Knife Blade Penetrating Stab Wound to the Brain —Case Report—

Neurol Med Chir (Tokyo) 45, 172¿175, 2005

Masaki IWAKURA,TetsuroKAWAGUCHI,KohkichiHOSODA,YujiSHIBATA, Hideki KOMATSU,AkiraYANAGISAWA,andEijiKOHMURA*

Department of Neurosurgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo; *Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo

Abstract

A 28-year-old man attempted to kill himself with a knife stab into the parietal area. Neuroimaging showed no vascular impairment except slow venous flow around the knife due to tamponading. After obtaining informed consent, the knife was removed through a craniotomy without new brain injury. Postoperative neurological findings showed no deficit. Follow-up angiography revealed no vascular impairment. No infection occurred. Brain stab wounds cause numerous complications, such as intracranial hemorrhage, injury of important vessels, and infections. Minimal blade movement during removal and precautions to prevent massive hemorrhage are essential.

Key words: penetrating stab wound, brain, operation

Introduction

Penetrating head injuries generally occur as the result of violence, including self-inflicted wounds, unexpected events, worker's accidents, etc.2,4,5,7,8,11) A knife blade is the most common agent, but wooden objects, scissors, firearms, and recently nail-guns have all featured. Transcranial stab wounds made with a knife mostly 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 wound of the skull at the midline of the parietal portion. Fig. 1 Skull radiographs on admission, showing Case Report the knife penetrating deep into the parietal area near the midline. A 28-year-old man with a history of schizophrenia attempted to kill himself with a knife stab into the tomography (CT) showed that the knife blade was parietal area. On admission, he had no neurological located near the corpus callosum without under- deficit. The knife blade was broken off just above lying tract hematoma (Fig. 2). Cerebral angiography the skull and did not protrude from the scalp. The demonstrated no apparent arterial damage or wound was irrigated and sutured, and intravenous extravasation. However, venous flow around the antibiotics were administered. Skull radiography knife was extremely slow because of tamponading. showed the knife blade penetrating deep into the We were unable to decide on which side of the dura parietal area near the midline (Fig. 1). Computed the knife was located, and whether it had penetrated

Received April 14, 2004; Accepted September 13, 2004 Author's present address: M. Iwakura, M.D., Department of Neurosurgery, Shinsuma Hospital, Kobe, Hyogo, Japan.

172 Intracranial Penetrating Stab Wound 173

Fig. 2 Computed tomography scans on admission, showing no apparent tract hematoma. A: normal window level (85), B: window level of 2000.

into the superior sagittal sinus (SSS) (Fig. 3). Surgery was performed under general anesthesia on Day 3 after obtaining informed consent and making careful preparations. His head was fixed in the semi-sitting position and a horse's hoof skin incision made around the wound. After reflecting the skin and muscle, the knife was found firmly lodged in the parietal bone a few millimeters to the left of the midline. Bilateral parietal bone craniotomy was performed, leaving the bone around the knife with minimal oscillatory movement (Fig. 4A). Opening of the dura on the right showed that the knife was not inserted on this side. However, the dura on the left could not be opened Fig. 3 A: Right common carotid arteriograms, because of the large bridging veins which adhered to arterial phase, showing no apparent vascu- the dura. After preparations had been made for the lar impairment. B: Left common carotid management of massive hemorrhage from the SSS arteriograms, arterial phase, also showing no apparent vascular impairment. C: Left or cerebral arteries, the anterior and posterior edges common carotid arteriograms, venous of the residual bone were carefully drilled, and the phase, showing slow venous flow around knife was removed with one bite of surrounding the knife caused by tamponading, but not bone to prevent any unnecessary movement of the the relationship between the knife and the knife. Finally, the knife insertion point was identi- superior sagittal sinus. fied as the left hemisphere 1 mm lateral to the SSS, without injury to the SSS (Fig. 4B). Observation of the injured brain under the operating microscope Discussion found swelling and erosion, but fortunately no massive bleeding. The dural defect was closed Brain stab wounds mainly cause intracranial hemor- without using artificial membrane. The bone flap rhage, injury of important vessels, and infection. was not restored because of the risk of infection. The penetration site, depth of penetration, type of Postoperatively, he recovered quickly with no object, transorbital trajectory, and other factors may neurological deficit. CT showed only a thin tract be important in determining the outcome.4,5,7,9,11) hematoma. At 1 month postoperatively, cranioplasty Infection frequently results from penetration of was performed. Follow-up examination found no objects through the air sinus or oropharyngeal evident infectious changes or new vascular abnor- mucosa, but seldom through the calvaria.4) All malities. previous patients could be treated with intravenous

Neurol Med Chir (Tokyo) 45,March,2005 174 M. Iwakura et al.

