DOI: https://doi.org/10.21203/rs.3.rs-1564845/v1
Head trauma due to falls is often seen in children, however Penetrating Brain Injury (PBI) – the most life-threatening condition of Traumatic Brain Injury (TBI) - is exceedingly rare. Herein, we report and discuss the challenges encountered in surgical and post-operative management of a 13-old-child patient with PBI by a pickaxe, admitted in Glasgow Coma Scale (GCS) 3 and that not only survived, but also achieved a Glasgow Outcome Scale (GOS) after one year of postoperative follow-up. To our knowledge, this is the first case of pickaxe-induced brain injury on the American Continent and the youngest survivor of this trauma reported in literature.
PBI is the most life-threatening condition of TBI: only 10–30% survive to reach the hospital, half of which ultimately die during initial resuscitation and the other half often suffer significant long-term neurologic sequelae[1–3].
Based on the speed of penetration, PBI is classified into two groups: missile injuries (> 100m/s) or non-missile injuries (< 100m/s). Non-missile injuries represent only 0,4% of overall head trauma[4, 5] and are even more rare in children, being commonly described as result of an accident while playing, assault, suicidal attempts or road traffic accident, but also as a result of domestic violence.
Several materials have been reported as PBI[1, 2, 12–19, 4–11], but little is known about penetrating pickaxe and its surgical management challenges. Herein, we report an PBI by a pickaxe in 13-old-child and discuss the challenges encountered in its surgical extraction and post-operative management.
A 13-years-old male patient was found on GCS 3 with a pickaxe (Fig. 1) onto his head owing to paternal violence and conducted to the hospital intubated, with right-sided hemiplegia, mydriatic left pupil and a left frontotemporal PBI. Computerized tomography (CT) showed a metallic object penetrating left frontotemporal skull and brain parenchyma in at a depth of 120mm and left orbit fracture (Fig. 2a).
After initial evaluation, and under general anesthesia, a Becker flap was made around the pickaxe, and the bone fixed under it was removed to prevent unnecessary movement. The pickaxe was slowly pulled out from the skull under direct visualization and hemostasis was performed. Necrosis and hemorrhage surrounding brain tissue was observed, but no major vessel injury was found. Brain relaxation was visualized, and dura mater was closed tightly using autologous and pericranial graft. Then, patient was transferred to intensive care unit and postoperative CT showed residual hematoma with no mass effect.
On the second day, bulging of the surgical wound region was noted and new CT showed Marshall score IV (Fig. 2b). Decompressive craniectomy was performed and patient was extubated in nine days. Initially, expressive aphasia was prominent. He could follow orders with his left side, but the right side was heavily paretic and ipsilateral amaurosis due to irreversible left optic nerve lesion was confirmed by ophthalmologist.
Three days later, he was transferred to the neurosurgical department and after completing 28-day antibiotic regimen, patient made another CT (Fig. 2c) and was discharged with GOS 3, instructions for homeschooling, physio and speech therapy. After 1 year, patient achieved GOS 5 despite sequelae alterations found in the control CT (Fig. 2d).
Since Phineas Gage in 1848[10], 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[9] 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%[21]. 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[11].
CT scan is, undoubtful, standard imaging for PBI[1] 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[2]. 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%[15]. 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[29]. 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.
TBI requires remarkable attention and quick action as it may lead to irreversible brain damage and death. Due to its complexity and rarity, this PBI by pickaxe report could contribute with feasible management suggestions and also to show that even in the most serious conditions, we could have hope.
Funding
The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.
Conflicts of Interest
The authors confirm that there are no known conflicts of interest with this publication and no relevant financial or non-financial interests to disclose.
Author Contributions
First draft of manuscript, literature review and data analysis: Raíssa Mansilla
Review and editing: Bárbara Contarato Pilon, Geraldo Paraguassu;
Material preparation and data collection: Luís Gustavo Duarte Amaral and Paulo Henrique Reigota Pinguelo
Article's idea: Paulo Henrique Reigota Pinguelo and Fernando Jorge Monteiro Martins
Ethics approval
Ethical approval was waived by the local Ethics Committee of Fluminense Federal University in view of the retrospective nature of the study and all the procedures being performed were part of the routine care
Consent to participate and publish (participant)
Written informed consent was obtained from the legal guardian of the child, including the consent for image publication available in Figure 2a.
Consent to publish (authors)
As corresponding author, I confirm that all authors read and approved the final manuscript.
|
Trauma Report |
Mansilla R et al. (2022) |
Mbengono JAM et al (2019) |
|
|---|---|---|---|
|
Country |
Brazil |
Cameroon |
|
|
Age |
13 |
34 |
|
|
Gender |
Male |
Male |
|
|
Transport to hospital |
Advanced Ground Ambulance |
Neighbor |
|
|
Aggression type |
Paternal violence |
Assault |
|
|
Time to hospital arrival |
30 minutes |
Not described |
|
|
Door-to-surgery time |
1 hour |
Not described |
|
|
Penetrating agent |
Pickaxe |
Pickaxe |
|
|
Material |
Metal |
Not described |
|
|
Entry point |
Frontotemporal |
Frontotemporal |
|
|
Side |
Left |
Left |
|
|
GCS on admission |
3 |
15 |
|
|
Pupils on admission |
Anisocoric (L > R) |
Anisocoric (R > L) |
|
|
Post-operative complication |
Yes. Hemorrhage and brain edema |
No. |
|
|
GOS-HD (hospital discharge) |
3 (severe disability) |
5 |
|
|
GOS-Late (12 months) |
5 (good recovery) |
5 |
|
|
Antibiotic prophylaxis |
28 days (ceftriaxone + metronidazole) |
5 days |
|
|
Tetanus prophylaxis |
Yes. 1st hour |
Yes. |
|
|
Inpatient hospital stays |
28 days |
5 days |
|
|
Rehabilitation |
Physio and speech therapy |
Not described |
|