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Clinical and Neurosurgical Management of Cranial Machete Injuries: The Experience of a Tertiary Referral Center in Nicaragua
Abstract
Background:
The neurosurgical literature rarely describes managing open head injuries caused by machetes, although this is a common head injury in developing countries. We present our experience managing cranial machete injuries in Nicaragua over a 5-year period.
Methods:
A retrospective chart review identified patients admitted to a neurosurgery service for cranial machete injury.
Results:
Among 51 patients studied, the majority (n=42, 82%) presented with mild neurological deficits (Glasgow Coma Scale score ≥14). Non-depressed skull fracture (25/37, 68%) was the most common injury identified on skull radiography and pneumocephalus (15/29, 52%) was the most common injury identified with computed tomography. Overall, 38 patients (75%) underwent surgical intervention for 1 or more conditions, including laceration length ≥10 cm (n=20), open intracranial wound (n=8), pneumocephalus (n=7), cerebral contusion (n=6), intracranial hemorrhage (n=5), and depressed fracture (n=5). All patients received aggressive antibiotic therapy. Patients without intracranial injury received a 7-day course of intravenous ceftriaxone, followed by a 10-day course of oral ciprofloxacin. Patients with violation of the dura received a 7- to 14-day course of intravenous metronidazole, ceftriaxone, and vancomycin, followed by a 10-day course of oral ciprofloxacin. Postoperative complications included a visible skull defect (n=6), infection (n=3), and unspecified neurological (n=2) and mixed (n=1) complications. At discharge, most patients had only minimal disabilities (n=47 [92%]). In-hospital mortality rate was zero.
Conclusions:
An aggressive approach to managing open head injury caused by machete yields good outcomes, with the majority of patients experiencing minimal disability at hospital discharge and a low rate of infection.
... Al momento del alta, 92% de los pacientes presentó discapacidad mínima, 6% moderada y 2% grave, con una tasa de mortalidad del 0%. 12 El método diagnóstico de elección es la tomografía computarizada (TC) simple de cráneo que permite determinar el trayecto, penetración y extensión de la lesión tisular. La TC con reconstrucción 3D facilitará el diagnóstico y la planificación prequirúrgica. ...
... Organic foreign bodies, such as wood or bamboo, are carriers and the best environment for infections (brain abscess, meningitis and cerebritis), so they must be removed in their entirety, while foreign bodies metallic or bones fragments adjacent to important structures and difficult to extract, could be retained in the brain, because extraction can cause further damage. [11][12][13] Among the complications of CPT are: posttraumatic epilepsy, vascular complications (5-40% pseudo or true traumatic aneurysms, arteriovenous malformations and vasospasm), leakage of cerebrospinal fluid and infections. Infection rates associated with the foreign body are estimated from 6 to 21%. ...
Abstract
Background: Cranioencephalic penetrating trauma (CPT) is caused by a sharp or short- pointed object that passes through the bone, dura mater, brain and other structures. Its incidence is unknown and few cases are described; penetrating injuries represent 0.4%, therefore there is no protocolized management.
Case report: A 24-year-old male patient suffered penetrating trauma at left parietal region with a “knife”; he was sutured and sent home with analgesics. Five days after the trauma, he was admitted for headache, disorientation and decreased visual acuity. X-ray (XR) of Cranium evidencing a foreign body, therefore it is sent to a reference hospital.
Evolution: The diagnosis is confirmed by a computerized tomography (CT) scan of the skull with 3-dimensional reconstruction (3D) plus CT angiography (angio CT), which shows “knife” in the left parietal region without vascular compromise. Neurosurgeons perform removal of the foreign body plus a dura mater plasty. Patient stay 12 days hospitalized with a favorable evolution and improvement of neurological symptomatology.
Conclusion: CPT due to a knife is an emergency and there is no protocolized management. The removal of the foreign body must be done in a hospital for the risk of lesions of large vessels.
