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Purpose: Civilian penetrating brain injuries (PBI) caused by firearms are a medical emergency with high rates of morbidity and mortality. The aim of this study was to evaluate the association between trajectory vectors in CT brain angiography and clinical outcomes in patients with civilian gunshots. Methods: This is a retrospective analytical cross-sectional study that includes patients over 15 years of age with PBI due to firearms, admitted from January 2019 to December 2021 at a University Hospital in Cali, Colombia. A brain CT with angio-CT was performed the first day of admission. An XYZ coordinate system centered on the Turk's saddle was developed. Trajectories of projectiles were plotted and compared to a patient 0 in a 3D-Slicer software. A bivariate analysis of the clinical and geometric characteristics of the trajectory was performed. Primary outcomes include mortality and disability at 6 months. Results: Twenty-eight patients with a mean age of 27.39 ± 11.66 years were included. The vectors of non-survivors show a trend, crossing at a specific area. This area was designated as a "potential lethal zone" and inside this area, injuries around 25.3 mm from the circle of Willis, were associated with greater mortality (p < 0.005). Conclusions: In our study PBI avoiding the ventricular system, brain stem, dorsum sellae and the circle of Willis were associated with more survivability. A "potential lethal zone" was detected and associated with poor outcome after civilian PBI due to firearms. A better evaluation of the performance of this "potential lethal zone" in larger studies will be required. [ABSTRACT FROM AUTHOR]

Penetrating head injury is rare and, their management is nonstandard with persistent cerebrospinal fluid (CSF) leakage being possibly challenging to treat. A 34-year-old man with no past medical history was referred in emergency room for an impressive accidental penetrating craniocerebral wound through which the brain was extruding due to the raised intracranial pressure. Computed tomography scan showed a comminuted frontal fracture extended to the anterior skull base and a severe bifrontal lobe concussion with a diffuse intracranial hemorrhage. A debridement and washout of the craniocerebral wound were achieved with careful hemostasis followed by a decompressive craniectomy. Fortunately, the patient survived but, the CSF continued to leak through the anterior skull base fracture with no endoscopic treatment possibility. Fifteen days after the initial trauma, a surgical sealing was decided using a large fascia lata sheath harvested on the right thigh by a "S"-shaped incision. A significant piece of fascia lata was cut off and meticulously sutured to the remaining dura mater rims in double-layered watertight fashion. Both cranial and right thigh wounds healed uneventfully and the CSF leak never reoccurred. Twenty-two weeks after the initial trauma, a custom-made titanium cranioplasty was inserted without any dissection difficulty. In case of persistent CSF leakage not amenable to endonasal endoscopic treatment, the use of a large piece of facia lata harvested on the thigh using an "S"-shaped incision is a simple, reliable way to efficiently repair a large dura mater defect. It requires neither special skills nor sophisticated instruments. [ABSTRACT FROM AUTHOR]

A 62-year-old man was referred for a transorbital injury. A preoperative computed tomography scanner confirmed an 8 cm long × 14 mm wooden piece penetrating the right orbit and perforating the anterior cranial base until the frontal lobe with no apparent prominent vascular injury. However, an unexpected posterior fossa tumor causing blocked hydrocephalus was unveiled. Extraction of the wooden stick was safely achieved after intracranial exploration followed by meticulous cleaning and careful watertight closure to prevent cerebrospinal fluid (CSF) leakage. Except the right eyesight loss, he initially recovered well, were it not for his hard-to-treat hydrocephalus. What at the time of its discovery seemed to be a less important but very likely the indirect cause of its injury, became unexpectedly problematic. Despite all CSF diversion procedures, the patient worsened gradually. Neither a failed attempt to remove the tumor due to the fourth ventricle floor broad infiltration nor the posterior fossa decompressive craniectomy succeeded in improving his neurological status. Despite the diagnosis of a grade II ependymoma, the tumor demonstrated an aggressive radiological behavior with an intense edema of the brainstem, possibly the cause of his drowsiness. Unfortunately, he died of tumor progression solely 52 days after his transorbital injury. [ABSTRACT FROM AUTHOR]

Background: Penetrating brain injury (PBI) can be caused by a variety of objects ranging from simple to complicated items. Nonetheless, it is strange and unusual to attack someone in the head with a long nail. Due to its rarity, care for them is still being developed and may include many steps. Case Description: We are presenting a 35-year-old guy who was neurologically intact and hemodynamically stable but complained of headaches following a nail blow into the skull during a domestic altercation by a gang of individuals. A computed tomography scan revealed the metallic item inside the brain parenchyma. The patient recovered well from the procedure, which included the early removal of the foreign body, evacuation of the hematoma, and dura repair. Our objective is to demonstrate a few broad management concepts that help enhance patient outcomes. We covered the clinical manifestation and effective treatment of such a rare injury in this study. Conclusion: Proper handling and rapid transport of patients to the advanced trauma center are crucial for victims of PBI. Timely and skilled interventions could prevent further nervous tissue damage and any related neurological dysfunction. [ABSTRACT FROM AUTHOR]

