Case Report
Nonmissile Penetrating Head Injuries: Surgical Management and Review of the Literature
Xi-Sheng Li, Jun Yan, Chang Liu, Yu Luo, Xing-Sheng Liao, Liang Yu, Shao-Wen Xiao
Key words
- Foreign object
- Nonmissile penetrating head injury
- Surgical management
Abbreviations and Acronyms
CSF: Cerebrospinal fluid
CT: Computed tomography
CTA: Computed tomography angiography
DSA: Digital subtraction angiography
ICA: Internal carotid artery
MRA: Magnetic resonance angiography
MRI: Magnetic resonance imaging
NPHI: Nonmissile penetrating head injury
PHI: Penetrating head injury
Department of Neurosurgery, The First Affiliated hospital of
Guangxi Medical University, Nanning, Guangxi, China
To whom correspondence should be addressed:
Shao-Wen Xiao, M.D.
[E-mail: xiaoshaowen2014@126.com]
Citation: World Neurosurg. (2017) 98:873.e9-873.e25.
http://dx.doi.org/10.1016/j.wneu.2016.11.125
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/ª 2016 The Authors. Published by Elsevier Inc.
This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
INTRODUCTION
Penetrating head injuries (PHIs) are
among the most severe traumatic brain
injuries and carry a high incidence of
morbidity and mortality, accounting
for 0.4% of all head injuries.1 They are
a major cause of death and disability as
a result of damage to critical
neurovascular structures, vascular disrup-
tion, concussion blast injury, or
meningitis.2,3
Based on the impact velocity of the
foreign object, PHIs can be grouped into
missile and nonmissile injuries. Missile
injuries are commonly caused by a foreign
object with an impact of velocity more
than 100 m/second.4 They more frequently
occur in military individuals, often caused
by the blast fragment from explosive
devices and other ammunitions, such as
bombs or guns.5 By contrast, the
nonmissile injuries are usually caused by
a foreign object with an impact velocity
of less than 100 m/second.4 They are
WORLD NEUROSURGERY 98: 873.e9-873.e25, FEBRUARY 2017
- BACKGROUND: Nonmissile penetrating head injuries (NPHIs) in the civilian
population are rare but potentially fatal. Although numerous cases have been
reported in the literature, the surgical management of such injuries is still
ambiguous, especially with development of surgical techniques. Here, we report
5 cases of NPHIs managed with different surgical techniques and review the
literature on surgical treatment of these injuries to outline the appropriate
management for these patients from a neurosurgical perspective.
- METHODS: We retrospectively reviewed 5 cases of NPHIs managed surgi-
cally in our department. The clinical data were collected, including cause, type
of objects, way of penetration, initial clinical evaluation, imaging, surgical
intervention, postoperative care, complication, follow-up, and outcome. In
addition, a systematic review of the literature was performed in the PubMed
database to search for articles on surgical treatment of these injuries.
- RESULTS: These 5 cases were caused by twisted steel bar, electric welding
rod, and sewing needle, respectively. Preoperative imaging, including computed
tomography, magnetic resonance imaging, and digital subtraction angiography,
was selectively performed to assist the operative plan. Foreign objects were
removed surgically in all cases. Postoperative prophylactic administration of
antibiotics and anticonvulsants was used to prevent infectious and epileptic
complications. Most of the patients achieved a better outcome except for one.
- CONCLUSIONS: NPHIs can be fatal but they can be managed with satisfac-
tory results by proper preoperative imaging evaluation, rapid appropriate sur-
gical management, and accurate postoperative care. Personalized surgical
intervention should be undertaken depending on the mechanism and extent of
the NPHI.
rarely reported in the civilian setting. Despite the large number of cases that
Most occur accidentally as a result of have been reported, how to surgically
violence, falls, work-related accidents, car manage such injuries is still ambiguous,
accidents, suicide, and psychotic disor- especially with new surgical technologies.
ders. Unlike missile injuries, nonmissile In this study, we present our experience in
injuries have no concentric zone of coag- the surgical management of 5 cases of
ulative necrosis caused by dissipated en- NPHIs and review the literature on surgi-
ergy.4 They are, therefore, more amenable cal treatment of these injuries. Through
to treatment and have a better prognosis discussion of our case management as
than missile injuries.6 well as review of the relevant literature, we
Nonmissile penetrating head injuries aim to summarize the appropriate surgical
(NPHIs) are relatively rare compared with management strategies of these patients
missile injuries. However, reports of from a neurosurgical perspective.
NPHIs are increasing worldwide. Since
the first case was described in the
literature as early as 1806,6 many METHODS
intracranially penetrated foreign objects The clinical data collected from the pa-
with various causes have been described tients was approved by the ethics com-
(Table 1). mittee of Guangxi Medical University. A
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XI-SHENG LI ET AL.
Table 1. Major Reported Cases of Nonmissile Penetrating Head Injuries Managed Surgically During 2011e2015
Age Location of Surgery Administration
Reference (years)/Sex Cause Image Entry Point Injured Brain Approach of Antibiotics Complication Outcome

