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ISSN: 0269-9052 (print), 1362-301X (electronic)
Brain Inj, 2014; 28(12): 16171621
! 2014 Informa UK Ltd. DOI: 10.3109/02699052.2014.934284
CASE STUDY
Impalement brain injury from steel rod causing injury to jugular bulb:
Case report and review of the literature
Andrew J. Grossbach1, Taylor J. Abel1, Janel Smietana1, Nader Dahdaleh2, Meryl A. Severson III3 & David Hasan1
Downloaded by [Complexo Hospitalario Universitario A Coruna] at 00:51 28 September 2015
Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA, 2Department of Neurosurgery, Northwestern University,
Chicago, IL, USA, and 3Division of Neurosurgery, National Capitol Consortium, Walter Reed National Military Medical Center, Bethesda, MD, USA
Abstract
Keywords
Background: The management of impalement penetrating brain injuries (IPBI) from non-missile
objects is extremely challenging, especially when vascular structures are involved. Cerebral
angiography is a crucial tool in initial evaluation to assess for vascular injury as standard
non-invasive imaging modalities are limited by foreign body artifact, especially for metallic
objects.
Case study: This study reports a case of an IPBI caused by a segment of steel rebar resulting in
injury to the left jugular bulb and posterior temporal lobe. It describes the initial presentation,
radiology, management and outcome in this patient and reviews the literature of similar
injuries.
Introduction
Penetrating brain injuries (PBIs) are a type of traumatic brain
injury that can be separated into two categories, missile and
non-missile injuries [1]. Missile injuries result from an object
penetrating the brain travelling at 4100 m s 1 and results in
brain injury from both kinetic and thermal energy [1, 2].
Non-missile PBIs are relatively uncommon injuries in the US
that result from various causes including motor vehicle
accidents, falls, violence, self-inflicted trauma and work
accidents [3, 4]. Although these injuries are often fatal [5],
patients who do survive the initial injury pose a unique set of
problems that must be addressed during management [3, 4].
There have been several reports of non-missile PBIs in the
literature resulting from impalement by various objects, most
commonly metallic objects [1, 3, 4, 6, 7]. This manuscript
describes the presentation and management of a patient
who was impaled by a segment of steel bar and reviews the
management of impalement penetrating brain injuries.
Case report
History and physical
A 22-year-old male presented to the University of Iowa
Hospitals and Clinics after a 12 foot fall from a ladder while
working at a construction site. The patient landed upright
on a piece of steel reinforcing bar (rebar) that penetrated
his neck and extended intracranially. Emergency services
Correspondence: Andrew J. Grossbach, MD, Department of
Neurosurgery, University of Iowa Hospitals and Clinics, 200 Hawkins
Drive, Iowa City, IA, 52245, USA. Tel: 206-679-2197. E-mail: andrewgrossbach@uiowa.edu
History
Received 6 November 2013
Revised 28 January 2014
Accepted 6 June 2014
Published online 14 July 2014
responded at the scene and cut the rebar from the concrete
from which it was imbedded. The patient was taken to the
emergency department with the rebar in place. He was
intubated en route after becoming combative. Upon arrival
in the emergency department, the patient was noted to be
stuporous. His pupils were equal and reactive. The patient was
moving all extremities spontaneously, but not following
commands. The rebar was noted to be piercing the left neck
and extending cranially (Figure 1).
A non-contrast computed tomography (CT) scan of the
head was obtained that showed the rebar had punctured the
soft tissues of the neck, travelled posterior to the mandible
and penetrated the skull base, traversing the medial mastoid
air cells and jugular fossa on the left (Figures 1 and 2).
The bar also pierced the left posterior temporal lobe with
termination in the left temporoparietal region. There was
intraparenchymal haemorrhage along the tract of the rebar,
ventricular haemorrhage in the left lateral ventricle and a
left subdural haemorrhage causing midline shift (Figure 1).
A CT angiogram (CTA) of the head and neck was performed
and did not show any evidence of injury to the intracranial
arteries; however, the scan was severely limited by metallic
artifact.
Operation
The patient was taken emergently to the operating room
where a right-sided ventriculostomy was placed for ICP
monitoring and drainage of cerebrospinal fluid (CSF). Given
the injury to the soft tissues of the neck and concern for
swelling, a tracheostomy was performed. An emergent
diagnostic cerebral angiogram was performed prior to craniotomy, given the high concern for injury to the cerebral
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A. J. Grossbach et al.
Figure 1. (A) Pre-operative photograph demonstrating entry site and trajectory of rebar. (B) Lateral XR showing the relationship of the rebar to the
cranium. There was haemorrhage along the tract of the rebar, intraventricular haemorrhage and a subdural haematoma evident on non-contrast CT (C).
The position of the rebar is depicted on coronal (D), sagittal (E) and axial (F) CT scans.
Figure 2. 3-D CT reconstruction demonstrating the entry point of the rebar in relation to the cranial bones.
DOI: 10.3109/02699052.2014.934284
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Figure 3. Cerebral angiogram demonstrating position of rebar (arrows in (A) and (B)) in relation to the cerebral vasculature. (A) AP left internal carotid
artery injection and (B) lateral left internal carotid artery injection.
Figure 4. Cerebral angiogram demonstrating extravasation of contrast dye from left jugular bulb during angiogram (vertical arrow, horizontal arrows
depict rebar). (D) Coil and onyx embolization of the left sigmoid sinus and jugular bulb (arrows).
Discussion
Impalement brain injuries pose unique challenges to surgeons
[3, 68]. These injuries often involve the orbit or temporal
areas, as these areas have thinner calvarium that is more
susceptible to penetration [1]. Several factors need to be taken
into account including associated trauma, the characteristics
of the penetrating object, the location of the penetration and
structures that could be involved, as well as the possibility
of vascular injury [4]. When dealing with PBIs, as with any
traumatic brain injury, secondary injury can be common from
mechanisms including increased ICP, hypotension, respiratory distress and coagulopathy, all of which have been
associated with increased mortality in PBI patients [3, 5].
Additionally, PBI management can be complicated by infection, cerebrospinal fluid leak and cerebral vasospasm [9].
Pre-hospital care should focus on standard Advanced
Trauma Life Support (ATLS) principles, the ABCs,
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A. J. Grossbach et al.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the paper.
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