Surviving a Tiger Attack

Neurosurg Rev (2012) 35:621–624 DOI 10.1007/s10143-012-0406-1 CASE REPORT Case report: surviving a tiger attack Pedram Emami & Thomas M. Kaiser & Jan Regelsberger & Einar Goebell & Jens Fiehler & Manfred Westphal & Oliver Heese Received: 5 September 2011 /Revised: 19 April 2012 /Accepted: 17 May 2012 /Published online: 10 July 2012 # Springer-Verlag 2012 Abstract Attacks on humans by large predators are rare, obvious penetration of the skull by the tiger’s canines. This especially in Northern Europe. In cases of involvement of seems to be related to the specific dynamics of the cranial the craniocervical compartment, most of the attacks are not assault and the reduced forces applied to the patient’s head survived. We report on a case where the patient survived a demonstrated in a 3D bite simulation. tiger attack despite severe head trauma and discuss the circumstances leading to the patient’s survival and excellent outcome. The patient we report on is a 28-year-old tamer, Introduction who was attacked by three tigers during an evening show. A bite to the head resulted in multiple injuries including left- Objectives and importance sided skull penetration wounds with dislocated fractures, dural perforations, and brain parenchyma lesions. The pa- Injuries to humans caused by attack from large predators are tient recovered without neurological deficits after initial ICU very rare, especially in Northern Europe. Most of the reports treatment. No infection occurred. In order to understand the found in the literature describe attacks that took place in ’ ’ mechanism of the tiger s bite to the patient s cranium, a Asia [8, 11, 12]; a few cases were reported on accidents in simulation of the attack was performed using a human and zoos [13] or animal farms [1] in the USA. In cases where the a tiger skull put together at identical positions to the bite craniocervical compartment is involved, most of the attacks marks in a CT scan. It seems that during the bite, the animal were not survived due to the enormous bite forces applied ’ was not able to clamp down on the patient s skull between [1, 5]. We report a case of a tiger attack that was survived by its canine teeth and therefore reduced bite forces were ap- the patient despite severe head trauma and discuss circum- plied. Survival of an attack by a large predator that targeted stances that presumably led to the patient’s survival. The – the cervical cranial compartment with an excellent outcome patient has consented regarding publication of the medical is not described in the literature. We were surprised to find data. only minor lesions of the brain parenchyma despite the Clinical presentation P. Emami (*) : J. Regelsberger : M. Westphal : O. Heese Department of Neurological Surgery, University Medical Center The patient we report on is a 28-year-old tamer who had Hamburg-Eppendorf, Martinistr. 52, slipped and fallen while performing in an evening show and 20246 Hamburg, Germany was subsequently attacked by three Siberian tigers (all 3 years e-mail: [email protected] old, two of them male, one female) The male tigers weighed about 220 kg, the female one weighed 150 kg. A physician in T. M. Kaiser Zoological Institute, University Hamburg, the audience provided adequate first aid, and the paramedics Hamburg, Germany who arrived within few minutes intubated the somnolent : patient. On arrival at the emergency room, the patient pre- E. Goebell J. Fiehler sented with stable vital parameters despite severe blood loss Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, (Hb 9.0 g/dL). This was due to soft tissue injuries including a Hamburg, Germany subtotal amputation of the left hand and numerous lacerations 622 Neurosurg Rev (2012) 35:621–624 Fig. 1 Initial CT scan demonstrating skull and brain parenchyma transverse fracture of the parietal squama (circle 1 in Fig. 2). c Pene- penetration of the four tiger canines. Upper panel soft tissue scan, tration of the left temporal region by the slightly smaller left lower lower panel bone scan. a Occipital penetration of the right upper canine apex (circle 3 in Fig. 2). d Penetration of left temporo-occipital canine with a cracked lambda suture and dislocated occipital squama region by the right lower canine, dislocated bone fragments impressed (circle 2 in Fig. 2). b Penetration in the left parietal region caused by and shifted cranially (circle 4 in Fig. 2) the left upper canine, small bone fragments dislocated intracranially, of the limbs and of the head. An instable fracture of the skull were removed as well as the protruding injured extradural was palpable and parts of the bony skull were visible. The brain tissue. A periosteal patch was used to cover the dural patient showed no signs of cerebral herniation such as patho- lesion and the largest free bone fragment was re-implanted logic