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Interventional cerebral angiogram performed 4 days following a penetrating gunshot wound to the head showing a 3.35mm fusiform pseudoaneurysm along the M4 segment of the right middle cerebral artery.
Source publication
![Figure 3: Patterns of penetrating head wounds [12]. Used with permission.](profile/David-Van-Wyck-2/publication/291017886/figure/fig2/AS:359843597701121@1462804807448/Patterns-of-penetrating-head-wounds-12-Used-with-permission_Q320.jpg)
Penetrating traumatic brain injury (pTBI) remains one of the most devastating and lethal forms of trauma. Prognosis is generally poor and, for those who survive long enough to make it to the hospital, the management of penetrating brain injury presents complex challenges to medical and surgical providers in the civilian sector. Recent experiences i...
Context in source publication
Context 1
... with the knowledge that mitochondrial damage in the cavitation zone results in the release of various neuro-inflammatory mediators that cause tissue necrosis and neuronal apoptosis in distant tissues, this information provides evidence that peri-lesional regions should be amenable to acute surgical and medical therapies and yet-to- be identified neuroprotectants [15] (Figure 4). In contrast to non-penetrating TBIs, hemorrhagic shock and cardiac arrest can occur secondary to blood loss. ...
Citations
... Improving access to pre-hospital, emergency, and good intensive medical care and prompt surgical interventions may improve the outcomes of TBI patients (Chowdhury et al., 2014;Van Wyck et al., 2015). Patients with head injuries usually require admission to the Intensive Care Unit (ICU) both before and after surgery (Stefiyan and Permono, 2021) and the Brain Trauma Foundation recommends the management of patients with TBI in the ICU (Stocchetti et al., 2017). ...
Background
Traumatic Brain Injury (TBI) is a substantial cause of morbidity and mortality across all age groups. However, there is a paucity of research on outcomes and associated factors of mortality among patients with TBI admitted to the Intensive Care Unit (ICU) in low-income countries, including Ethiopia.
Objective
To assess the outcomes and associated factors of mortality among patients with TBI admitted to ICU in comprehensive specialized hospitals in Amhara region, Ethiopia.
Methods and materials
Institutional-based cross-sectional study was conducted among 241 patients with TBI and selected by using simple random sampling method. Data collected by using Kobo collect was exported into SPSS version 25 for analysis. An Adjusted Odds Ratio (AOR) with 95% Confidence Intervals (CI) was computed, and variables with a P-value < 0.05 were considered statistically significant.
Result
From a total of 241 TBI patients admitted to the ICU, 50.2%, 39.4%, 5.4% and 5% were improved, died, transfer out and left against medical advice, respectively. The presence of complications (AOR = 4.53, 95% CI: 1.87, 11.00), Glasgow Coma Scale (GCS) score < 9 (AOR = 4.97; 95% CI: 1.76, 14.06), comorbidity (AOR = 3.35, 95% CI: 1.35, 9.10), co-existing injury (AOR = 3.31, 95% CI: 1.44, 7.60), and being on mechanical ventilation (AOR = 2.81, 95% CI: 1.18, 6.70) were all significantly associated with mortality.
Conclusions
The overall mortality of patients with traumatic brain injury who admitted to the ICU was high. GCS score < 9, presence of complications, comorbidity, co-existing injury, and being on mechanical ventilation were significantly associated with mortality. Special attention should be given to those TBI patients with lower GCS, comorbidity, co-existing injury, and being on mechanical ventilation.
... Penetrating brain injury (PBI) is a subtype of traumatic brain injury (TBI) causing significant mortality in trauma patients [1]. The incidence of PBI has increased in the past 2 decades with approximately 32,000-35,000 deaths reported in the USA among all age groups [2]. In the civilian setting, the most common causes of PBI are firearm related, accounting for most presentations to large medical centers across the country [2,3]. ...
... The incidence of PBI has increased in the past 2 decades with approximately 32,000-35,000 deaths reported in the USA among all age groups [2]. In the civilian setting, the most common causes of PBI are firearm related, accounting for most presentations to large medical centers across the country [2,3]. ...
... Historically, penetrating brain injury (PBI) is far less common than closed-head trauma in children [7]. However, penetrating trauma carries a worse prognosis, with mortality reaching 90% in many cases [2]. Due to this, it is imperative that further evaluation be performed if there is even a slight suspicion of penetrating trauma to the brain, as failure to diagnose can result in catastrophic consequences and irreparable damage. ...