Background: Pediatric penetrating brain injuries (PBIs) are rare but critical traumatic events, often involving foreign objects. This report will emphasize the clinical presentation, diagnosis, and treatment strategies for pediatric PBI cases. Case Description: This report presents a case of a 7-year-old male patient with a PBI resulting from a nail that penetrated the left mastoid region following a fall from a tree. On admission, the patient maintained consciousness, displayed stable vital signs, and showed no neurological deficits. Crucial radiological examinations, including skull X-rays and head computed tomography (CT) scans, revealed a 6.5 mm caliber nail penetrating 5.5 cm into the brain, with intraventricular hemorrhage filling the bilateral posterior horns of the lateral ventricles. In addition, the CT angiography (CTA) of the head provided a visual of the internal carotid arteries and the vertebrobasilar artery system, obscured by metal artifacts but showing no evidence of thrombus, aneurysm, or vascular malformation. The patient underwent an urgent mastoidectomy and retro sigmoid craniotomy to remove a foreign object, involving a multidisciplinary team. Subsequent to the intervention, the patient sustained full consciousness without neurological impairments and received intensive care. Conclusion: Radiological tools, notably skull X-rays and head CT scans, are pivotal for the precise diagnosis of pediatric PBI. The combined mastoidectomy and retro sigmoid craniotomy approach offers a safe and efficient means of foreign body removal. Tailoring treatments to individual patient needs enhances outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background Penetrating trauma to the brain is a rare mode of self-harm in individuals with depressive psychosis. It may have variable presentations ranging from intact neurological status to non-survivable damage and the subjects may be surprisingly apathetic to pain. It is even unusual for such an injury to have an excellent prognosis despite coming late to clinical attention. Case presentations We report two cases of patients with psychotic depression who attempted suicide by hammering nails into their heads. On imaging, deep penetration within the brain parenchyma was noted; however, neither case had any neurological deficit or symptoms attributable to brain trauma. Conclusions Self-inflicted penetrating brain injuries with peculiar objects such as nails are rarely encountered in practice. They need prompt management for their removal and addressing the underlying mental health illnesses.

Penetrating brain injury (PBI) is a subtype of traumatic brain injury (TBI) that has been steadily increasing in prevalence and causing significant mortality in trauma patients. In an emergent setting, it is important to determine the mechanism of injury and decide whether a PBI or a blunt TBI has occurred in order to guide diagnostic imaging and subsequent treatment. In cases where a PBI has been likely or has occurred, it is important to initiate treatment expeditiously as rapid interventions have been shown to lead to better outcomes. However, in cases of unwitnessed pediatric trauma, it can be difficult to ascertain the specific method of injury due to a lack of reliable sources. In such cases of unwitnessed trauma, PBI should be included in the differential of any orbitocranial injury. In this series, we present two cases of unwitnessed pediatric orbitocranial injury that highlight the importance of gathering a detailed history, obtaining appropriate imaging studies, and using physician intuition. [ABSTRACT FROM AUTHOR]

Background: Penetrating trauma to the brain is a rare mode of self-harm in individuals with depressive psychosis. It may have variable presentations ranging from intact neurological status to non-survivable damage and the subjects may be surprisingly apathetic to pain. It is even unusual for such an injury to have an excellent prognosis despite coming late to clinical attention. Case presentations: We report two cases of patients with psychotic depression who attempted suicide by hammering nails into their heads. On imaging, deep penetration within the brain parenchyma was noted; however, neither case had any neurological deficit or symptoms attributable to brain trauma. Conclusions: Self-inflicted penetrating brain injuries with peculiar objects such as nails are rarely encountered in practice. They need prompt management for their removal and addressing the underlying mental health illnesses. [ABSTRACT FROM AUTHOR]

The French poet Apollinaire enrolled in the French army during World War I. In 1916, he sustained a penetrating brain injury when a fragment of shrapnel pierced his helmet in the right temporal region. Neurosurgical techniques were at that time standardized to manage the significant number of war-related neurosurgical casualties. Apollinaire, who experienced transient fainting followed by left-sided hemiparesis 2 months after his trauma, underwent trepanation. The poet's personality and behavior changed dramatically after his trauma. These neurobehavioral changes, associated with preserved cognition and no other neurologic dysfunction, were later described as Apollinaire syndrome. These personality changes were accompanied by flourishing writing changes. Hence, 15 months after his penetrating brain injury, the poet introduced the term "surrealism" to the world in his play The Breasts of Tiresias , giving birth to a major movement that paved the way for the 20th century. Linguistic shifts such as phonologic and semantic word games were at the forefront of the narrative process of the play. Traumatic brain injury often leads to cognitive impairment. In the case of Apollinaire, if the ballistic trauma were also responsible for diffuse axonal injury, it could have also led to semantic and social cognition impairment, in addition to the neuropsychological disorders that had already been widely documented by his friends and family. The world will always remember Apollinaire's writing genius as deeply associated with the birth of surrealism. But what if the poet's new writing style was caused, at least in part, by the unexpected help of a lost shrapnel fragment? [ABSTRACT FROM AUTHOR]

Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and healthcare costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. A preliminary literature search revealed a need for updated guidelines, supported by the Brain Trauma Foundation. Methodologists experienced in TBI guidelines were recruited to support project development alongside two cochairs and a diverse steering committee. An expert multi-disciplinary workgroup was established and vetted to inform key clinical questions, to perform an evidence review and the development of recommendations relevant to pTBI. The methodological approach for the project was finalized. The development of up-to-date evidence- and consensus-based clinical care guidelines and algorithms for pTBI will provide critical guidance to care providers in the pre-hospital and emergent, medical, and surgical settings.