Tewari et al.7 35/M Sharp rod Radiography Right orbit Frontal lobe Frontotemporal Yes None Discharged on tenth
www.SCIENCEDIRECT.com

craniotomy day without any

neurologic deficit
restricted right
eyeball movement to
supero lateral and
ptosis
Estebanez 19/M Tree branch CT, CTA Right orbit Temporal and Craniotomy via a Yes Intracranial Discharged from the
et al.8 occipital lobes lateral orbital fungal intensive care unit 11
infection days post injury with
a GOS score of 4 and
total loss of vision on
the affected side
23/M Wooden CT, CTA Left orbit Frontal lobe Craniotomy via a Yes None Discharged 10 days
fragment lateral orbital after the accident
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.11.125

with a GOS score of 5

and partial loss of
vision on the affected
side
24/M Butcher’s knife CT, CTA Left orbit Temporal lobe Craniotomy via a Yes None Discharged with a
lateral orbital GOS score of 5 and
normal vision in both
eyes
23/M Wooden CT, CTA Left orbit Frontal lobe Craniotomy via a Yes None Discharged home 7
pencil lateral orbital days later with a GOS
score of 5 and total
loss of vision on the

NONMISSILE PENETRATING HEAD INJURIES

affected side
Rana et al.9 59/M Knife Radiography, Left orbit Infratemporal region Bifrontal craniotomy Not reported Not reported Uneventful recovery
DSA and no neuro-
ophthalmologic
deficits at long-term
follow-up
Chen et al.10 66/F Steel bar 3D-CT Left Frontal lobe Bicoronal Yes None Survived without
submandibular craniotomy sequelae except for
area blindness of the right
eye
Jeon et al.11 43/M Nail Radiography, CT Left parietal Parietal lobe Circumferential Yes None Uneventful recovery

CASE REPORT
region craniectomy except for right-side
hemiparesis
WORLD NEUROSURGERY 98: 873.e9-873.e25, FEBRUARY 2017

XI-SHENG LI ET AL.
Chen et al.12 91/M Nail CT, CTA Right frontal Frontal lobe Frontoparietal Yes None Discharged on the
region decompressive 11th hospital day with
craniectomy a GCS of 5 and
tracheostomy
Williams 55/M Spear 3D-CT, CTA Left Temporal horn of Craniotomy Yes An abscess Died 33 days after the
et al.13 submandibular the lateral ventricle, along the tract initial suicide attempt
area posterior aspect of
the frontal lobe and
temporal lobe
Grossbach 22/M Steel bar CT, CTA, DSA Left neck Posterior temporal Hemicraniectomy Not reported Cerebrospinal Showed dense right
et al.14 lobe fluid hemianopia and mild
leakage from cognitive slowing 18
cranial months after injury
incision
Borkar et al.15 10/F Wooden stick CT Right orbit Cavernous sinus Frontotemporo- Yes None Uneventful recovery
orbital craniotomy
Ijaz and 3.5/F Wheel spoke 3D-CT Right orbit Frontal lobe Removal without Yes None Uneventful recovery
Nadeem16 craniotomy and discharged on the
fourth postoperative
day
Kazim et al.17 22/M T-shaped Radiography, CT Left parieto- Parieto-occipital Decompressive Yes None Uneventful recovery
metallic occipital region lobe and craniectomy and discharged on
spanner contralateral sixth postoperative
occipital lobes day
Miscusi 35/M Rod fence Right orbit Frontal lobe Bifrontal craniotomy Yes None Discharged to a
et al.18 rehabilitation unit in
good general
condition, without
focal neurologic signs
www.WORLDNEUROSURGERY.org

Xu et al.19 19/M Bakelite comb CT, MRI, MRA Left orbit Brian stem Frontotemporal Yes Carotid Uneventful recovery
craniotomy with cavernous sinus and left blindness

NONMISSILE PENETRATING HEAD INJURIES

lateral superior fistula remained 1 year later
orbitotomy
Skoch et al.20 35/F Toothbrush CT, CTA Right orbit Anterior temporal Frontotemporal Yes None Pupil remained
lobe orbitozygomatic nonreactive and
craniotomy enlarged
Carrillo 70/M Railroad nail Radiography, CT Right frontal Frontal lobe Craniotomy Yes None Uneventful recovery
et al.21 region and GOS remained
stable at 15 during 2-
week follow-up

M, male; CT, computed tomography; CTA, computed tomography angiography; GOS, Glasgow Outcome Scale; DSA, digital subtraction angiography; F, female; 3D, three-dimensional; MRI, magnetic resonance imaging; MRA, magnetic resonance