Keywords: craniocerebral trauma, post-head injury, gun violence, knife, craniotomy, cerebral hemorrhage
... Organic foreign bodies, such as wood or bamboo, are carriers and the best environment for infections (brain abscess, meningitis and cerebritis), so they must be removed in their entirety, while foreign bodies metallic or bones fragments adjacent to important structures and difficult to extract, could be retained in the brain, because extraction can cause further damage. [11][12][13] Among the complications of CPT are: posttraumatic epilepsy, vascular complications (5-40% pseudo or true traumatic aneurysms, arteriovenous malformations and vasospasm), leakage of cerebrospinal fluid and infections. Infection rates associated with the foreign body are estimated from 6 to 21%. ...
Background: Cranioencephalic penetrating trauma (CPT) is caused by a sharp or short- pointed object that passes through the bone, dura mater, brain and other structures. Its incidence is unknown and few cases are described; penetrating injuries represent 0.4%, therefore there is no protocolized management. Case report: A 24-year-old male patient suffered penetrating trauma at left parietal region with a "knife"; he was sutured and sent home with analgesics. Five days after the trauma, he was admitted for headache, disorientation and decreased visual acuity. X-ray (XR) of Cranium evidencing a foreign body, therefore it is sent to a reference hospital. Evolution: The diagnosis is confirmed by a computerized tomography (CT) scan of the skull with 3-dimensional reconstruction (3D) plus CT angiography (angio CT), which shows "knife" in the left parietal region without vascular compromise. Neurosurgeons perform removal of the foreign body plus a dura mater plasty. Patient stay 12 days hospitalized with a favorable evolution and improvement of neurological symptomatology. Conclusion: CPT due to a knife is an emergency and there is no protocolized management. The removal of the foreign body must be done in a hospital for the risk of lesions of large vessels.
... Al momento del alta, 92% de los pacientes presentó discapacidad mínima, 6% moderada y 2% grave, con una tasa de mortalidad del 0%. 12 El método diagnóstico de elección es la tomografía computarizada (TC) simple de cráneo que permite determinar el trayecto, penetración y extensión de la lesión tisular. La TC con reconstrucción 3D facilitará el diagnóstico y la planificación prequirúrgica. ...
El trauma penetrante craneoencefálico representa alrededor del 0.4% de los casos, pocos son los descritos en la literatura, por lo cual, no existe un manejo protocolizado del mismo.
Describimos un caso de un paciente masculino de 24 años que sufre un trauma penetrante a nivel de región parietal izquierda con arma blanca “cuchillo”, dejando incrustada la hoja del mismo. La Tomografía computarizada simple de cráneo con reconstrucción en 3 dimensiones más angiografía, confirma el diagnóstico y descarta el compromiso vascular. Se realiza la extirpación completa del cuerpo extraño, sin complicaciones. Evolución favorable con mejoría de la sintomatología neurológica al alta.
Este tipo de trauma es una emergencia que puede poner en riesgo la vida del paciente dependiendo del área afectada. La extirpación del cuerpo extraño debe realizarse en un medio hospitalario por la afectación de grandes vasos. Se debe tener una alta sospecha diagnóstica asociada al antecedente.
... A good knowledge of pattern and outcome of machete cut fracture can facilitate preventive strategies and intervention aimed at achieving optimum care of the victims. However, there is very scanty data on machete cut fractures; the ones available in literature are either anecdotal case reports or case series that focused on machete cut fractures involving specific anatomical region of the body 7,[9][10][11][12] . Thus, paucity of data on machete cut fractures necessitated this study. ...