Background: Penetrating injuries to the brain are rare and have a mortality rate of 40% if they are high velocity. They could occur accidentally or intentionally from suicidal or homicidal attempts. Impalement head injuries could be complicated by intracranial hemorrhage, neurological deficits, infection, and epilepsy but usually have good prognosis. A craniotomy is the preferred surgical intervention for such injuries. Case summary: A 20-year-old male with bipolar disorder presented to a primary-care facility with a nail at the vertex of the head, presumed to be self-inflicted, and was referred to Tamale Teaching Hospital. The GCS was 14/15 with no focal neurological deficits. All other examinations remained normal. A skull x-ray and head computed tomography (CT) scan revealed the position of the nail and aided in diagnosis. A delayed mini craniectomy was performed on the 11th day of admission and the nail was successfully removed with no complications. Conclusion: Nail impalement brain injury is a complex injury whose management can pose challenges to the neurosurgeon in a low-resource center.

Traumas are the most important cause of mortality in the pediatric population. Bleeding is an important complication, especially in traumatic brain injuries with coagulation problem addition. Low-velocity penetrating brain injuries may be caused by sewing needles, nails, and knives. There are few studies in the literature for this injury type. This study presented a surgical technique and treatment to increase hemostasis in a 2-year-old patient after a sewing needle injury. [ABSTRACT FROM AUTHOR]

Retained foreign bodies following penetrating brain injuries continue to pose therapeutic dilemmas. Previously used aggressive approach involving extensive wound debridement and removal of foreign bodies caused additional neurological deficit with higher mortality. Less aggressive approach used more recently involving decompressive craniectomy has lead to higher incidence of retained foreign bodies with potential of infective sequelae. We describe one such case where, in presence of a retained foreign body, an intracranial abscess formed after a gap of 17 yrs. The case has peculiar radiological and morphological findings. [ABSTRACT FROM AUTHOR]

Objective: The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma. Background: While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field. Methods: We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners. Results: Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level. Conclusions: Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement. [ABSTRACT FROM AUTHOR]

The primary treatment for a penetrating brain injury is craniotomy because of the presence of a foreign body. Craniocerebral computed tomography is the main imaging method for this condition, and cranial reconstruction is an important basis for formulating relevant surgical protocols. It is necessary to use antibiotics to prevent infection after surgery., (© 2025 The Author(s). Clinical Case Reports published by John Wiley & Sons Ltd.)

Background: Nail gun injuries to the brain are rare but increasingly more common in patients with suicidal ideation and psychiatric disturbances. Utilizing a bio-psycho-socio-ecological (BPSE) prism, the authors of this article describe the treatment and outcome of a patient with a history of psychiatric episodes who presented with a self-inflicted bilateral penetrating brain injury by nail gun. The patient described in this report initially had no formal psychiatric diagnosis but was subsequently diagnosed with schizoaffective disorder following the injury., Observations: A 28-year-old male presented to the emergency department after sustaining a self-inflicted nail gun injury to the right parieto-occipital and left frontoparietal region of the head. The authors review the current literature on the treatment and outcomes of nail gun injuries while providing a narrative account of the biological, psychosocial, and ecological factors that can influence and modify the patient's injury and course of care., Lessons: The case illustrates the importance of exploring the BPSE context of patients with TBI to guide multidisciplinary care that optimizes outcomes and to inform prevention strategies that can reduce the incidence of similar injuries. https://thejns.org/doi/10.3171/CASE24520.

Abstract Background BB guns or non-powder guns created in the modern era are able to reach exceedingly fast velocities as a result of advances in compressed-gas technology. While missile penetrating trauma has been well documented in neurosurgical literature, penetrating intracranial injury secondary to non-powder guns, along with their associated complications and treatments, is not well described, and even less so in the pediatric population. Case presentation Here, we describe an unusual case of a 6-year-old Indigenous child who was accidentally shot with a BB gun to the head. He subsequently developed delayed acute right-sided weakness due to symptomatic vasospasm. His symptoms resolved following hypertensive therapy, balloon angioplasty intervention, and intra-arterial milrinone therapy. Conclusions This case highlights the unique complication of delayed symptomatic vasospasm in a child following a non-missile intracranial penetrating injury. Intracranial vasospasm needs to be considered in the presence of delayed neurological deficit given its potential reversibility. This case also emphasizes the importance of gun safety and education when handling and storing these potential weapons around children.

The incidence of a penetrating brain injury due to a pressure cooker blast is quite rare. We are presenting this case of a 24-year-old female who sustained anterior skull base injury, with the nozzle of the pressure cooker penetrating through left orbit on account of the blast. A combined multidisciplinary approach was utilized and the patient recovered uneventfully.