CASE REPORT
873.E11

angiography.
Continues
873.E12

XI-SHENG LI ET AL.
Table 1. Continued
Age Location of Surgery Administration
Reference (years)/Sex Cause Image Entry Point Injured Brain Approach of Antibiotics Complication Outcome
Sedney 4/M Nail Radiography, CT Coronal suture Sagittal sinus Minicraniotomy Yes None Discharged from the
et al.22
www.SCIENCEDIRECT.com

hospital several days

after the surgery with
no ill effects
Aric et al.23 34/M Nail Radiography, Right Parietal and Minicraniotomy Not reported Not reported Uneventful recovery
3D-CT, CTA parietotemporal temporal lobe
region
Arslan et al.24 13/M Metal bar Radiography, CT Right orbit Third ventricle, Frontoparietal Yes None Died after 10
occipital lobe craniotomy postoperative days
Abdulbaki 5/F Tip of the pen CT, 3D-CT Right orbit Frontal lobe Removal without Yes Brain abscess Mild right eye ptosis
et al.25 craniotomy
Regunath 3/F Nail Radiography, CT Right frontal Frontal lobe Bifrontal craniotomy Yes None Discharged without
et al.26 region any neurologic deficit
21/M Metal object CT Right frontal Frontal lobe Frontal craniotomy Not reported None Made a good recovery
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.11.125

region except for anosmia on

the right side
Burkhardt 4/M Wooden stick CT Left orbit Cavernous sinus and Pterional craniotomy Not reported Not reported Remained right
et al.27 emporoparieto- with transnasal amaurosis
occipital lobe endoscopic
approach
Sonmez 4/F Pencil CT Right orbit Inferior frontal lobe Minicraniotomy Yes None Remained with mild
et al.28 ptosis without
extraocular movement
limitation on the
affected side
Al-Otaibi and 34/M Spear CT Submental Frontal lobe Minicraniotomy Yes None Discharged on eighth

NONMISSILE PENETRATING HEAD INJURIES

Baeesa29 region day without
neurologic deficit
Olivas et al.30 2/F End tip of CT Right orbit Frontal lobe Bifrontal craniotomy Not reported Not reported Discharged on
ballpoint pen postoperative day 10
without any
neurologic deficit
Koyanagi 53/M Chopstick CT, DSA Sphenoid sinus Occipital lobe Endoscopic surgical Not reported Not reported Uneventful recovery
et al.31 procedure
Lee et al.32 85/M Wooden stick CT, CTA Right orbit Temporal lobe Frontotemporal Yes None Died as a result of
craniotomy herniation

CASE REPORT
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XI-SHENG LI ET AL.
Zweckberger 40/M Wooden CT Right jaw Frontal lobe Bifrontal craniotomy Yes None Discharged with a
et al.33 branch moderate frontal lobe
syndrome and a loss
of vision of the injured
eye
18/M Rebar CT Right parietal Motor cortex Parietal craniectomy Not reported None Uneventful recovery
region
Kumar et al.34 25/M Scissors Radiography, CT Left parietal Parietal lobe Circumferential Not reported None Uneventful recovery,
region craniectomy power of 3þ/5 on all
joints in right side of
body
Kataria 18/M Sickle Radiography Right parietal Parietal lobe Craniotomy Yes None Discharged from the
et al.35 region hospital after 7 days
with power 4 þ/5 on
the left side
7/M Compass Radiography, CT Right temporal Temporal lobe Craniotomy Yes None Uneventful recovery
(caliper) region and discharged
without neurologic
deficit
40/M Scissors Radiography, CT Vertex Sagittal sinus Craniotomy Yes None Uneventful recovery
and discharged
without neurologic
deficit
30/M Fan blade Radiography, CT Left frontal Frontal lobe Craniotomy Yes None Gradually improved
region and discharged with
mild hemiparesis on
right side
2/M Nail Radiography, CT Left frontal Frontal lobe Removal without Yes None Uneventful recovery
region craniotomy and discharged
www.WORLDNEUROSURGERY.org

without neurologic
deficit

NONMISSILE PENETRATING HEAD INJURIES

2/M Branch of a Radiography, CT Right parietal Parietal lobe Craniotomy Yes None Uneventful recovery
tree region and discharged
without neurologic
deficit
2/M Stone Radiography, CT Left frontal Frontal lobe Craniotomy Yes None Uneventful recovery
region and discharged
without neurologic
deficit

M, male; CT, computed tomography; CTA, computed tomography angiography; GOS, Glasgow Outcome Scale; DSA, digital subtraction angiography; F, female; 3D, three-dimensional; MRI, magnetic resonance imaging; MRA, magnetic resonance
angiography.