Penetrating brain injury (PBI) is a subtype of traumatic brain injury (TBI) that has been steadily increasing in prevalence and causing significant mortality in trauma patients. In an emergent setting, it is important to determine the mechanism of injury and decide whether a PBI or a blunt TBI has occurred in order to guide diagnostic imaging and subsequent treatment. In cases where a PBI has been likely or has occurred, it is important to initiate treatment expeditiously as rapid interventions have been shown to lead to better outcomes. However, in cases of unwitnessed pediatric trauma, it can be difficult to ascertain the specific method of injury due to a lack of reliable sources. In such cases of unwitnessed trauma, PBI should be included in the differential of any orbitocranial injury. In this series, we present two cases of unwitnessed pediatric orbitocranial injury that highlight the importance of gathering a detailed history, obtaining appropriate imaging studies, and using physician intuition.
... In the United States, gun-related violence over the past 20 years has correlated with a rising number of penetrating brain injuries annually. 22,23 It is estimated that these gunshot related brain injuries account for between 32,000 and 35,000 civilian deaths per year. [24][25][26] Penetrating brain injuries are estimated to count for 12% of all traumatic brain injuries. ...
... 22 The annual cost for an economic lifetime from traumatic brain injury in the United States is estimated to be $76.5 billion with ninety percent of the cost originating from traumatic brain injuries hospitalizations and fatal outcomes which includes direct and indirect costs. 23,27,28 Firearms have been linked to account for nearly 35% of traumatic brain injury related deaths, with over half cases due to attempted suicide, followed by motor vehicle trauma and falls. 23,27,29 Only ten percent survive long enough to reach the hospital, and up to half who survive long enough to reach the hospital die during resuscitation attempts. ...
... 23,27,28 Firearms have been linked to account for nearly 35% of traumatic brain injury related deaths, with over half cases due to attempted suicide, followed by motor vehicle trauma and falls. 23,27,29 Only ten percent survive long enough to reach the hospital, and up to half who survive long enough to reach the hospital die during resuscitation attempts. 23,25,30,31 This is of course what accounts for the higher likelihood of dying from GSW to the H&N found in our study with nearly 20% having a brain injury. ...
Background:
Gun violence in the United States rose continuously from 2010 to 2022, spiking during the pandemic, and peaking in 2021 at 48,830 deaths (14.8 per 100,000). Previous reports investigated health and financial burden associated with gunshot wounds (GSWs) during 2004 to 2013; however estimates related specifically to head and neck (H&N) injuries have been lacking. This population-based study aims to examine incidence, morbidity, mortality, and health resource utilization of H&N injuries utilizing the Nationwide Inpatient Sample database.
Methods:
A population-based study was undertaken using the National (Nationwide) Inpatient Sample (NIS) database (2015Q4-2017Q4). The International Classification of Diseases, Tenth Revision (ICD-10) codes were used to create a composite variable (inclusive of brain, eye, facial nerve, and facial fractures) resulting from GSW to the H&N. Incidence per 100,000 hospitalizations and case fatality rates were calculated to determine the health burden of H&N injuries. Length of hospital stay, and inflation- adjusted hospital charges were compared among H&N and non-H&N injuries. Χ2 (classical and bootstrapped) and Mann-Whitney tests were used to compare groups.
Results:
Of 101,300 injuries caused by firearms, 16,140 injuries (15.9%) involved H&N region. The average incidence of H&N injuries was 20.1 cases per 100,000 hospitalizations, with intentional injuries having the highest case fatality rates of 32.4%. Patients with H&N injuries had extreme loss of function (33.4% versus 18.3%, P<0.001) and extreme likelihood of mortality (27.0% versus 11.3%, P<0.001) than non-H&N injuries. Statistically significant differences in the median length of stay (4.8 d versus 3.7 d; P<0.001) and median inflation-adjusted hospital charges ($80,743 versus $58,946, P<0.001) were found among H&N and non-H&N injuries.
Conclusions:
Injuries due to GSW remain an inordinate health care and financial burden, with trauma to the H&N carrying an especially high cost in dollars, morbidity, and mortality.
... For instance, cerebral artery vasospasm is due to subarachnoid hemorrhage and traumatic intracranial aneurysm formation. [15] Regarding infection, Staphylococcus aureus is considered the most frequent pathogenic agent in intracranial infections after a penetrating brain injury. [16] Usually, the development of infection will occur within 6 weeks after a penetrating brain injury. ...
... [16] Prophylactic antibiotic use should be determined individually, considering the patient's overall risk of infection, and collaboration with the infectious disease department is strongly advised. [15] e recommended course duration of antibiotics is 10-14 days, while for anticonvulsant drugs is at least 6-12 months. [17] Moreover, tetanus vaccination should also be administered as a routine prophylactic measure in traumatic head injuries. ...
Background
Penetrating traumatic brain injury (TBI) caused by a low-velocity object is a rare entity with a potential range of critical complications.