Introduction: Unihemispheric head gunshot wound (HGSW) are associated with improved survival; however, specific clinical and radiographic characteristics associated with survival have not been clearly defined. To further guide prognosis estimates and care discussions, this study aims to identify unihemispheric HGSWs injury patterns; comparing them to bihemispheric HGSWs characterizing factors associated with improved clinical outcomes and survival.Methods: Patients presenting to our Level 1 trauma center from January 2013 through May 2019 with HGSW injury were reviewed. Patients were grouped into those with unihemispheric versus bihemispheric HGSWs and survivors versus non-survivors. Clinical variables and head computed tomography (CT) features were compared using comparative statistics.Results: 62 HGSW patients met study criteria (unihemispheric = 33, bihemispheric = 29). Regardless of injury type, avoidance of injury to multiple lobes, temporal, parietal and basal ganglia brain regions and intracranial vascular injury were also associated with survival (p < 0.05). Lower admission GCS score and lower motor GCS score was associated with reduced survival in unihemispheric HGSW injury (p < 0.05). Unihemispheric HGSW survivors demonstrated improved clinical outcomes, with reduced hospital length of stay (5 days vs. 47 days, p = 0.014) and intensive care unit length of stay (3 days vs. 20 days, p = 0.021) and more favorable disposition location.Conclusion: We found presenting clinical features and CT imaging patterns previously associated with improved survival in HGSW patients is similar in unihemispheric specific injuries. Importantly, a more favorable admission GCS score may portend survivability in unihemsipheric HGSW. Furthermore, unihemispheric HGSW survivors may have improved clinical outcomes, length of stay and disposition location. [ABSTRACT FROM AUTHOR]

Background: Penetrating brain injuries (PBIs) are a severe subtype of traumatic brain injuries (TBIs), where an object pierces the cranium and meninges. Based on the speed of penetration, it can be classified into high and low-velocity penetration. Low-velocity penetrating injury (LVPBI) cause lacerations to the scalp, depressed skull fractures as well as localized brain tissue and blood vessel damage along the object's path of travel. There have been many case reports and small case series published describing these events. However, there is no standardized guideline for general management to improve patient outcomes. In this report we discuss our experience of using the hybrid theatre to manage such cases. Case presentations: We present the clinical management of a 10-year-old boy who was shot in the head with a harpoon. Computed Tomography Angiography (CTA) demonstrated that the harpoon punctured through the jugular foramen and had a high probability of internal jugular vein (IJV) and internal carotid artery (ICA) involvement. The surgery was performed seven days after injury in a hybrid operating room (OR). We used intraoperative digital subtraction angiogram (DSA) to guide our decision to permanently occluded the IJV and ICA. The patient had a good postoperative recovery and was sent home after three weeks of observation in the hospital. Conclusions: Despite the high cost, intraoperative cerebral angiography in hybrid theatre for selected patients with penetrating brain injury where major blood vessel damage is anticipated might benefit overall patient outcome.

Abstract Background Civilian gunshot wounds to the head refer to brain injury caused by projectiles such as gun projectiles and various fragments generated by explosives in a power launch or explosion. Gunshot wounds to the head are the deadliest of all gun injuries. According to literature statistics, the survival rate of patients with gunshot wounds to the head is only 9%. Due to the strict management of various types of firearms, they rarely occur, so the injury mechanism, injury and trauma analysis, clinical management, and surgical standards are almost entirely based on military experience, and there are few related reports, especially of the head, in which an individual suffered a fatal blow more than once in a short time. We report a case with a return to almost complete recovery despite the patient suffering two gunshot injuries to the head in a short period of time. Case presentations We present a case of a 53-year-old man who suffered two gunshot injuries to the head under unknown circumstances. On initial presentation, the patient had a Glasgow Coma Scale score of 6, was unable to communicate, and had loss of consciousness. The first bullet penetrated the right frontal area and finally reached the right occipital lobe. When the patient reflexively shielded his head with his hand, the second bullet passed through the patient’s right palm bone, entered the right frontotemporal area, and came to rest deep in the lateral sulcus. The patient had a cerebral hernia when he was admitted to the hospital and immediately entered the operating room for rescue after a computed tomography scan. After two foreign body removals and skull repair, the patient recovered completely. Conclusions Gunshot wounds to the head have a high mortality rate and usually require aggressive management. Evaluation of most gunshot injuries requires extremely fast imaging examination upon arrival at the hospital, followed by proactive treatment against infection, seizure, and increased intracranial pressure. Surgical intervention is usually necessary, and its key points include the timing, method, and scope of the operation.

BackgroundPenetrating brain injury (PBI) is a heterogeneous condition with many variables. Few data exist on civilian PBI. In some publications, PBI differentiation between low-velocity injury (LVI) and high-velocity injury (HVI) is made, but exact definitions are not given yet. The incidence of PBI depends heavily on the country of origin. Furthermore, captive bolt pistol (CBP) injuries represent a rare type of LVI and almost no reports exist in the human medical literature. Treatment of PBI has been controversially discussed due to high morbidity and mortality with results varying considerably between series. Prognostic factors are of utmost importance to identify patients who presumably benefit from treatment.MethodsA retrospective, single-center analysis of a consecutive patient series was performed from September 2005 to May 2018. We included all patients with PBI who reached our hospital alive and received any neurosurgical operative procedure.ResultsOf 24 patients, 38% died, 17% had an unfavourable outcome, and 46% had a favourable outcome. In total, 58% of patients with PBI were self-inflicted. Leading causes of injury were firearms, while captive bolt pistols were responsible for 21% of injuries. LVI represented 54%, and HVI represented 46%. The outcome in HVI was significantly worse than that in LVI. A favourable outcome was achieved in 69% of LVI and 18% of HVI. Low GCS and pathological pupillary status at admission correlated significantly with an unfavourable outcome and death.ConclusionsPBI is a heterogeneous injury with many variables and major geographical and etiological differences. Differentiation between LVI and HVI is crucial for decision-making and predicting outcomes. In patients presenting with object trajectories crossing the midline, no favourable outcome could be achieved. Nevertheless, in total, a favourable outcome was possible in almost half of the patients who succeeded in surgery.

