CLINICAL ARTICLE J Neurosurg Pediatr 18:550–557, 2016 Neurological findings in pediatric penetrating head injury at a university teaching hospital in Durban, South Africa: a 23-year retrospective study Kadhaya David Muballe, MD,1 Timothy Hardcastle, MMed, PhD,2 and Erastus Kiratu, MBChB1 Department of 1Neurosurgery and 2Trauma Surgery, Inkosi Albert Luthuli Central Hospital and University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa OBJECTIVES Penetrating traumatic brain injuries (TBIs) can be divided into gunshot wounds or stab wounds based on the mechanisms of injury. Pediatric penetrating TBIs are of major concern as many parental and social factors may be involved in the causation. The authors describe the penetrating cranial injuries in pediatric patient subgroups at risk and presenting to the Department of Neurosurgery at the University of KwaZulu-Natal, by assessment of the Glasgow Coma Scale (GCS) score and review of the common neurological manifestations including cranial nerve abnormalities. METHODS The authors performed a retrospective chart review of children who presented with penetrating TBIs be- tween 1985 and 2007 at a university teaching hospital. Descriptive statistical analysis with univariate and multivariate logistic regression was used to assess the variables. RESULTS Out of 223 children aged 16 years and younger with penetrating TBIs seen during the study period, stab wounds were causal in 127 (57%) of the patients, while gunshot injuries were causal in 96 (43%). Eighty-four percent of the patients were male. Apart from abnormal GCS scores, other neurological abnormalities were noted in 109 (48.9%) of the patients, the most common being cranial nerve deficits (22.4%) and hemiparesis. There was a strong correlation between left-sided stab wounds and development of seizures. The mean age of patients with neurological abnormalities was 11.72 years whereas that of patients with no neurological abnormalities was 8.96 years. CONCLUSIONS Penetrating head injuries in children are not as uncommon as previously thought. There was no cor- relation between the age group of the patients and the mechanism of injury, which implies that stab or gunshot injuries could occur in any of our pediatric population with the same frequency. While gunshot injuries accounted for 56% of the patient population, stab injuries still accounted for 44%. Following penetrating head injuries, neurological abnormalities tend to occur in the older subgroup of the pediatric patients. The most common neurological abnormalities were hemiparesis followed by cranial nerve deficits. Facial nerve deficits were the most commonly seen cranial nerve abnormality. Immediate convulsions were a significant feature in patients with stab injuries to the head compared to those with gunshot injuries. http://thejns.org/doi/abs/10.3171/2016.5.PEDS167 KEY WORDS penetrating traumatic brain injury; gunshot; head; stab wound; neurological sequelae; trauma HE magnitude, management, sequelae, and con- penetrating head injuries include pens, nails, needles, table tributing factors associated with penetrating head knives, forks, scissors and other instruments.6 injuries are well established in the literature.3,16 A cranial stab wound is usually caused by a weapon TPenetrating traumatic brain injuries (TBIs) are common with a small impact area, and it often produces a slot skull in war; however, low-velocity penetrating pediatric TBIs fracture with an underlying tract hematoma.7 Aggressive in situations other than war are uncommon and are said to debridement of penetrating missile injuries has been the have a better prognosis when treated.3 Various causes of accepted mode of management, but it is not necessarily ABBREVIATIONS GCS = Glasgow Coma Scale; TBI = traumatic brain injury. SUBMITTED December 31, 2015. ACCEPTED May 13, 2016. INCLUDE WHEN CITING Published online July 29, 2016; DOI: 10.3171/2016.5.PEDS167. 550 J Neurosurg Pediatr Volume 18 • November 2016 ©AANS, 2016 Unauthenticated | Downloaded 09/24/21 06:07 AM UTC Neurological findings in pediatric patients with penetrating TBI the rule in the current neurosurgical practice, especially TABLE 1. Age distribution* 5,7 in a civilian population. In penetrating brain injuries, Age Range in Yrs Frequency Percentage CSF fistulas may occur in 0.63%–8.9% of cases among patients who have sustained missile injuries in war situ- 0–2 31 13.9 ations.13 3–12 83 37.2 A review of the local experience with pediatric pen- 13–16 109 48.9 etrating TBIs in Durban, one of the major cities in South Total 223 100 Africa, was lacking. In this study we determined the com- mon neurological manifestations, subgroups at risk, and * The mean age 10.3 years; 48.9% of the patients were 13–16 years, and 70% of the patients were males aged 13–16 years. presenting Glasgow Coma Scale (GCS) scores among children with penetrating head injury. Methods mean duration of hospitalization