PHINEAS GAGE REVISITED: AN “INDIAN CROWBAR CASE”

Sathwik R Shetty MD, K M Bopanna MD, Praveen M Ganigi MCh, T.Hegde MCh1, Susheel Wadhwa MD1

Department of Neurosurgery, Manipal Hospital and 1Narayana Multispecialty Hospital, Bangalore, India.

We report on the management of an extremely rare perforating head injury in a 17year old boy a la Phineas Gage. The range of complications that occurred with this unusual form of trauma, the stormy clinical course and the unique management concerns have been discussed.

Perforating head injuries- injuries having entry and exit sites- are extremely uncommon and are often associated with a fatal outcome1. Most of the existing literature is on penetrating head injury and its management . Reports on perforating head injury are few, mainly from war time data. Most of these do not address the management of perforating head injuries in particular 2. The present case highlights the successful management of a perforating head injury and proposes a paradigm for the management of such cases.

History and examination:A 17yr old male sustained unusual head injury from a high speed motor vehicle accident in February 2007. Upon arrival in the ER 4 hours post trauma ; he was conscious and complaining of neck pain. On examination, GCS was E 3 V 5 M 6 (14/15). His pupils were bilaterally 3mm and reacting well to light. He had a right LMN type 12th nerve palsy. His motor power was grade 5/5 in all limbs. The rest of the neurological exam was unremarkable and he had no other systemic injuries.

Investigations and management:DAY 0: CT head with CVJ with CT angiogram:

Safe corridor!! : Transfrontosphenoethmoid caudal to the canalicular course of the optic nerves proceeding to cause a tangential fracture of the clivus lateral to the ponto medullary neurovascular structures. Thereafter it fractured the medial right occipital condyle and projected exiting suboccipitally.

Procedure : Tracheostomy + In line extirpation of the rod. Interventional radiologist stand by. Debridement and suturing of entry and exit wounds.

Post procedure : E4VTM6

DAY 3: GCS rapidly dropped to 8T/15 along with CSF rhinorrheaCT SCAN

Procedure : Evacuation of frontal contusions + ACF base repair (Split calvarial graft + fascia lata and pedicled pericranial graft). Post procedure: CSF rhinorrhea stopped. GCS improved to E4VTM6.

Day 10: Decannulated and tracheostomy closed.

Day 15: Low grade fever, lapsed into altered sensorium and had a sudden respiratory arrest.Resuscitated : GCS : E4VTM6 but was quadriplegic.

CT SCAN: EVD placed. CSF analysis: 330 cells, 90% neutrophils, sugar 10mg/dl, protein 84mg/dl.CSF Culture: Klebsiella

Anti meningitic dose of Intravenous antibiotics along with intraventricular Amikacin.

MRI for quadriplegia deferred due to the presence of the metal screw.

CT of Cervical spine and CVJ: No evidence of overt instability.

Day 20:Screw retrieved through the occipital exit wound. EVD site changed.MRI BRAIN and CVJ:Cerebellar tonsils herniating through foramen magnum with compression of the cervical spinal cord and hyperintense signal changes within the cervical cord.

Day 42:Right ventriculo-peritoneal shunt following sterile CSF culture after 3 weeks of antibiotics.

He steadily improved and was ambulant with mildly impaired joint position sense. Over the next 6 weeks he regained continence. MRI of the CV junction showed persisting downward migration of the cerebellar tonsils, but intervention was deferred, considering that he improved clinically. Dynamic CT and X rays of his CVJ have shown no instability.

Day 116:He walked home with minimal support and right 12th nerve palsy. He had gone back to Engineering College and was doing well at his last follow up, 10 years after discharge, with no neck pain or dorsal column signs.

Penetrating head injuries, inclusive of perforating head injuries, account for less than 10% of head injuries3. Over 60 % of those with perforating head injuries showed poor outcome or death in war time data studies indicating the life threatening nature of this type of head injury3.Cranial tissue damage in penetrating head injuries may result from a combination of direct crush, centrifugal cavitations and diffuse shock waves. Extent of cerebral injury and outcome depend upon projectile trajectory and transfer of energy. A unilateral unilobar trajectory is relatively safer than the unilateral multilobar injury1. Transventricular trajectory and bilateral injuries are associated with a poor outcome. The treatable complications of such injuries include life threatening intracranial hemorrhage, seizures (6-30%), CNS infection (5-20%)2 and vascular anomalies (false aneurysm 7-15%). The incidence of CNS infection in penetrating head injury steadily increases up to 49.2% when the head injury is associated with an external CSF fistula4.Penetrating head injuries require wound debridement with retrieval of the embedded

fragments and treatment of sequelae like intracranial hemorrhage, seizures and infection. The decision to retrieve foreign objects is a judicious one being influenced by location and depth of the embedded object5.Most existing literature does not address perforating head injury and its treatment in particular. The unique management concerns we faced were: 1) A long core of devascularized and contaminated tissue with deep implantation of debris 2) Simultaneous surgical access to the entry, and exit sites was challenging 3) Establishing a dural barrier simultaneously at these sites to reduce the likelihood of infection and 4) The impaled (retained) perforating cranial object might have tamponaded a major blood vessel - a critical factor in the management paradigm.

Considering the rare nature of these injuries and the lack of treatment guidelines, we propose the following paradigm. 1) Impaled cranial objects need to be left alone till arrival in the OR.2) Require frequent neuro and angio imaging with involvement of interventional radiologist.3) Early repair of the wide traumatic osseous and dural defects and surveillance for evolving hydrocephalus following CSF fistula repair.4) Post-operative recovery may be prolonged by multiple infectious sequelae that require prompt management.

“There are only 2 ways to live your life. One is as though nothing is a miracle. The other is as though everything is a miracle”- Albert Einstein

References:1.Ishikawa E, Meguro K, Yanaka K, Murakami T, Narushima K, Aoki T, Nose T: Intracerebellar penetrating injury and abscess due to a wooden foreign body. Neurol Med Chir 40:458-462, 2000(Tokyo)2.Aarabi B: Surgical outcome in 435 patients who sustained missile head wounds during the Iran- Iraq War. Neurosurgery 27(5):692-695, 19903.Hammon WM, Kempe LG: Analysis of 2187 consecutive penetrating wounds of the brain from Vietnam. J Neurosurg 34:127–131,19714.Nagib MG, Rockswold GL, Sherman RS, Lagaard MW: Civilian gunshot wounds to the brain: prognosis and management. Neurosurgery 18:533–537, 195.Surgical management of penetrating brain injury, J Trauma 51(2) Suppliment:S16-25, 2001

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Phineas GageManeesh