reflexes (e.g., Babinski’s sign) or impairment of the and fixed by plates and screws. An intracranial pressure pupillar reflexes. probe was implanted locally and the patient was put into In the initial cranial CT scan, severe trauma was predom- deep sedation and ventilation for the following days. The inantly seen to the left of the skull, including dislocated initial prophylactic antibiotic therapy with Cefuroxim was fractures and cracked sutures. Intracranial injuries were mi- continued for 6 weeks, although no pathogenic bacteria nor with small areas of intracerebral contusion and bleeding, were found in the smear cultures obtained during the initial as well as subdural air accumulation in the areas where the cranial surgery. tiger’s canines penetrated the skull (Figs. 1 and 2). During the intensive care period, the intracranial pressure was stable, as well as the cardiopulmonary conditions of the Intervention/technique patient. After the cessation of sedation, he rapidly regained consciousness and showed no neurological deficiencies. The neurosurgical intervention included an expanded Three months later, the patient was completely recovered wound debridement of the lacerations; small bone fragments neurologically, and he had already started to perform with Fig. 2 3D reconstruction of the initial CT scan (the reduced quality is upper canine (1) caused a transverse fracture of the parietal region. b due to a slice thickness of only 3 mm in the emergency setting). a Left-sided view showing all four tooth impressions, including the two Cranial view indicating tooth impressions of left (1) and right (2) upper marks left by the lower canines of the tiger at a distance of approxi- tiger canines, which penetrated at a distance of approximately 7 cm. mately 5 cm. c Anterolateral view demonstrating all four penetrating The right upper canine (2) cracked the lambda suture, resulting in an skull fractures outward dislocation of large parts of the left occipital region. The left Neurosurg Rev (2012) 35:621–624 623 his tigers in the arena again since he did not consider the Measured at the apex of the caninae, which may exceed incident as a malicious attack but rather as intent by the 7 cm in length, forces of approximately 1,500 N are easily tigers to “play” with him as he unexpectedly stumbled applied [5]. For comparison, a Mayfield clamp for routine between them. skull fixation in daily neurosurgical practice develops forces In order to understand the mechanism of the tiger’sbiteto of about 60 N. the cranium on the one hand and the benign clinical cause of An attack by a large predator targeting the cervical– the attack and the excellent recovery of the patient on the cranial compartment is mostly fatal; cases with an excellent other, a simulation of the attack was performed. Firstly, a 3D outcome are not described in the literature [4, 7, 10]. Not reconstruction of the initial CT scan was done. The CT scans only physiological, but also psychological difficulties are were performed using a 128 row scanner (256 iCT, Philips, postulated to be important in the post-acute management of Best, Netherlands) with a slice thickness of 3 and a 3 mm these patients. The pattern of injury often refers to the increment (120 KV, 250 mAs). Reconstruction and rendering predatory attack on the neck and posterior cranial region of the emergency room CT dataset was performed using [6]. We were surprised to find only minor lesions of the Osirix for Mac. Despite its poor resolution, we were able to brain parenchyma despite the obvious penetration of the postulate the following hypothesis: since the upper canines skull by the tiger’s canines. Taking into account the jaw did not penetrate the skull beneath its apex it seemed that forces possible, this is considered a rare and lucky coinci- during jaw closure the upper canines slid downwards, result- dence. Evaluation of the initial CT scan of the injured ing in a reduced application of bite forces (Fig. 2). In order to patient (Fig. 2) and simulating the bite with a tiger and strengthen this hypothesis, we simulated the tiger bite to the human skull by matching the tooth marks revealed a sur- head in a CT scan using a human skull and a tiger skull (ZMH prising observation. It seems that during the bite, the animal S-7520; provided by the Zoological Museum of Hamburg was unable to instantaneously clamp down on the patients University, Panthera tigris, weight 160 kg, length 203 cm) skull between its canine teeth, but instead both upper can- placed in identical positions of the bite marks. Reconstruction ines slid downwards at the moment of jaw closure (Fig. 3), was performed in 0.8 mm slices in a 512×512 matrix. Subse- causing soft tissue trauma but no further bone lesions. This quently, a 3D reconstruction was performed (Fig.

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