was 8.3 days for 70% of This was a retrospective chart review of medical records patients, and for 5.5% of the patients hospitalization was and imaging studies of pediatric patients who had sus- prolonged. tained a penetrating TBI who were admitted to and man- Neurological Sequelae Overview aged at the Department of Neurological Surgery at Inkosi Albert Luthuli Central Hospital, University of KwaZulu- The number of patients who presented with neuro- Natal (a national quaternary care hospital and Level 1 logical sequelae was 109 (48.9%) (Table 3). The common trauma center). The records evaluated were of patients ad- neurological sequelae were as follows: cranial nerve ab- mitted between January 1985 and December 2007. Charts normalities were seen in 50 patients, which accounted for were reviewed for injury patterns, risk groups, neurologi- 22.4% of the population overall and 45.9% of patients with cal sequelae, and presenting physiological parameters, in- neurological sequelae. Among patients with cranial nerve cluding GCS score. Ethical approval was obtained from abnormalities, 38 (76%) had facial nerve deficits, 9 (18%) the University of KwaZulu-Natal and the KwaZulu-Natal had oculomotor problems, and 3 (6%) had optic nerve defi- Department of Health, including a waiver of individual cits. consent, as this was a chart review. Statistical analysis was Forty-one patients presented with right-sided hemipa- performed using the chi-square and Fisher tests and with resis following injury, accounting for 41.4% of patients regression analysis. A statistically significant difference with neurological abnormalities and 18.4% of the total number of patients with penetrating TBI. Thirty-six pa- between the events was defined as a p < 0.05. tients (16.1%) presented with left-sided hemiparesis. Up- per-limb monoparesis/monoplegia was noted in 5 (2.2%) Results of the 223 patients, lower-limb monoparesis/monoplegia Overview occurred in 4 (1.8%) of the 223 patients. Nine (4.0%) of the Over the period from January 1985 to December 2007, 223 patients presented with convulsions (Table 3). 18,982 patients with head injury were admitted to the neu- rological surgery service. Of these, 3020 were children Associations Concerning the Mechanism of Injury under 16 years of age. Two hundred twenty-three children Neurological sequelae following gunshot and stab in- with penetrating head injuries were identified. These in- juries were present in 63 (49.6%) and 46 (47.9%) patients, juries resulted from either a gunshot or stab injury and respectively (Table 4). The neurological abnormality pro- constituted 7.4% of all pediatric neurotrauma admissions files for the two types of mechanisms were fairly similar and 1.2% of all TBI patients admitted to the only public without a statistically significant difference (chi-square neurosurgical department in KwaZulu-Natal. 4.245, p = 0.751). Age, Sex, Mechanism of Injury, and Duration of Mechanism of Injury and Side of Entry Wound Hospital Stay Stab wounds occurred more on the left side, while The patients were categorized into the following age gunshot wounds occurred more on the right side (Table groups: 0–2, 3–12, and 13–16 years (Table 1). Of the 223 5). Left-sided injuries were seen in 56 (58.3%) of the 96 patients admitted with penetrating TBIs, 31 (13.9%) were patients with stab injuries, while right-sided injuries oc- in the 0–2 age group, 83 (37.2%) were in the 3–12 age group, and 109 (48.9%) were in the 13–16 age group. The mean age was 10.3 years and the median age was 12 years; TABLE 2. Mechanism of injury versus age* 75% of the patients were males aged 3–16 years (Table 1). One hundred eighty-nine (84.8%) of the patients with Age in Yrs penetrating TBI were males. In 127 (57%) of the patients, Mechanism 0–2 3–12 13–16 Total the TBI was caused by a gunshot, while in 96 (43%) it was caused by stabbing, a difference that is not statisti- Stab wound 18 53 56 127 cally significant (Table 2). There was also no statistically Gunshot 31 83 109 273 significant relationship between age and mechanism of * There was no statistically significant relationship between age and mecha- injury (chi-square test 3.011, p = 0.222) (Table 2). The nism of injury (chi-square 3.011, p = 0.222). J Neurosurg Pediatr Volume 18 • November 2016 551 Unauthenticated | Downloaded 09/24/21 06:07 AM UTC K. D. Muballe, T. Hardcastle, and E. Kiratu TABLE 3. Neurological abnormalities as percentages of the total TABLE 5. Mechanism of injury and side of entry wound* number of patients Mechanism No. of Patients Neurological Abnormality Percentage of Patients of Injury Lt Side Rt Side Total Cranial nerve deficit 22.4 Gunshot 49 78 127 Rt hemiparesis 18.4 Stab 56 40 96 Lt hemiparesis 16.1 Total 105 118 223 Convulsions 4.0 * Stab wounds occurred more frequently on the left side, whereas gunshot Blindness 3.6 wounds occurred more on the right side (chi-square 8.56; p = 0.003).