Penetrating head injury
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Joanna Ekabua, M.D. [2]
Synonyms and keywords:: Penetrating head injury
Overview
A penetrating head injury, or open head injury, is a life-threatening condition in which the dura mater, is breached. Penetrating injury can be caused by high-velocity projectiles or objects of lower velocity such as knives, or bone fragments from a skull fracture that are driven into the brain. A perforating head injury is one in which the object passes through the head and leaves an exit wound. Although penetrating head injuries can be dramatic in appearance and presentation, the trajectory is of particular importance the case of gunshot wounds. Immediate neurosurgical consulting mandatory.
Historical Perspective
Classification
Penetrating head injury can be classified as
Pathophysiology
- Though it is more likely to cause infection, penetrating trauma is similar to closed head injury such as cerebral contusion or intracranial hemorrhage in a number of ways. As in closed head injury, intracranial pressure is likely to increase due to swelling or bleeding, potentially crushing delicate brain tissue. Most deaths from penetrating trauma are caused by damage to blood vessels, which can lead to intracranial hematomas and ischemia, which can, in turn, lead to a biochemical cascade called the ischemic cascade. The injury in penetrating brain trauma is mostly focal (affects a specific area of tissue).[3] Sometimes in penetrating injuries, the brain releases thromboplastin, which can lead to problems with clotting.[4]
- In penetrating injury from high-velocity missiles, injuries may occur not only from initial laceration and crushing of brain tissue by the projectile but also from the subsequent cavitation. High-velocity objects create centrifugal forces and can create a shock wave that cause stretch injuries, forming a cavity that is three to four times greater in diameter than the missile itself.[3] A pulsating temporary cavity is also formed by a high-speed missile and can have a diameter thirty times greater than that of the missile.[3] Though this cavity is reduced in size once the force is over, the tissue that was compressed during cavitation remains injured. Destroyed brain tissue may either be ejected from entrance or exit wounds or packed up against the sides of the cavity formed by the missile.[3]
- Low-velocity objects usually cause penetrating injuries in the regions of the skull's temporal bones or orbital surfaces, where the bones are thinner and thus more likely to break.[3] Damage from lower-velocity penetrating injuries is restricted to the tract of the stab wound because the lower-velocity object does not create as much cavitation.[3] However, low-velocity penetrating objects such as slow bullets may ricochet inside the skull, continuing to cause damage until they stop moving.[5]
Causes
Common causes of penetrating head injury
Differentiating Penetrating Head Injury from other Diseases
Penetrating head injury must be differentiated from
Epidemiology and Demographics
The highest-velocity injuries tend to have the worst associated damage.[9] Penetrating injury from any missile such as a bullet has a mortality rate of 92%.[3] Thus, firearms cause the most head injury-related deaths.[5] Perforating injuries have an even worse prognosis.[3]
Penetrating head trauma can cause loss of abilities controlled by parts of the brain that are damaged. A famous case of penetrating head trauma was that of Phineas Gage, whose personality drastically changed after he sustained a penetrating injury to his frontal lobe.
Up to 50% of patients with penetrating brain injuries get late-onset epilepsy.[10]
Risk Factors
Screening
Natural History, Complications, and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
- Glasgow Coma Scale (GCS)
- *GCS 8-15 and somnolence: Sleepy, easy to wake
- *GCS 8-15 and stupor: Hypnoid, hard to wake
- *GCS ≥ 13: Mild Head Injury
- *GCS 9–12: Moderate Head Injury
- *GCS ≤ 8: Severe Head Injury
- *GCS 7-8: Light coma; Coma Grade I
- *GCS 5-6: Light coma; Coma Grade II
- GCS 4: Deep coma; Coma Grade III
- GCS 3: Deep coma; Coma Grade IV
Laboratory Findings
Electrocardiogram
X-ray
Ultrasound
CT Scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
See also
References
- ↑ 1.0 1.1 Khan KA, Gandhi A, Sharma V, Jain S (2019). "Penetrating head injury due to angle grinder: an occupational hazard". Br J Neurosurg. 33 (2): 202–206. doi:10.1080/02688697.2018.1467375. PMID 29693468.
- ↑ Drosos E, Giakoumettis D, Blionas A, Mitsios A, Sfakianos G, Themistocleous M (2018). "Pediatric Nonmissile Penetrating Head Injury: Case Series and Literature Review". World Neurosurg. 110: 193–205. doi:10.1016/j.wneu.2017.11.037. PMID 29155117.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7
- ↑ Orlando Regional Healthcare, Education and Development. 2004. "Overview of Adult Traumatic Brain Injuries." Retrieved on September 6, 2007.
- ↑ 5.0 5.1 Brain Injury Association of America (BIAUSA). "Types of Brain Injury." Retrieved on February 6, 2007.
- ↑ Awori J, Wilkinson DA, Gemmete JJ, Thompson BG, Chaudhary N, Pandey AS (2017). "Penetrating Head Injury by a Nail Gun: Case Report, Review of the Literature, and Management Considerations". J Stroke Cerebrovasc Dis. 26 (8): e143–e149. doi:10.1016/j.jstrokecerebrovasdis.2017.04.004. PMID 28551290.
- ↑ Ramos R, Antunes C, Machado MJO, Almeida R (2017). "Penetrating head trauma injury with an excellent outcome". BMJ Case Rep. 2017. doi:10.1136/bcr-2017-219746. PMC 5612542. PMID 28775085.
- ↑ Ball CG (2015). "Penetrating nontorso trauma: the head and the neck". Can J Surg. 58 (4): 284–5. doi:10.1503/cjs.012814. PMC 4512872. PMID 26022154.
- ↑ Dawodu S. 2007. "Traumatic Brain Injury: Definition, Epidemiology, Pathophysiology" Emedicine.com. Retrieved on February 6, 2007.
- ↑ Shepherd S. 2004. "Head Trauma." Emedicine.com. Retrieved on February 6, 2007.