A 34-year-old healthy male presented as a trauma activation after sustaining a gunshot wound to his face. CT head imaging was suggestive of a ballistic fragment adjacent to a posterior wall sphenoid sinus fracture with likely a small volume of adjacent blood products. He was ultimately diagnosed with hypopituitarism which included central diabetes insipidus, central hypothyroid, and adrenocorticotropic hormone deficiency secondary to cortisol deficiency. This case illustrates the spectrum of endocrine dysfunction that can occur with skull base injuries, and the appropriate pituitary-function screening and treatment that should be performed if there is clinical concern. Early recognition and prompt treatment of pituitary insufficiency can facilitate overall rehabilitation after TBI.

Background: Low-velocity penetrating brain injury (PBI) is an uncommon variant of traumatic brain injury (TBI). Patients affected by PBI can present with highly variable injury patterns, which, along with guideline-directed TBI care, may require the employment of unique operative management strategies. There are no strict guidelines for the management of low-velocity penetrating injuries. Characterizing approaches and outcomes for various injury patterns may be of use in guiding surgical decision-making. The authors report their experience with two cases of PBI by mechanism of a nail gun with a retained intracranial foreign body requiring surgical removal., Observations: The two patients were managed using different operative approaches with directly visualized nail removal, and both cases were managed with different empiric antibiotic regimens. Both patients were neurologically intact at follow-up and had no perioperative complications., Lessons: These cases illustrate two methods of foreign body removal and the perioperative management protocol utilized at the authors' institution. https://thejns.org/doi/10.3171/CASE24522.

A transorbital intracranial penetrating injury (TOPI) is an unusual traumatic brain injury that requires multidisciplinary management. TOPI may cause traumatic cerebrovascular injury (TCVI) and fatal brain damage with a high mortality rate. Herein, the authors described an 8-year-old male patient who was injured from a handmade gun; a projectile (marble) had penetrated the left frontal base via the left orbit. TOPI caused left anterior cerebral artery compression. A transorbital approach with an intraoperative transcranial approach on standby was performed to remove the foreign body. Postoperative intensive broad-spectrum antibiotics were administrated, and the patient made an uneventful recovery. In summary, TOPI is an uncommon TBI that risks TCVI. Intracranial vascular investigation should be performed before surgical management, and postoperative complications, such as meningitis, brain abscess, and delayed pseudoaneurysm, should be monitored. [ABSTRACT FROM AUTHOR]

Traumatic carotid-cavernous fistulas (tCCFs) after penetrating brain injury (PBI) have been uncommonly described in the literature with little guidance on optimal treatment. In this case series, we present two patients with PBI secondary to gunshot wounds to the head who acutely developed tCCFs, and we review the lead-up to diagnosis in addition to the treatment of this condition. We highlight the importance of early cerebrovascular imaging as the clinical manifestations may be limited by poor neurological status and possibly concomitant injury. Definitive treatment should be attempted as soon as possible with embolization of the fistula, flow diversion via stenting of the fistula site, and, finally, vessel sacrifice as possible therapeutic options.

Abstract Penetrating brain injury is a rare pathology generally requiring emergency surgical intervention. We discuss a case of penetrating brain injury by the umbrella in which surgical intervention was performed 14 days after the injury, and obtained good clinical results.

Civilian penetrating head injury caused by foreign objects is rare in Germany (Europe), but can result in complex neurovascular damage. We report on a patient who in suicidal intent inflicted on himself a penetrating brain injury near the vertex with a captive bolt gun. A laceration at the junction of the middle to the posterior third of the superior sinus occurred by bolt and bone fragments leading to critical stenosis and subsequent thrombosis. Upon surgery, the proximal and distal sinus openings were completely thrombosed. The sinus laceration was closed by suture and the intraparenchymal bone fragments were retrieved. Postoperative angiography disclosed persistent occlusion of the superior sagittal sinus. The patient did not develop any symptoms due to venous congestion (edema, hemorrhage), suggesting sufficient collateral venous outflow. The patient completely recovered despite the complexity of the lesion.

We present the challenges and nuances of management in a rare case of multiple migrating intracranial fragments after pediatric gunshot wound to the head (GSWH). A 13-year-old girl suffered left parietal GSWH, with new neurologic decline 3 days after initial debridement. Serial imaging showed the largest intracranial fragments had migrated into the left trigone, and descended further with head of bed (HOB) elevation. HOB was iteratively decreased, with concurrent intracranial pressure monitoring. After extubation, with an alert and stable neurologic exam, HOB was decreased to −15 degrees, allowing gravity-assisted migration of the fragments to an anatomically favorable position within the left occipital horn. The patient underwent occipital craniotomy for fragment retrieval on hospital day 27. Two large and >20 smaller fragments were retrieved using neuronavigation and intraoperative ultrasound. Forensics showed these to be.45 caliber handgun bullet fragments. The patient recovered well after 2-months of intensive inpatient rehabilitation. During new neurologic decline after GSWH, bullet migration must be considered and serial cranial imaging is requisite. Surgical retrieval of deep fragments requires judicious planning to minimize further injury. Tightly controlled HOB adjustments with gravity assistance for repositioning of fragments may have utility in optimizing anatomic favorability prior to surgery. [ABSTRACT FROM AUTHOR]

