Since Phineas Gage in 1848, PBI have been broadly reported, but is still rare in children. Our case is the first on American continent and the only one in a pediatric patient with a surgical view. An African case was reported and, despite the age difference, both were male patients victims of violence with left frontotemporal injury, consistent with general PBI literature related. The higher incidences in the left side could be explained due to right-handedness of the aggressor[5, 20] and, although the most common entrance site in non-missile PBI is the roof of the orbit, it is followed by the squamous part of the temporal bone due to its thinner wall[4, 6]. Complete comparison of the cases is available on Table 1.
The time trauma to hospital arrival is directly related with in-hospital all-cause mortality and for each 10-minute enlargement in prehospital time the odds of death increases 9%. Fortunately, Brazil has an effective public prehospital trauma care which certainly was the watershed between life and death in this case. Foreign body removal at the scene was not recommended because could reduce pressure on vascular structures inducing hemorrhage.
CT scan is, undoubtful, standard imaging for PBI and angiography should be obtained in suspected vascular injuries. In our case, owing to patient gravity, we decided to immediate surgical treatment and no other exams were performed. Timing of surgical intervention is likewise important to avoid secondary injuries and, for that, the door-to-surgery time must be within the first hour[1, 22]. In this case, patient was quickly transferred to hospital but, unfortunately, this target is more achievable in trauma centers, which is not available in all regions of Brazil neither worldwide.
Despite disagreements among neurosurgeons about surgical indication according to admissional GCS, there is a general agreement that once the surgery is proposed, it must be adopted the following precepts: 1) remotion of the foreign body in the operation room; 2) Evacuation of any hematomas or lesions causing mass effect; 3) debridement only around the injury tissue; 4) vigorous hemostasis; 5) Watertight dural and scalp closure [5, 12, 17, 23–26].
Furthermore, is fundamental adequate post-operative care to prevent and treat early (< 1 week) and late (> 1 week) complications following PBI: hemorrhage and infection (most commons)[7, 27], cerebral contusion or edema, ischemic or vascular injury, hydrocephalous, liquor leakage and foreign body migration. In our case, patient suffered an early complication promptly diagnosed and treated, demonstrating that post-operative imaging and follow-up are crucial to identify complications[5, 8, 14, 23].
Although infection associated with TBI ranges from 5–23%[2, 17, 28], in pediatric PBI reaches over 40%. Prophylaxis with broad-spectrum antibiotics should be done, but its duration is still under discussion[1, 5, 7, 17, 19, 25]. Our patient received 4 weeks of intravenous Ceftriaxone and Metronidazole and no infection was observed. Also, we routinely administer anticonvulsants within 7 days. Afterwards, medication is discontinued and all were followed up for a minimum of 2 years, since 80% of PBI patients have seizure during this time[17, 30].
Prognosis of PBI depends on multiple factors and the first golden hour post-trauma is decisive. In our case, patient survived with good neurologic status not only being promptly operated, but also by the multidisciplinary team post-operative management.