Machete cut fracture is an important component of morbidity associated with machete injuries although it is under reported. This was a retrospective study to assess machete cut fractures in patients seen in Federal Teaching Hospital Abakaliki and National Orthopaedic Hospital Enugu from 2009 to 2018. There were 91 patients with 154 fractures, male- to- female ratio was 10:1 and mean age was 31.6 ± 14.6 years. The aetiological factors were assault (57, 62.6%), armed robbery (29, 31.9%) and accidental injury (5, 5.5%). The three top bones involved were ulna, metacarpal and finger-phalanx. Fracture was communited in (17, 11.0%), and Gustilo Anderson grade IIIC in (22, 14.3%). Injury to hospital arrival interval later than 6 h was common and correlated with prolonged length of hospital stay (p < 0.001). Anaemia, wound infection and hemorrhagic shock were the three top complications. Nine (5.8%) fractures ended in extremity amputation. Eleven (12.1%) patients left against medical advice, and 5 (5.5%) were transferred. Normal union in 98.3% of the fractures treated and followed up for a minimum of one year. Case fatality rate was 2.2%; none of the patient that died had pre hospital care, and hemorrhagic shock accounted for all the mortality. These call for appropriate injury preventive mechanisms, and improved rates of early presentation of patients to hospital, and pre hospital care.
There have been limited reports on machete wounds to the cranium. This study was carried out to document the injury profile in a series of patients who have sustained cranial injuries from machete wounds in this setting. Between 1 January 1998 and 1 January 2008, demographic and clinical data were retrospectively collected from all patients treated with complicated head injuries from machete wounds with at least one of the following clinical or radiological features: a recorded Glasgow Coma Score < 8 at any point during admission; compound skull fractures; protruding brain matter; cerebrospinal fluid (CSF) leaks; intra-cranial bleeding; parenchymal contusions; lacerations and/or oedema. The data were analysed using the SPSS version 12.0. Of the 40 patients with complex injuries to the cranium, there was a 6:1 male preponderance with a mean age of 32.5 ± 13.7 years (Mean ± SD). The injuries included open skull fractures in all the 40 (100%) patients, depressed skull fractures in 20 (50%) patients, CSF leaks in 4 (10%) patients, protruding brain matter in 4 (10%) patients, cerebral contusions in 3 (7.5%) patients and extra cranial injuries in 16 (40%) patients. Tetanus prophylaxis and intravenous antibiotics were administered to all patients, and phenytoin was required in 16 (40%) cases. There were 37 (92%) patients requiring operative intervention at a mean of 10.4 h after presentation (SD ± 18.1; Median 6). The operative procedures included elevation of depressed fractures in 20 (54.1%) patients, dural repair in 10 (27.0%) patients and intra-cranial debridement in 7 (18.9%) patients. There were three deaths (7.5%), and seizures were recorded in 5 (12.5%) cases with no reports of infectious morbidity. Eighty percent of patients had a normal Glasgow outcome score on discharge. Complicated machete head trauma is uncommon at this health care facility in Jamaica. We achieved a satisfactory outcome with aggressive management consisting of prompt assessment of the extent of injury, appropriate antibiotics, anticonvulsants for those with seizures or cortical injury and early operation to decrease the risk of complications.
Traumatic brain injury (TBI) is one of the leading causes of death and disability worldwide. The burden of TBI is greatest in low- and middle-income countries (LAMIC), yet little is known about patient outcomes in these settings.
Complete data on 8927 patients from 46 countries from the corticosteroid randomization after significant head injury (CRASH) trial were analysed to explore whether outcomes 6 months after TBI differed between high-income countries and LAMIC.
Just under half of patients experienced a good recovery, one-third moderate or severe disability and one-quarter died within 6 months of their injury. Univariate analyses showed that patients in LAMIC were more likely to die following severe TBI, but were less likely to be disabled following mild and moderate TBI. These results were confirmed in multivariate analyses. Compared to patients in high-income countries, patients in LAMIC have over twice the odds of dying following severe TBI (OR 2.23, 95% CI 1.51-3.30) but half the odds of disability following mild (OR 0.41, 95% CI 0.23-0.72) and moderate TBI (OR 0.53, 95% CI 0.35-0.81). There were no differences between settings in the odds of death following either mild or moderate TBI.