CASE REPORT
873.E13

Continues
 CASE REPORT
XI-SHENG LI ET AL. NONMISSILE PENETRATING HEAD INJURIES

systematic review of articles in the litera-

M, male; CT, computed tomography; CTA, computed tomography angiography; GOS, Glasgow Outcome Scale; DSA, digital subtraction angiography; F, female; 3D, three-dimensional; MRI, magnetic resonance imaging; MRA, magnetic resonance
skilled nursing facility

and discharged home

Return to work at 3-
Uneventful recovery

Uneventful recovery
ture published in English was performed

without neurologic

month follow-up
Discharged to a
and discharged
in the PubMed database (2011e2015).
Outcome

deficit
Search terms included “penetrating
head injury,” “penetrating brain injury,”
“penetrating cerebral injury,” “nonmissile
penetrating head injury,” and “nonmissile
penetrating brain injury.” From the results
Complication

of these searches, articles about missile

Not reported

Not reported
Not reported PHIs and firearm-related PHIs were
None

excluded. Articles about patterns of injury,

causes, diagnosis, surgical treatment, and
follow-up were included in our review.
Given the rarity and heterogeneity of
Administration
of Antibiotics

Not reported

cases, no meta-analyses were performed.

Yes

Yes
Yes

CASE REPORT

Case 1
Presentation and Examination. A 34-year-
Approach
Craniotomy

Craniotomy
Craniotomy

Craniotomy
Surgery

old worker fell from a 3-m-high construc-

tion site while working, and a steel bar
impaled in his head as he landed. On
arrival at the emergency department, he
chiefly reported right-sided facial pain,
Cavernous sinus and

headache, and loss of vision in his right

Ventricular system
Injured Brain
Location of

eye. On physical examination, a steel bar

Frontal lobe

Frontal lobe
cistern

was found to have penetrated his mandib-

ular area (Figure 1A) and the patient was
neurologically intact except for swelling
and complete ophthalmoplegia in the
right eye with a fixed and dilated right
Submental area

Right temporal

pupil. A computed tomography (CT) scan

Entry Point
Left frontal

Left orbit
region

region

of the head with skull reconstruction

showed that the steel bar penetrated into
the oral cavity and traversed the
inferolateral right maxillary sinus, orbital
Radiography, CT,
Radiography, CT

cavity, and cranial cavity to terminate out

of the right frontal bone (Figure 2C and
CT, CTA

CT, CTA
Image

CTA

D). There were associated comminuted

fractures of those areas, as well as
interruption of the right optic canal.

Operation and Treatment. The patient was

Corkscrew
Cause
Stone

given high-dose intravenous methylpred-

Knife

Knife

nisolone to protect the optic nerve and taken

urgently to the operating room to have the
steel bar removed. After nasal intubation of
the patient, the steel bar was cut shorter
(years)/Sex

with a hydraulic clamp, as used by fire ser-

13/M
Age

21/F

21/F
5/M

vices (Figure 1B). A frontotemporal incision

Table 1. Continued

was made, and a frontotemporal

craniotomy was performed, allowing for
adequate exposure of the foreign body.
angiography.
Reference

The steel bar was then removed under

Sweeney

direct visualization with help from the

et al.6

otolaryngologist using an endoscope to

view the nasal sinus (Figure 2). The

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 CASE REPORT
XI-SHENG LI ET AL. NONMISSILE PENETRATING HEAD INJURIES

necrotic brain tissues were removed and the

damaged dura was repaired by sewing
artificial dura mater to prevent
cerebrospinal fluid (CSF) leakage. The
cranium slice was removed. Cefuroxime
was used for 2 weeks to prevent
posttraumatic infection. Sodium valproate
was given for 1 week to prevent early
posttraumatic seizures.

Postoperative Course. Head CT showed

intracerebral hemorrhages along the tract
of the steel bar on the first postoperative
day (Figure 3AeC). The patient recovered
without intracranial infection or abscess,
CSF leakage, or epilepsy. Except for right
eye blindness, no neurologic sequelae
were observed at discharge (Figure 3D).
At follow-up visits for 3 weeks after sur-
gery, he continued to have no light
perception in the right eye. Head CT
angiography (CTA) showed no delayed
vascular injuries. A cranioplasty was per-
formed 3 months postoperatively.