Case Description
We report a unique case of a 30-year-old male presenting with penetrating TBI caused by a rifle’s cleaning rod. The rod passes through the left nostril to reach the frontal lobe after transgressing the sella turcica. A cranial computed tomography scan shows the extension of brain damage and the trajectory of the rod with no evidence of an associated vascular injury. Surgical removal of the rifle rod was performed using a transnasal approach by a multidisciplinary with the postoperative course went uneventfully.
Conclusion
Transbasal penetrating TBI through the nose is an extremely rare entity. This type of head injury carries its own peculiarities that deviate from the classic treatment algorithms.
... PCVI may be evident on presentation in the form of active extravasation, significant intracranial or cervical hemorrhage, or may be highly suspected in certain cases of non-missile PCVI [1]. Much of the literature on its diagnosis and management has been obtained from wartime data [22]. ...
Traumatic brain injury is a complex and highly heterogeneous disease due to the host of concomitant injuries that may accompany the initial insult. Due to the dynamic interplay between the injuries that may arise, the management of these injuries is challenging. In a small subset of patients with traumatic brain injury, cerebral vascular injury may occur, which presents its own diagnostic and therapeutic challenges. These vascular injuries often present in a delayed fashion, thereby going unnoticed by clinicians. Early recognition and treatment of these injuries is crucial, given their high morbidity and mortality. Through a critical review of the literature, we present the spectrum of cerebrovascular injuries that may occur with traumatic brain injury and discuss classification systems that are used to stratify cerebrovascular injury. We then focus on the diagnosis of cerebral vascular injury using different neuroimaging modalities. Lastly, we explore the treatment of these injuries ranging from antiplatelet therapies to endovascular and open vascular procedures. By highlighting the pitfalls and challenges of this complex disease, we hope to provide clinicians with the framework to recognize and treat vascular injuries that are seen in patients with traumatic brain injury.
... PBI can be classified based on the injury velocity and mechanism of injury. 3 High-velocity injuries create damage beyond the immediate point of contact, while low-velocity injuries cause localized damage along the trajectory of penetrating object. The kinetic energy generated by the penetrating object is equal to the mass times square of its velocity (Ek ¼ ½ mv 2 ). 3 Bullets or missile injuries have less mass, but travel at higher velocities and is accompanied by percussion waves during its transit through brain matter causing significant cavitation, explosive skull fractures, and widespread destruction of neuronal cell membranes that may propagate as far down as the medulla oblongata. ...
... The kinetic energy generated by the penetrating object is equal to the mass times square of its velocity (Ek ¼ ½ mv 2 ). 3 Bullets or missile injuries have less mass, but travel at higher velocities and is accompanied by percussion waves during its transit through brain matter causing significant cavitation, explosive skull fractures, and widespread destruction of neuronal cell membranes that may propagate as far down as the medulla oblongata. 3 Nondeforming projectiles like marbles have a tendency to yaw inside tissue, which increases penetrating and results in a moderate wound cavity. ...
... The kinetic energy generated by the penetrating object is equal to the mass times square of its velocity (Ek ¼ ½ mv 2 ). 3 Bullets or missile injuries have less mass, but travel at higher velocities and is accompanied by percussion waves during its transit through brain matter causing significant cavitation, explosive skull fractures, and widespread destruction of neuronal cell membranes that may propagate as far down as the medulla oblongata. 3 Nondeforming projectiles like marbles have a tendency to yaw inside tissue, which increases penetrating and results in a moderate wound cavity. Most nonbullet penetrating objects, such as nails or knives, impart less damage to the skull and brain because they have less kinetic energy to transfer on impact. ...
Penetrating brain injury from marble is rare. Marbles, commonly known as “guli” among locals, is a popular children's traditional game in Malaysia. This study discusses two cases of intracranial marble injury, both accidentally shot by children with home-made air guns during the period of Movement Control Order with one elderly patient who passed away. While the diagnosis was uneventful, the management was not straightforward. Strategies of prehospital, operative, postoperative management, and rehabilitation are discussed, including prognostic factors. Because of its rarity, the management of such injuries is complex and nonstandardized.
... Although infection associated with TBI ranges from 5-23% [2,17,28], in pediatric PBI, it reaches over 40% [15]. Prophylaxis with broad-spectrum antibiotics should be performed, but its duration is still under discussion [1,5,7,17,19,25]. ...