Traumatic carotid-cavernous fistulas (tCCFs) after penetrating brain injury (PBI) have been uncommonly described in the literature with little guidance on optimal treatment. In this case series, we present two patients with PBI secondary to gunshot wounds to the head who acutely developed tCCFs, and we review the lead-up to diagnosis in addition to the treatment of this condition. We highlight the importance of early cerebrovascular imaging as the clinical manifestations may be limited by poor neurological status and possibly concomitant injury. Definitive treatment should be attempted as soon as possible with embolization of the fistula, flow diversion via stenting of the fistula site, and, finally, vessel sacrifice as possible therapeutic options. [ABSTRACT FROM AUTHOR]

Background: BB guns or non-powder guns created in the modern era are able to reach exceedingly fast velocities as a result of advances in compressed-gas technology. While missile penetrating trauma has been well documented in neurosurgical literature, penetrating intracranial injury secondary to non-powder guns, along with their associated complications and treatments, is not well described, and even less so in the pediatric population.Case Presentation: Here, we describe an unusual case of a 6-year-old Indigenous child who was accidentally shot with a BB gun to the head. He subsequently developed delayed acute right-sided weakness due to symptomatic vasospasm. His symptoms resolved following hypertensive therapy, balloon angioplasty intervention, and intra-arterial milrinone therapy.Conclusions: This case highlights the unique complication of delayed symptomatic vasospasm in a child following a non-missile intracranial penetrating injury. Intracranial vasospasm needs to be considered in the presence of delayed neurological deficit given its potential reversibility. This case also emphasizes the importance of gun safety and education when handling and storing these potential weapons around children. [ABSTRACT FROM AUTHOR]

Penetrating brain injury from marble is rare. Marbles, commonly known as "guli" among locals, is a popular children's traditional game in Malaysia. This study discusses two cases of intracranial marble injury, both accidentally shot by children with home-made air guns during the period of Movement Control Order with one elderly patient who passed away. While the diagnosis was uneventful, the management was not straightforward. Strategies of prehospital, operative, postoperative management, and rehabilitation are discussed, including prognostic factors. Because of its rarity, the management of such injuries is complex and nonstandardized. [ABSTRACT FROM AUTHOR]

Penetrating brain injury is a rare pathology generally requiring emergency surgical intervention. We discuss a case of penetrating brain injury by the umbrella in which surgical intervention was performed 14 days after the injury, and obtained good clinical results. [ABSTRACT FROM AUTHOR]

Background and importance: Transorbital penetrating brain injury (PBI) due to a non-projectile foreign body is rare. It can lead to life-threatening severe neurovascular damage. Surgery is the primary treatment choice; however, there are a number of approaches that can be considered based on the patient's condition in terms of foreign body location and state of the patient. Clinical presentation: An 18-year-old male carpenter was hit by a log and sustained transorbital PBI while cutting wood with a machine. Computed tomography (CT) scan showed a wooden spike that was approximately 11 cm from the left medial orbital to the superior part of the posterolateral of the petrous bone, crossing the right side at the base of the skull. CT angiography (CTA), magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) revealed no internal carotid artery (ICA) and cavernous sinus lesions, respectively. We had a 3D-printed model for preoperative planning, and surgery was performed using a transorbital approach to extract the wood 14 days after the accident. The impacted wood was removed without any complications. Conclusion: There are many surgical approaches for transorbital PBI. We decided to perform the transorbital approach because it is perpendicular to the entry zone. Surgeons should consistently perform minimally invasive procedures based on the clinical and radiological findings.

Although post-traumatic stress disorder (PTSD) has been associated with worse cognitive outcomes after mild traumatic brain injury (TBI), its impact has not been evaluated after more severe TBI. This study aimed to determine whether PTSD symptoms are related to cognition after complicated mild, moderate, severe, and penetrating TBI. Service members (n = 137) with a history of complicated mild/moderate TBI (n = 64) or severe/penetrating TBI (n = 73) were prospectively enrolled from United States Military Treatment Facilities. Participants completed a neuropsychological assessment one year or more post-injury. Six neuropsychological composite scores and an overall test battery mean (OTBM) were considered. Participants were excluded if there was evidence of invalid responding. Hierarchical linear regressions were conducted evaluating neuropsychological performance. The interaction between TBI severity and PTSD Checklist-Civilian version total score was significant for processing speed (β = 0.208, p = 0.034) and delayed memory (β = 0.239, p = 0.021) and trended toward significance for immediate memory (β = 0.190, p = 0.057) and the OTBM (β = 0.181, p = 0.063). For each of these composite scores, the relationship between PTSD symptoms and cognition was stronger in the complicated mild/moderate TBI group than the severe/penetrating TBI group. Within the severe/penetrating TBI group, PTSD symptoms were unrelated to cognitive performance. In contrast, within the complicated mild/moderate TBI group, PTSD symptoms were significantly related to processing speed (R2Δ = 0.077, β = -0.280, p = 0.019), immediate memory (R2Δ = 0.197, β = -0.448, p < 0.001), delayed memory (R2Δ = 0.176, β = -0.423, p < 0.001), executive functioning (R2Δ = 0.100, β = -0.317, p = 0.008), and the OTBM (R2Δ = 0.162, β = -0.405, p < 0.001). The potential impact of PTSD symptoms on cognition, over and above the impact of brain injury alone, should be considered with service members and veterans with a history of complicated mild/moderate TBI. In addition, in research comparing cognitive outcomes between patients with histories of complicated-mild, moderate, severe, and/or penetrating TBI, it will be important to account for PTSD symptoms. [ABSTRACT FROM AUTHOR]