Figure 1. Case 1. Preoperative photograph and computed tomography imaging. (A) Preoperative
Case 2
photograph shows a visible deep penetrating laceration by a steel bar. (B) Preoperative photograph Presentation and Examination. A 22-year-
shows the firefighter’s hydraulic clamp that was used to cut the steel bar shorter. (C) Head computed old man was injured by a steel bar that fell
tomography scan shows a steel bar in the brain and its relationship to the cranium. (D) A
from a 4-m-high floor and impaled in his
three-dimensional computed tomography scan shows the trajectory of the steel bar.
head. On arrival at the emergency
department, the patient was in a coma. On
physical examination, a steel bar was
found to have penetrated his right parietal
bone (Figure 4A). The patient was
neurologically left hemiplegic and the
right pupil was dilated 5 mm. Head CT
showed that the steel bar involved the
right temporal, parietal lobe, and right
cavernous sinus (Figure 4B). Digital
subtraction angiography (DSA) with skull
reconstruction showed that the steel bar
had penetrated the cranial cavity and
traversed the inferolateral right maxillary
sinus to terminate in the oral cavity,
without involving the right internal
carotid artery (ICA) (Figure 4C and D).

Operation and Treatment. Because of the

severity of his injury, the patient was taken
urgently to the operating room for removal
of the twisted steel bar. After tracheotomy
was performed, the steel bar was cut
shorter as in case 1. The incision and
craniotomy were performed as in case 1,
allowing adequate visualization of the
portion of the steel bar penetrating
Figure 2. Case 1. Operative photographs of steel bar removal (AeD).
the cranial base. By transsylvian fissure,
the twisted steel bar was explored and

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XI-SHENG LI ET AL.
Figure 3. Case 1. Postoperative computed tomography and photograph. (AeC) Postoperative brain
computed tomography shows the intracerebral hemorrhages along the tract of the steel bar with
pneumocephalus on the first postoperative day. (D) The patient at time of discharge.
then removed under direct visualization
(Figure 5). The dural tears caused by bone
fragments were repaired primarily. The
cranium slice was removed. Ceftazidime
was used for 2 postoperative weeks.
Sodium valproate was given in the first
postoperative week.
Postoperative Course. Head CT showed a
few delayed intracerebral hemorrhages
along the track on the first postoperative
day (Figure 6). Two weeks later, CT with
enhancement showed an abscess along
the tract of the steel bar (Figure 7).
Metronidazole was added to the
treatment for 4 weeks. At 6 weeks
postoperatively, CT and enhanced
magnetic resonance imaging (MRI)
showed abscess recession (Figure 8AeC).
The patient was discharged without CSF
leakage or epilepsy (Figure 8D). At
follow-up visits for 2 months after sur-
gery, no neurologic sequelae were
observed. Head CTA showed no delayed
vascular injuries. A cranioplasty was per-
formed 3 months postoperatively.
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NONMISSILE PENETRATING HEAD INJURIES
Case 3
Presentation and Examination. A 52-year-
old man was punctured by an electric
welding rod during an accident in the
workplace. On arrival at the emergency
department, the patient was in a coma and
had difficulty in breathing. Nasal intuba-
tion was given immediately. On physical
examination of the patient, an electric
welding rod was found to be protruding
from his left orbit (Figure 9A). Head CT
showed that the electric welding rod had
penetrated the left orbit and terminated
in the brainstem (Figure 9B and C).
Three-dimensional DSA imaging showed
that the left ICA was involved (Figure 9D).
Balloon test occlusion was negative
(Figure 9E and F).
Operation and Treatment. The patient was
taken urgently to the operating room and
cerebrovascular DSA was performed. A
balloon catheter was inflated in the left
ICA before craniotomy (Figure 9E).
Balloon test occlusion was negative
(Figure 9F). The incision and craniotomy
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.11.125
CASE REPORT
were performed as in case 1. The electric
welding rod was then removed under
direct visualization. The left ICA tears
caused by the electric welding rod were
sutured primarily to restore blood flow.
The cranium slice was removed.
Cefuroxime was used for 2 weeks
postoperatively. Sodium valproate was
given for 1 week postoperatively.
Postoperative Course. Head CT on the first
postoperative day showed brainstem
edema without delayed intracerebral
hemorrhages (Figure 10A and B). CTA
showed that the left ICA (C3) was narrow
(Figure 10C and D). After 2 months of
treatment, the patient remained
unconscious.
Case 4
Presentation and Examination. A 2-year-old
infant fell from his baby chair when eating
and a metallic chopstick impaled in his
mouth. On arrival at the emergency
department, the baby was crying. On
physical examination of the child, a
chopstick was found to be protruding
from his mouth (Figure 11A). There were
no neurologic deficits except for a wound
in the pharynx. Head CT with skull
reconstruction showed that a steel
chopstick had penetrated the mouth
cavity and traversed the sphenoid sinus
to terminate in the sella with
involvement of the pituitary gland
(Figure 11BeD). CTA showed that the
chopstick did not involve the major
arteries (Figure 11E). Blood tests showed
that the function of the pituitary gland
was normal.
Operation and Treatment. The infant was
taken urgently to the operating room after
examination. The nose was prepared with
povidone iodine solution. A right sphe-
noidotomy under endoscopy was per-
formed to visualize the portion of the
chopstick penetrating the sella base. The
chopstick was then removed under direct
visualization. Belly fat with glue was used
to reconstruct the sella base, avoiding CSF
leakage and preventing infection. Cefur-
oxime was used for 2 weeks
postoperatively.
Postoperative Course. Head CT showed no
delayed intracerebral hemorrhages on the
first postoperative day (Figure 11F). After
treatment, the patient recovered without
 CASE REPORT
XI-SHENG LI ET AL. NONMISSILE PENETRATING HEAD INJURIES

CSF leakage. At follow-up visits for 2 months

after surgery, no neurologic sequelae or
delayed pituitary insufficiency were observed.

