [3].
Differential Diagnosis List
Acute penetrating intracerebral hemorrhage with Rt frontal hemosinus with multiple fragmentary fracture of cranial base.
Intracerebral Hematoma
Sub-arachnoid Hemorrhage
Intraventricular Hemorrhage
Final Diagnosis
Acute penetrating intracerebral hemorrhage with Rt frontal hemosinus with multiple fragmentary fracture of cranial base.
References
[1] Frederico C Vinas, Chief Editor: Allen R Wyler (2011) Penetrating Head Trauma. http://emedicine.medscape.com/article/247664-overview#a0199
[2] Karim T, Topno M (2010) An unusual case of penetrating head injury in a child. J Emergency Trauma Shock 3:197-8 (PMID: 20606803)
[3] John R Haaga (2009) CT and MRI of the whole body. Central Nervous System Trauma. 5th edition VOL-1 PG NO:321-322.
Case information
| URL: | https://www.eurorad.org/case/9932 |
| DOI: | 10.1594/EURORAD/CASE.9932 |
| ISSN: | 1563-4086 |
Figure 2
AXIAL CT SCAN IMAGE.
Strong metallic artefact shown, therefore unable to identify the basal and middle structures of the brain and fractures.
Figure 3
POST-OPERATIVE AXIAL CT SCAN IMAGE.
Haemorrhage extending from the right frontal lobe to the anterior limb of the internal capsule and putamen.
Hemorrhage appearing as a hyperdens mass with surrounding edema and effacement of the Sylvian fissure and the anterior and posterior horn of the right lateral ventricle associated with mass effect.
Figure 4
POST-OPERATIVE INTRAORBITAL CT FINDINGS.
PRE-OPERATIVE CT SCAN IMAGES.
SCOUT VIEW SHOWING FOREIGN BODY.
Department of Radiology, Central Clinical Hospital Tbilisi, Georgia 2012.
Department of Radiology, Central Clinical Hospital Tbilisi, Georgia 2012.
3D RECONSTRUCTION VR
Department of Radiology, Central Clinical Hospital Tbilisi, Georgia 2012.
Department of Radiology, Central Clinical Hospital Tbilisi, Georgia 2012.
SUPERIOR INFERIOR OBLIQUE PLANE.
Department of Radiology, Central Clinical Hospital Tbilisi, Georgia 2012.
Department of Radiology, Central Clinical Hospital Tbilisi, Georgia 2012.
MIP RECONSTRUCTION.
Department of Radiology, Central Clinical Hospital Tbilisi, Georgia 2012.
Department of Radiology, Central Clinical Hospital Tbilisi, Georgia 2012.
AXIAL CT SCAN IMAGE.
Strong metallic artefact shown, therefore unable to identify the basal and middle structures of the brain and fractures.
Department of Radiology, Tbilisi Central Clinical Hospital Tbilisi Georgia 2012.
Department of Radiology, Tbilisi Central Clinical Hospital Tbilisi Georgia 2012.
POST-OPERATIVE AXIAL CT SCAN IMAGE.
Haemorrhage extending from the right frontal lobe to the anterior limb of the internal capsule and putamen.
Department of Radiology, Tbilisi Central Clinical Hospital Tbilisi Georgia 2012.
Department of Radiology, Tbilisi Central Clinical Hospital Tbilisi Georgia 2012.
Hemorrhage appearing as a hyperdens mass with surrounding edema and effacement of the Sylvian fissure and the anterior and posterior horn of the right lateral ventricle associated with mass effect.
Department of Radiology, Tbilisi Central Clinical Hospital Tbilisi Georgia 2012.
Department of Radiology, Tbilisi Central Clinical Hospital Tbilisi Georgia 2012.
POST-OPERATIVE INTRAORBITAL CT FINDINGS.
Bony fragments were seen around the medial aspect of the right sclera, within the retrobulbar space and soft tissue around the medial side of the orbit.
Department of Radiology, Tbilisi Central Clinical Hospital Tbilisi Georgia 2012.
Department of Radiology, Tbilisi Central Clinical Hospital Tbilisi Georgia 2012.
Increased attenuation in the right frontal sinus suggesting hemorrhage, ie hemosinus and multiple fractures of the right orbital roof.
Department of Radiology, Tbilisi Central Clinical Hospital Tbilisi Georgia 2012.
Department of Radiology, Tbilisi Central Clinical Hospital Tbilisi Georgia 2012.