Objective: To determine the factors associated with mortality in penetrating brain injury (PTBI) and proposed the nomogram predicting the risk of death. Methods: A retrospective cohort study was conducted on all patients who had sustained PTBI between 2009 and 2018. Collected data included clinical characteristics, neuroimaging findings, treatment, and outcomes. Prognostic factors analysis was conducted using a forest plot. Therefore, the nomogram was developed and validated. For the propose of evaluation, the nomogram’s sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Receiver Operating Characteristic (ROC) curve and the area under the receiver operating characteristic (AUC) were determined for validating the optimal cut-off point of the total scores. Results: During the study period, 62 individuals enrolled. In the univariate analysis, factors associated with the morality were normal pupils’ reactivity to light (OR 0.04, p < 0.001), hypotension (OR 9.91, pp=0.04), bihemispheric injuries (OR 19.0, p=0.001), multilobar injuries (OR 21.5, p< 0.001), subarachnoid hemorrhage (OR 6.9, p= 0.02), intraventricular hemorrhage (OR 26.6, p= 0.006), basal cistern effacement (OR 28.8, , p>5 mm (OR 0.19, pp=0.03), normal pupils’ reactivity to light (OR 0.07, p =0.01), midline shift >5 mm (OR 18.23, p Conclusions: PTBI is the fatal injury depend on both clinical and neuroimaging parameters. The nomogram is the alternative method providing prognostic parameters toward implication for clinical decision making.

Pellet guns are non-powder guns but their related injuries have been reported worldwide. They represent a significant cause of injury especially among children and teenagers. We present two cases of non-powder firearms. First case was a 13-year old male with a chief complaint of headache following gunshot accident towards his head. The bullet’s entry point was from the buccal region, going upwards fracturing the orbital roof, hitting the inner table of the frontal skull and ricocheted towards the parietal region. Second case was a 14-year old male who presented with cerebrospinal leakage, pulsating at the bullet’s entry point in the frontal area. Despite several opinions existed for these type of injuries, aggressive management for surgical extraction of the foreign body is the largely accepted treatment. The leaded bullet had to be extracted to avoid future damage from the metal’s known neurotoxicity. Often under-appreciated, we found difficulties in our experience for increasing the understanding and awareness for potentially fatal outcome regarding the gunshot wound brain injury. This obstacle often hinders the patient of consenting to surgical intervention in our population.

Purpose of Review: Civilian firearm-inflicted penetrating brain injury (PBI) carries high morbidity and mortality. Concurrently, the evidence base guiding management decisions remains limited. Faced with large volume of PBI patients, we have made observations in relation to coagulopathy and cerebrovascular injuries. We here review this literature in addition to the question about early prognostication as it may inform neurosurgical decision-making. Recent Findings: The triad of coagulopathy, low motor score, and radiographic compression of basal cisterns comprises a phenotype of injury with exceedingly high mortality. PBI leads to high rates of cerebral arterial and venous injuries, and projectile trajectory is emerging as an independent predictor of outcome. Summary: The combination of coagulopathy with cerebrovascular injury creates a specific endophenotype. The nature and role of coagulopathy remain to be deciphered, and consideration to the use of tranexamic acid should be given. Prospective controlled trials are needed to create clinical evidence free of patient selection bias. [ABSTRACT FROM AUTHOR]

Background: Fishing spearguns are a rare cause of nonmissile penetrating brain injuries (PBIs). Discussion of their injury patterns and treatments has been published only sporadically. Here, we report a case of a self-inflicted PBI caused by this type of weapon and present an extensive review of previous case reports to help ascertain the appropriate surgical approach. Case Description: A 26-year-old man with a preexisting psychiatric illness was transferred to our hospital after a selfinflicted shot with a fishing speargun through his mouth. The ensuing injuries included the impalement of a spear intracranially through the soft palate and posterior oropharyngeal wall. The spear was surgically accessed by the otolaryngology team by splitting the soft palate and was removed by the neurosurgery team in the retrograde direction. Cerebral angiographies were done pre- and postoperatively, and these did not detect any vertebrobasilar arterial system injuries. The patient's postoperative care was uneventful, and he was followed up by a psychiatrist for his long-term care. Conclusion: This example of a complicated case of nonmissile PBI caused by an uncommon type of weapon shows how this type of medical emergency can be managed successfully with effective teamwork using a multidisciplinary approach. [ABSTRACT FROM AUTHOR]