Head trauma due to falls is often seen in children, however Penetrating Brain Injury (PBI) – the most life-threatening condition of Traumatic Brain Injury (TBI) - is exceedingly rare. Herein, we report and discuss the challenges encountered in surgical and post-operative management of a 13-old-child patient with PBI by a pickaxe, admitted in Glasgow Coma Scale (GCS) 3 and that not only survived, but also achieved a Glasgow Outcome Scale (GOS) after one year of postoperative follow-up. To our knowledge, this is the first case of pickaxe-induced brain injury on the American Continent and the youngest survivor of this trauma reported in literature.
... Although infection associated with TBI ranges from 5-23% [2,17,28], in pediatric PBI, it reaches over 40% [15]. Prophylaxis with broad-spectrum antibiotics should be performed, but its duration is still under discussion [1,5,7,17,19,25]. ...
Head trauma due to falls is often seen in children; however, penetrating brain injury (PBI), the most life-threatening condition of traumatic brain injury (TBI), is exceedingly rare. Herein, we report and discuss the challenges encountered in the surgical and postoperative management of a 13-year-old child patient with PBI by a pickaxe who was admitted to Glasgow Coma Scale (GCS) 3 and who not only survived but also achieved a good Glasgow Outcome Scale (GOS) after one year of postoperative follow-up. To our knowledge, this is the first case of pickaxe-induced brain injury on the American continent and the youngest survivor of this trauma reported in the literature.
... Transcranial stab wounds made with a knife or sickle mainly produce a classic slot skull fracture and underlying tract hematoma and often cause severe neurological deficits. We treated a patient with a self-inflicted penetrating skull injury at the right parietal portion [2]. ...
... Penetrating injuries are those where the projectiles penetrate the skull and brain parenchyma and remain there. Perforating injuries, the most devastating of all penetrating traumatic brain injury (pTBI), usually the result of high-velocity projectiles or those fired at close range, penetrate the skull and then exit at a site distal from the entry point ( Figure 5) [2], [3]. ...
... No data exists to support the advantages of craniectomy over craniotomy, though recent data from the military suggesting improved mortality with early decompression. The placement of drains, either subgaleal, epidural, or both, are common and have shown in at least one analysis to result in a trend toward fewer postoperative complications [2]. There is an extensive list of delayed complications that can arise from pTBI. ...
BACKGROUND: Penetrating head injuries are a significant public health problem in worldwide, with an estimated 35.000 civilian deaths annually. Patients that survive to reach the hospital require rapid triage and imaging evaluation. This case report describes a patient with late-onset seizures and left hemiparesis after unusual craniocerebral penetrating injury by a rusty sickle. CASE PRESENTATION: A 26-year-old man reported that he had a sickle stabbed into the right-side parietal area. On admission, he had no neurological deficits. The rusty sickle was broken off just above the skull and did not protrude from the scalp. Computed tomography showed that the knife blade was in the parenchyma without underlying tract hematoma. Surgery was performed after 2 h of admission. Post-operatively, he recovered with no neurological deficit. After 16th days postoperatively, he was complaining of seizure and left hemiparesis. CT scan with contras showed edema and hypodense lesion at the right side of hemisphere. A course of intravenous phenytoin 100 mg/8 h and ceftriaxone 2 g/day was initiated. Physical therapy was done on the patient for 2 weeks. CONCLUSION: Traumatic brain injury (TBI) is the result of energy being transferred from an object to the human skull and underlying brain. Post-traumatic epilepsy is a common complication and can occur as early or late manifestations related to penetrating TBI. Prophylactic treatment of post-traumatic seizures (PTS) is currently not routinely recommended beyond 1 week following head injury (role of antiseizure prophylaxis). Phenytoin is the most rigorously tested AED for PTS.
... Computer tomography scans (CT-scan), Skull X-ray anteroposterior (AP), and lateral are the most common and practical tools to evaluate gunshot head injury. The addition of CT 3D, CT angiography, and digital subtraction angiography (DSA) provides a reasonable initial assessment when available [3,4]. ...
... Moreover, surgery attempts to prevent a secondary injury caused by increasing ICP and infection and ischemic. Usual surgery procedures include brain stem decompression, hemostasis, and evacuation of a mass lesion like hematoma, bone fragment, missile residual, and the repair of wounds [3,4]. ...
A gunshot is a rare subset of penetrating head injury, and generally, the victim dies before arriving at the hospital. This paper reported an intracranial gunshot injury in an eight-year-old boy shooting by a hunter who has hunted a bird using an airgun. A missile projectile penetrated from the right zygoma and entering the transverse sinus. Vital signs were stable with GCS 14 from a physical examination. After the patient had an immediate craniotomy debridement, evacuated the foreign body (bullet) in C-arm guiding, the patient was administered to the pediatric intensive care unit (PICU) for three days. Than, patient was discharged from our hospital with a stable condition, GCS 15, without any significant neurological deficits.