Case 5
Presentation and Examination. A 25-year-
old woman was punctured by a sewing
needle. On arrival at the outpatient
department, her chief symptom was epi-
lepsy. Neurologic examination was intact.
Head CT showed that a sewing needle in
the brain had penetrated the anterior
fontanel, terminating in the right frontal
brain (Figure 12AeC). Head CT with skull
and angiography reconstruction showed
that the needle had penetrated through
the sagittal sinuses (Figure 12DeF).

Operation and Treatment. During the

operation, an intraoperative navigation
system was used to precisely locate the
needle. A frontal circumferential crani-
otomy was performed, allowing good
visualization of the needle penetrating
Figure 4. Case 2. Preoperative photograph and imaging. (A) Preoperative photograph shows the entry
through the sagittal sinuses. The needle
site of the steel bar. (B) Preoperative bone computed tomography shows the relationship of the steel was then removed under direct visualiza-
bar to the cranium; the steel bar involves the right temporal, parietal lobe, and right cavernous sinus. tion by fluorescein angiography during the
(D) Three-dimensional digital subtraction angiography reconstruction shows the trajectory of the steel operation (Figure 13A). Cefuroxime was
bar and the position of the steel bar in relation to the internal carotid artery.
used for 2 weeks after operation. Sodium
valproate was given on admission to
prevent early seizures and continually for
1 postoperative week.

Postoperative Course. Head CT showed that

there were few intracerebral hemorrhages
along the tract on the first postoperative
day (Figure 14AeC). The patient recovered
without epilepsy or CSF leakage or
infection after treatment. At 1 year
follow-up, results of a CT scan were
normal. The patient had no vivid memory
of how the needle had punctured at that
location and her family also claimed to be
unaware of such an incident. We deduced
that it might have been inserted through
the anterior fontanel during early child-
hood, based on the location and her
illness history. The patient has been fol-
lowed for more than 3 years and has
remained asymptomatic with impeccable
recovery (Figure 14E).

DISCUSSION

Preoperative Management of NPHIs

Acute Preoperative Management. Preoper-
ative care should focus on airway, breath-
Figure 5. Case 2. Operative photographs of steel bar removal (AeD).
ing, and cardiovascular support to manage