Reduced death rates following severe TBI in patients from high-income countries may be due to differences in medical care which may result in a higher proportion of patients surviving with a disability. Socio-cultural factors may explain the lower levels of disability after mild and moderate TBI in LAMIC.
Traumatic brain injury (TBI), according to the World Health Organization, will surpass many diseases as the major cause of death and disability by the year 2020. With an estimated 10 million people affected annually by TBI, the burden of mortality and morbidity that this condition imposes on society, makes TBI a pressing public health and medical problem. The burden of TBI is manifest throughout the world, and is especially prominent in Low and Middle Income Countries which face a higher preponderance of risk factors for causes of TBI and have inadequately prepared health systems to address the associated health outcomes. Latin America and Sub Saharan Africa demonstrate a higher TBI-related incidence rate varying from 150-170 per 100,000 respectively due to RTIs compared to a global rate of 106 per 100,000. As highlighted in this global review of TBI, there is a large gap in data on incidence, risk factors, sequelae, financial costs, and social impact of TBI. This should be addressed through planning of comprehensive TBI prevention programs in LMICs through well-established surveillance systems. Greater resources for research and prioritized interventions are critical to promote evidence-based policy for TBI.
Traumatic Brain Injury (TBI) is a critical public health problem affecting more than 10 million people worldwide and is set to surpass many diseases as the leading cause of mortality and morbidity by the year 2020. The burden of this often neglected injury disproportionately affects low and middle income countries (LMICs) which face not only a higher preponderance of risk factors for TBI but also have less developed health systems to deal with the associated health outcomes. Thus, both the incidence of TBI and the case-fatality from TBI can be high and devastating. Given that TBI can lead to significant mortality and long term morbidity, not to mention the social and financial implications, the silently growing epidemic of this injury is a pressing public health concern. The lack of data concerning the burden of TBI within LAC should be addressed to develop a detailed epidemiological profile in order to plan comprehensive TBI prevention programs. Prioritizing and coordinating funds for the generation of appropriate evidence and research is critical to meet the need to promote evidence-based policy for TBI in the region. Language: en
Machete-related wounds are a source of appreciable morbidity in many developing nations. We describe a case of radial nerve injury resulting from a machete attack in Haiti. Twenty-two additional cases of machete-related wounds treated during a 3-month humanitarian mission to Haiti are reported. Sixty-five percent were accidental in nature, occurring from a variety of routine activities, whereas the remainder were secondary to assaults. The upper extremity was injured in 85% of the cases, often resulting in complicated wounds with nerve, tendon, and joint injuries. A treatment protocol for peripheral nerve injuries incurred in austere conditions is presented.
Traumatic brain injury (TBI) not only has considerable morbidity and mortality, but it is a major cause of epilepsy. We wish to determine the frequency of TBI, special groups at risk for TBI, and mortality from TBI.
We reviewed studies of TBI that are either population based or derived from definable catchment areas that allow determination of incidence, identification of risk groups, and mortality. We review methodology used in epidemiologic studies of TBI and try to distinguish this data from that of head injury not necessarily affecting the brain. We report epidemiologic characteristics of TBI, including incidence, differences by age, gender, race and ethnic group, and geographic variation, and mortality.
Population-based studies in the United States suggest that the incidence of TBI is between 180 and 250 per 100,000 population per year. Incidence may be higher in Europe and South Africa. There are groups at high risk for TBI. This includes males and individuals living in regions characterized by socioeconomic deprivation. There are selective age groups at risk for TBI. This includes the very young, adolescents and young adults, and the elderly. Mortality varies by severity but is high in those with severe injury and in the elderly.
TBI is a major public health problem as well as a major cause of epilepsy. If primary prevention is to be undertaken, we must understand the epidemiology of the condition. The primary causes of TBI vary by age, socioeconomic factors, and geographic region, so any planned interventions must be tailored accordingly.