Penetrating brain injury (PBI) is the most devastating type of traumatic brain injury. Development of coagulopathy in the acute setting of PBI, though common, remains of unclear significance as does its reversal. The aim of this study is to investigate the relationship between coagulopathy and clinical presentation, radiographical features, and outcome in civilian patients with PBI. Eighty-nine adult patients with PBI at a Level I trauma center in Chicago, Illinois who survived acute resuscitation and with available coagulation profile were analyzed. Coagulopathy was defined as international normalized ratio [INR] >1.3, platelet count <100,000 /μL, or partial thromboplastin time >37 sec. Median age (interquartile range; IQR) of our cohort was 27 (21–35) years, and 74 (83%) were male. The intent was assault in 74 cases (83%). The mechanism of PBI was gunshot wound in all patients. Forty patients (45%) were coagulopathic at presentation. In a multiple regression model, coagulopathy was associated with lower Glasgow Coma Scale (GCS)-Motor score (odds ratio [OR], 0.67; confidence interval [CI], 0.48–0.94; p = 0.02) and transfusion of blood products (OR, 3.91; CI, 1.2–12.5; p = 0.02). Effacement of basal cisterns was the only significant radiographical features associated with coagulopathy (OR, 3.34; CI, 1.08–10.37; p = 0.04). Mortality was found to be significantly more common in coagulopathic patients (73% vs. 25%; p < 0.001). However, in our limited sample, reversal of coagulopathy at 24 h was not associated with a statistically significant improvement in outcome. The triad of coagulopathy, low post-resuscitation GCS, and radiographical effacement of basal cisterns identify a particularly ominous phenotype of PBI. The role, and potential reversal of, coagulopathy in this group warrants further investigation. [ABSTRACT FROM AUTHOR]

Background: This study investigates the presence of cerebrovascular injuries in a large sample of civilian penetrating brain injury (PBI) patients, determining the prevalence, radiographic characteristics, and impact on short-term outcome. Methods: We retrospectively reviewed patients with PBI admitted to our institution over a 2-year period. Computed tomography head scans, computer tomography angiograms and venograms of the intracranial vessels were evaluated to determine the wound trajectory, intracranial injury characteristics, and presence of arterial (AI) and venous sinus (VSI) injuries. Demographics, clinical presentation, and treatment were also reviewed. Discharge disposition was used as surrogate of short-term outcome. Results: Seventy-two patients were included in the study. The mechanism of injury was gunshot wounds in 71 patients and stab wound in one. Forty-one of the 72 patients (60%) had at least one vascular injury. Twenty-six out of 72 patients suffered an AI (36%), mostly pseudoaneurysms and occlusions, involving the anterior and middle cerebral arteries. Of the 72 patients included, 45 had dedicated computed tomography venograms, and of those 22 had VSI (49%), mainly manifesting as superior sagittal sinus occlusion. In a multivariable regression model, intraventricular hemorrhage at presentation was associated with AI (OR 9.9, p = 0.004). The same was not true for VSI. Conclusion: Acute traumatic cerebrovascular injury is a prevalent complication in civilian PBI, frequently involving both the arterial and venous sinus systems. Although some radiographic features might be associated with presence of vascular injury, assessment of the intracranial vasculature in the acute phase of all PBI is essential for early diagnosis. Treatment of vascular injury remains variable depending on local practice. [ABSTRACT FROM AUTHOR]

Introduction and Importance: Transorbital penetrating traumatic brain injury (TPTBI) is a rare cause of penetrating head injury, yet the diagnoses can be overlooked in some cases due to incomplete history, trivial trauma, and the absence of immediate neurologic deficits., Case Presentation: A 4-year-old male child was admitted with a diagnosis of TPTBI by a wooden object. Noncontrast enhanced CT scan revealed a linear hypodense structure extending from the superior wall of the right orbit into the frontal lobe with displaced fragments into the brain. Additionally, cerebral contusion, pneumocephalus, and hematoma with surrounding edema were seen in the frontal lobe. Early extraction of the foreign body was performed by a multidisciplinary team of neurosurgeons and ophthalmologists. The wooden fragment of size 10 cm×1 cm×1 cm was removed by a small mini-craniotomy of the right frontal supraorbital bone with the gentle pulling of it through the dura mater and frontal cortex. The postoperative course was uncomplicated, vision was restored, and there were no neurologic deficits at the time of discharge on the seventh postoperative day with good postoperative outcomes., Clinical Discussion: Delayed removal of TPTBI may be complicated by misidentification of entry points, extensive scarring around the foreign body, adherence to the intracranial vessels, and increasing mortality due to infectious complications. Therefore, early exploration with the help of a multidisciplinary team will most likely result in successful debridement, good neurologic outcomes, and lower morbidity and mortality., Conclusion: Accurate diagnosis and early intervention for TPTBI may prevent possible infectious and neurologic complications., Competing Interests: All authors declare no conflicts of interest.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Accidental injuries in the pediatric population are common. The response to injury also differs owing to anatomical and physiological differences in children. While such injuries carry a risk of lifelong morbidity, some cases may follow a benign course despite their distressing appearance. We report two cases of accidentally incurred penetrating trauma in the pediatric population with unusual objects, including a pencil and a toy wheel. Despite their intracranial extension, neither of the patients exhibited any discernible neurological deficits. Penetrating brain injuries require early removal and meticulous perioperative care to minimize the risk of long-term adverse neurological events in children., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)