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XI-SHENG LI ET AL.
Figure 6. Case 2. Computed tomography imaging on the first day after operation. There was
hemorrhage along the tract of the steel bar and a subdural hematoma with pneumocephalus (AeD).
immediate life-threatening injuries. Above
all, early anticipation of potential airway
compromise is crucial for patient survival
and successful surgery.36,37 When the
airway is potentially at risk, intubation is
strongly recommended. The method of
intubation includes oral or nasal intuba-
tion, and tracheostomy. Oral intubation is
usually preferred; however, nasal or
tracheal intubation is performed when the
buccal cavity is affected by the foreign
object.38 In our series, 1 patient with injury
in the transmandibular region required
nasal intubation because the foreign
object interfered with oral intubation.
Two patients received tracheostomy
because the embedded iron bar
interfered with the oral and nasal pathway.
Although preoperative care should be
taken to prevent undue movement of the
intracranial object even if the foreign object
outside the wound is moving freely,39
sometimes, the object is too long for
transport or to fit through the CT scanner.
The proximal half of the object has to be
cut shorter. This procedure in previously
reported cases was performed with a cold
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NONMISSILE PENETRATING HEAD INJURIES
saw30 or wire cutter.40 The 2 patients
reported here received help from a
firefighter using a hydraulic clamp, which
may avoid secondary injury to the brain.
Imaging. Performing an appropriate pre-
operative imaging examination is impera-
tive for NPHIs. The precise understanding
of the position of a foreign object within
the surrounding anatomic structures
helps neurosurgeons to choose the most
convenient approach. As shown in
Table 1, preoperative imaging such as
plain skull radiography, CT, MRI, and
DSA can be selected.
Plain skull radiographs offer valuable
information about the shape of the pene-
trating object and the existence of skull
fractures or an intracranial foreign object41
and is especially useful in identifying
metallic foreign objects. However, plain
skull radiographs do not provide enough
information to assess intracranial
structures.
CT is the most useful tool for preoper-
ative investigation of NPHIs. CT is quick
and adequately identifies the extent of
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CASE REPORT
intracranial injury. It not only shows skull
fractures and intracranial injuries but also
provides information about the relation-
ship between the penetrating object and
the intracranial anatomic structures.41
Multilayer CT three-dimensional recon-
struction can fully show the nature, size,
length, direction, and position of an
intracranial foreign object at different an-
gles, which is beneficial for surgeons
making an optimal operation plan.42 If
vascular injury is suspected, noninvasive
investigative CTA can be a good option,
which can decrease unnecessary
exploratory surgery and conventional
angiography in stable patients. CTA has
played an increasing role in evaluation of
patients with NPHIs. In our series, most
patients underwent CT scanning with
skull and angiography reconstruction.
We believe that CT with skull and
angiography reconstruction should be the
initial and basic routine preoperative
procedure for NHPIs, providing a highly
useful visualization of the anatomic
region of interest.
An intracranial wooden foreign object is
easily missed by routine CT. MRI has been
shown to be superior to CT when
nonmagnetic objects are suspected, such
as wooden objects.43 Another noninvasive
investigation, magnetic resonance
angiography (MRA), can be selected if
vascular injury is suspected. However,
the lack of availability of emergency care
and inappropriateness of use in the
unstable patient limit the preoperative
application of MRI in NHPIs. CT is
recommended as the initial imaging
choice for NPHIs, whereas MRI plays an
important role in the subacute setting, in
which it supports prognosis prediction
and postoperative follow-up44 as in case 3.
DSA is considered to be the standard
examination to detect intracranial arterial
injuries after PHIs.45 Preoperative DSA is
recommended when there is a possibility
of vascular injury. However, DSA is
potentially difficult to perform in a timely
manner when equipment or qualified
personnel are limited and alternative
noninvasive methods such as CTA and
MRA are widely available and hence,
DSA does not seem to be the optimal
choice for all patients with NPBIs.46
However, CTA and MRA may show
artifacts, making accurate interpretation
difficult or impossible.44 DSA has still

