Low-velocity penetrating brain injuries (PBIs), also referred to as nonmissile brain injuries, typically result from stabbings, industrial or home accidents, or suicide attempts. A great deal of literature has focused on the injury patterns and management strategies of high-velocity PBIs. However, there are substantially fewer large, contemporary studies focused solely on low-velocity PBIs. Here, we present an interesting and uncommon case of a patient who suffered a bihemispheric stab wound involving the basal ganglia. A 22-year-old man presented to the hospital with a stab wound to the left calvarium. His initial Glasgow Coma Scale (GCS) score was 13, but he rapidly declined to a six and was intubated. He was emergently taken to the operating room for craniectomy, knife removal, and external ventricular drain placement. On the first postoperative day, the patient was following commands with all extremities. He was discharged to a rehabilitation facility 13 days postinjury. One year after the injury, the patient was free of major neurologic sequelae. This report illustrates a rare case of a good functional outcome after a transcranial stabbing with multiple imaging and exam findings usually associated with poor outcomes.
Keywords: penetrating brain injury, low velocity penetrating brain injury, non-missile brain injury, bihemispheric injury, transcranial stab wound
A 22 year old man was brought to a level one trauma center by emergency medical services from the scene of a stabbing. Emergency medical personnel reported the patient was found in the field with a large kitchen knife protruding from the left side of his head (Figure 1). Upon arrival, the patient was awake, alert, and moving all extremities. His initial Glasgow Coma Scale (GCS) score was 13. However, he subsequently became combative, declined to a GCS of six, and was intubated for airway protection.
Primary and secondary surveys did not reveal additional injuries. Physical exam was significant for a large knife protruding from the left cranium approximately 10 cm. Medical history was obtained from the next of kin, which was only remarkable for illicit drug use. Laboratory investigations were remarkable for a leukocytosis of 13 K/µL and a lactate of 5.8 mmol/L. The patient was taken for noncontrasted head CT exam, which showed a moderate right lateral intraventricular hemorrhage, a small intraparenchymal hemorrhage in the right basal ganglia, a 3 mm subdural hematoma along the left cerebral convexity, and a small subarachnoid hemorrhage in the basal cisterns (Figure 2).
There was approximately 10 cm of intracranial penetration projecting from the left temporal bone through the left basal ganglia and ultimately terminating in the right basal ganglia. Subsequent CT angiogram of the brain did not show a definitive vascular injury, although there was significant beam artifact from the knife (Figure 3).
The patient was taken emergently to the operating room by the neurosurgery team. The patient received cefazolin, vancomycin, cefepime, and metronidazole prior to skin incision due to the contaminated nature of the wound. A left pterional incision was made and T’d into the knife. A left temporal craniectomy was drilled around the knife. Once the craniectomy was completed, the knife was carefully removed from the cranium. An external ventricular drain was placed after an intraoperative head CT scan showed increased hemorrhage along the injury tract. The patient’s postoperative head CT scan is shown in Figure 4.
The patient was following commands with all extremities on the first postoperative day. He developed hydrocephalus requiring cerebrospinal fluid (CSF) diversion, so the external ventricular drain was left in place for six days. A formal cerebral angiogram was done on postoperative day six showing a focal area of vasospasm of the left inferior division of the middle cerebral artery M2 segment (Figure 5). This was treated with intra-arterial verapamil with mild improvement on completion angiogram.
The patient was febrile early in his postoperative course and therefore completed 12 days of broad spectrum antibiotics. Two sets of blood cultures were negative. He completed seven days of levetiracetam for early seizure prophylaxis. He was discharged to an inpatient rehabilitation facility 13 days postinjury. He was discharged to home from rehab on postinjury day 21. The patient has not followed up with neurosurgery since his discharge. However, he returned to the ER for suture removal almost one year after the injury and did not appear to have neurologic sequelae. Based on chart review of this visit, the patient’s Glasgow Outcome Score would be five.
Copyright © 2019, Ebeling et al.