RESUMEN

The head and neck region is a complex anatomical area with vulnerable nervous and vascular structures, auditory and visual organs and upper aero-digestive tract. Penetrating foreign bodies of head and neck region are not uncommon and pertain mostly to wood, metal and glass (Levine et al. in Am J Emerg Med 26:918-922, 2008). This case report describes an airborne high velocity foreign body blown off from a lawn mower penetrating the left side of the face, penetrating deep into nasopharynx and opposite parapharyngeal space through paranasal sinuses. A multidisciplinary team managed this case successfully, avoiding injuries to adjacent vital skull base structures.

RESUMEN

PURPOSE: Penetrating brain injury (PBI), a relatively uncommon injury, is associated with remarkable secondary complications such as vascular injury, intracranial haemorrhage, infection, and mortality. Non-missile PBI (NMPBI) due to sharp or blunt objects is usually treated surgically by removing the penetrating object, evacuating the associated haemorrhage, identifying possible bleeders along with haemostasis, and performing debridement. Various approaches are used for different scenarios of non-missile PBI according to the object's characteristics, penetrating site, depth, associated intracerebral haemorrhage (ICH), and presence of vascular injury along the penetrating tract. NMPBI cases are rarely reported among civilians. We herein describe a patient who was successfully treated for NMPBI, as well as frontal ICH, by simultaneously removing the heavy, metallic penetrating foreign body. METHODS: We performed corticotomy through a shorter tract instead of a deep penetrating trajectory, which minimizes the extent of damage to the brain and enables immediate management of vascular injury under direct vision while removing the foreign body, and intraoperative sonography, which provides real-time information of the penetrating object and the surrounding brain structure. We did not perform computed tomography angiography and digital subtraction angiography (DSA) because the stab location was at the frontal region, with low risk of vascular injury. Moreover, DSA is time-consuming, which may delay decompressive surgery. RESULTS: The patient was successfully treated through an alternative approach removing the long, heavy, metallic penetrating foreign body and eliminating the accompanying frontal ICH simultaneously. Focal brain abscess developed 8 days after the injury and resolved completely after antibiotics treatment. Dysphasia gradually improved but right distal limbs weakness with spasticity is still present. CONCLUSIONS: Our findings suggest prompt diagnosis by preoperative imaging, screening of vascular injury, decompression with debridement, and antibiotics treatment are important. The alternative surgical approach we proposed is exceptional and should be considered while treating patients with deep NMPBI.

RESUMEN

Penetrating brain injury caused by a nail is an extremely rare neurosurgical emergency that poses a challenge for neurosurgeons. Nail entering the brain from the orbit and lodging within the cranial cavity is even more unusual. A 53-year-old male was found unconscious at a construction site, and brain CT revealed not only the presence of a nail beneath the inner table of the parietal bone, but also traumatic intracerebral hematoma. Consequently, accurate localization of the nail and hematoma was mandatory for surgical plan. During surgical planning, computational model reconstruction and trajectory calculation were completed using preoperative CT in 3D Slicer. Under the guidance of a head-mounted mixed-reality holographic computer, the neurosurgeon was able to visualize and interact with the hologram of the surgical plan, and intraoperative findings demonstrated that our low-cost portable wearable mixed-reality holographic navigation assisted precise localization of the nail and intracerebral hematoma, assuring less injury to the already compromised brain. After the surgery, the patient could obey commands, and postoperative imaging ruled out the possibility of brain abscess during follow-up. To the best of our knowledge, this is the first report on using a low-cost wearable mixed-reality holographic navigation to guide the management of penetrating intracranial injury caused by a nail.

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RESUMEN

BACKGROUND: The incidence of penetrating intracranial foreign bodies is rare, and to date, not many relevant studies have been published worldwide. In particular, a nail penetrating intracranially, just near the superior sagittal sinus (SSS), is extremely rare. We treated the case of a large nail that penetrated the middle of the head and strategized its removal. CASE DESCRIPTION: A 70-year-old man had experienced headache lasting a day. Computed tomography of the brain revealed a nail penetrating the middle of his head; in particular, the tip of the nail had penetrated the right ventricle, causing a slight subarachnoid hemorrhage. Angiography showed that the nail was very close to the SSS and that the venous flow was normal. However, there was a risk of the nail penetrating through the SSS or injuring other arteries, and we removed the nail directly from the intracranial view to stop bleeding from the SSS or other vessels. Fortunately, there was no bleeding, and we washed the hole created by the nail penetration and concluded the surgery. CONCLUSIONS: Our technique is useful and safe for removing large nails penetrating the head.

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