Management of penetration of the sinus is a very important and difficult problem. In the case of only small sinus laceration, Surgicel, fibrin glue, piece of fascia, and external pressure may be recommended, despite using artificial products. If this procedure fails, repair of the lacerated sinus with or without vein graft is necessary.14) In this case, the lacerated point of the sinus was thought to be small or absent, and the shape was thought to be linear fashion (not across the sinus), because the knife blade could not be found in the right intradural space (contralateral side). We wanted to check the relationship between the knife blade and the left intradural space. However, the dura on the left could not be opened because of the large bridging veins which adhered to the dura. Before removal of the knife blade, fibrin glue and piece of fascia for filling the laceration and 6-0 nylon for suturing the lacerated point were prepared, and the patient's head was elevated more to reduce the intracranial venous pressure. Blind removal of the penetrating object is dan- gerous, because blind removal may rock or twist the object, resulting in secondary vascular impairment and brain damage.7,8,10,11,13) Therefore, we removed the knife fixed in the skull with minimum move- Fig. 4 A: Schematic drawing of craniotomy show- ment. Hemorrhage might be prevented by tampon- ing the bone margin of a few millimeters ading injured cerebral vessels, even if only mild around the knife. Asterisks indicate the tract hematoma occurs at first. Therefore, we portion of the final bite for removal. B: Schematic drawing of coronal view showing should take special care to prevent massive hemor- 4) the knife inserted into the left parietal lobe 1 rhage after blade removal. We were concerned mm lateral to the superior sagittal sinus about massive hemorrhage after removal of the (SSS), without injury to the SSS. knife in our patient, because preoperative cerebral angiography indicated extremely slow venous flow around the knife due to tamponading. antibiotics. However, patients with septic complica- References tions sometimes developed brain abscess.10) Preoperative cerebral angiography is very im- 1) Aarabi B: Traumatic aneurysms of the brain due to high velocity missile head wounds. Neurosurgery 22: portant to evaluate vascular disorders and to select 1056–1063, 1988 the therapeutic method. Vascular disorders occur in 2) Al-Mefty O, Holoubi A, Fow JL: Value of angiogra- 30% of cases of transcranial penetration: aneurysm phy in cerebral nail-gun injuries. AJNR Am J in 15%, carotid-cavernous fistula in 7%, other Neuroradiol 7: 164–165, 1986 arteriovenousfistulaein4%,occlusionin4%,tran- 3) Asari S, Nakamura S, Yamada O, Beck H, Sugatani sectionin3%,andseverevasospasmin3%.5) The H, Higashi T: Traumatic aneurysms of peripheral occurrence of vascular disorders is mainly related to cerebral arteries: Report of two cases. JNeurosurg46: the depth of penetration and involvement of the 795–803, 1977 petrous bone.4) Risk factors for the incidence of 4) du Trevou MD, van Cellen JR: Penetrating stab traumatic aneurysm are penetration near the wound to the brain: the timing of angiography in patients presenting with the weapon already pterion, association with intracerebral hematoma, removed. Neurosurgery 31: 905–912, 1992 and penetration crossing the midline.1) Traumatic 5) Kieck CF, De Villiers JC: Vascular lesions due to aneurysm usually develops several days after injury, transcranial stab wounds. J Neurosurg 60: 42–46, and ruptures within the first week in 19% of cases, 1984 of which 32% result in death.3) Follow-up angiogra- 6) McDonald EJ, Winestock DP, Hoff JT: The value of phy is essential, because traumatic aneurysms some- repeated cerebral arteriography in the evaluation of times appear several years after injury.2,4–7,11,12) trauma. AJR Am J Roentgenol 126: 792–797, 1976

Neurol Med Chir (Tokyo) 45, March, 2005 Intracranial Penetrating Stab Wound 175

7) Miller P, Lipschitz R: Transclival penetrating injury. 12) Thompson JR, Harwood-Nash DC, Fitz CR: Cerebral Neurosurgery 21: 92–94, 1987 aneurysm in children. AJR Am J Roentgenol 118: 8) Nath FP, Teasdale E, Mendelow AD: Penetrating 163–175, 1973 injury of the tuberculum sellae. Neurosurgery 14: 13) van Dellen JR, Lipschitz R: Stab wounds of the skull. 598–600, 1984 Surg Neurol 10: 110–114, 1978 9) Nathoo N, Boodhoo H, Nadvi SS, Naidoo SR, Gouws 14) Wu JJ, Shih CJ: Unusual penetrating injury of the su- E: Transcranial brainstem stab injuries: A retrospec- perior sagittal sinus. Surg Neurol 17: 43–46, 1982 tive analysis of 17 patients. Neurosurgery 47: 1117–1123, 2000 10) Shih TY, Kuo YL: Development of intracranial complications following transoral stab wounds in Address reprint requests to:M.Iwakura,M.D.,Department children. Pediatr Neurosurg 37: 35–37, 2002 of Neurosurgery, Shinsuma Hospital, 4–1–6 11) Taylor AG, Peter JC: Patients with retained trans- Isonare–cho, Suma–ku, Kobe, Hyogo 654–0047, cranial knife blades: a high-risk group. JNeurosurg Japan. 87: 512–515, 1997

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