XI-SHENG LI ET AL.
Figure 7. Case 2. Computed tomography imaging obtained 2 weeks after surgery. Computed
tomography scans with enhancement show a brain abscess along the tract of the steel bar.
been the gold standard for the evaluation
of vascular injuries.
Surgical Treatment of NPHIs
Surgical removal of the foreign object in
NPHIs is often indicated to prevent or
minimize secondary damage and delayed
complications. Hence, the preferred
strategy for the treatment of penetrating
injury is early surgical removal. However,
there is no standardized strategy for
removal of the object through surgery. The
surgical strategy is usually determined by
factors including the location of the
foreign object, the characterization of the
object trajectory, the mechanism and
extent of brain injury, and the surgeon’s
philosophy.
Surgical intervention in the form of
craniotomy formed the backbone of the
management of these injuries, because
most cases are treated by a formal crani-
otomy (Table 1). Craniotomy has the
advantages of protection of critical
neurovascular structures, debridement of
necrotic brain tissue, evacuation of the
hematoma, and repair of dural defects
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NONMISSILE PENETRATING HEAD INJURIES
after removal. If significant mass effect
exists, a decompression craniectomy can
be performed to control intracranial
pressure, which can relieve devastating
brain edema and decrease the subsequent
cumulative ischemic burden.47 Early
decompressive craniectomy improved
functional outcome and survival rate.48 In
our series, craniotomy for decompression,
as well as for removal of the foreign
object, was key to management of these
patients and improved their survival.
Surgical management is more chal-
lenging if injury to a major vessel or the
venous sinuses is anticipated. Injury to a
major vessel or dural sinus can result in
massive intraoperative blood loss. Surgical
treatment assisted by an endovascular
approach or under fluorescence guidance
to manage these lesions can be chosen.
Vascular control can be obtained before
removal via endovascular techniques.49 In
case 3, the electric welding rod was
removed by craniotomy with support
from balloon catheter trapping
evacuation, by inserting the balloon
catheter into the left ICA. In case 5,
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CASE REPORT
involving sagittal sinus injury,
intraoperative fluorescence was applied
to locate the sagittal sinus and examine
the blood flow after removal. By contrast,
intraoperative fluorescence guidance
seems be more convenient.
There is an increasing trend toward
avoidance of unnecessary surgical explo-
ration in stable patients. Minimally inva-
sive procedures are viable options in
removing a penetrating project, which can
avoid complications associated with open
craniotomy. As in case 5, under guidance
of the stereotactic navigation system,
circumferential minicraniectomy was per-
formed safely. Therefore, image-guided
minimal craniectomy is recommended in
stable patients.
Endoscopic sinus surgery has been used
to treat lesions in the anterior and central
skull base.50 As in case 4 involving the
cranial base, the penetrating object was
carefully removed under constant
endoscopic vision and the defect cranial
base was reconstructed under endoscopy.
According to that case and others in the
literature,32,51 the transnasal endoscopic
approach as a minimal invasive
technique can provide an alternative to
craniotomy for removing a foreign object
involving the cranial base.
Postoperative Complication Management
of NPHIs
Infection. Patients with a PHI with an un-
sterile foreign body are at risk of devel-
oping infections, such as brain abscesses
and meningitis. Administration of anti-
biotic therapy can minimize infectious
complications, as shown in Table 1.
Prophylactic therapy with antibiotics that
cross the blood-brain barrier was also
given to our patients immediately after
operation. Even with routine antibiotic
therapy, delayed infection still developed
in one of our cases and presented typically
in the form of cerebral abscess. After
antibiotic administration was continued
for at least 4 weeks based on microbio-
logical culture, the capsule of the abscess
disappeared and follow-up CT and MRI
showed no further infection. We believe
that the main reason for delayed abscess
in this case is that the object trajectory was
too long to be completely debrided. It
seems that adequate debridement of the
cranial trajectory is essential to minimize
infections.
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XI-SHENG LI ET AL.
Figure 8. Case 2. Computed tomography imaging and photograph obtained 6 weeks after surgery. (A)
Computed tomography scan indicates the brain abscess disappeared. (B, C) Magnetic resonance
imaging scans with enhancement confirm no abscess present. (D) The patient at time of discharge.
Epilepsy. About 30%e50% of patients
with PHIs develop seizures because of
direct traumatic injury to the cerebral
cortex with subsequent scarring.17 Hence,
anticonvulsants were administered to our
patients with cerebral cortex injury
during the first week. Although initial
studies did not confirm the beneficial
effect of prophylactic anticonvulsants, we
recommend prophylactic anticonvulsants
in the first week after injury because of
the high risk of epilepsy in traumatic
brain lesions with cerebral cortex injury.
Our patients, who received
anticonvulsant therapy, did not present
any sign of seizures.
Vascular Injury. Vascular injuries, such as
posttraumatic aneurysms, arteriovenous
fistulas, major vessel occlusion, venous
thrombosis, and vasospasm have been
reported previously.52 If cerebrovascular
injury is suspected, angiography is
strongly recommended, especially with
delayed or unexplained subarachnoid
hemorrhage or intracranial hematoma
development. Sometimes, vascular
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NONMISSILE PENETRATING HEAD INJURIES
injuries are invisible on initial
angiography. Even if the first scan is
negative, it is better to repeat the
examination 2e3 weeks later.53 In our
series, most patients underwent follow-
up postoperative angiography. No other
obvious vascular complications were
found except for stenosis of the ICA.
CSF Leakage. The overall incidence of CSF
leakage after cerebral injury is 0.5%e
3%.54 Compared with PHIs, CSF leakage
in NPHIs is a rare complication. The low
incidence is clearly related to careful and
watertight suture of the disrupted dura
mater. No patients in our series had
postoperative CSF leakage.
Endocrinologic Complications. Pituitary
dysfunction, immediate or delayed, can
occur, resulting in endocrinologic
complication of NPHIs. However, pituitary
dysfunction as a direct result of NPHIs has
been rarely reported.55 In our series,
although there was a case with direct
evidence of sella penetration, pituitary
dysfunction was not found.
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CASE REPORT
Prognosis and Follow-Up of NPHIs
These types of injuries can be life threat-
ening. Their prognosis mainly depends on
the penetration site and the rapidity of
their management. The outcome is also
affected by clinical status, associated
complications, and other factors.
A penetration site in the frontal, tem-
poral, and occipital lobe has a better
outcome, as shown in Table 1. Our 3
patients who injured their frontal lobe
had better recovery. However,
penetrating sites involving the brainstem
are usually fatal. Direct penetrating
brainstem injuries as in case 3 are
marked with poor vital and functional
prognosis.
The first operative hour is paramount.
After careful assessment of the degree and
location of the initial injury, the rapidity of
operative exploration and debridement
can avoid delayed secondary injury. Our
patients survived penetrating injury mainly
because of prompt operative management.
This finding indicates that prompt and
meticulous management may achieve
better outcomes in potentially fatal
injuries.
Long-term follow-up is recommended,
including not only clinical examinations
but also imaging studies. In addition to
clinical follow-up, all our patients under-
went follow-up with outpatient CT to
show adequate recovery. Patients with
vascular injury were followed up with CTA
to evaluate delayed vascular injuries, such
as pseudoaneurysm.
CONCLUSIONS
NPHIs are rare but potentially fatal in-
juries. The rapid appropriate management
of these injuries is crucial. According to
our experience, preoperative management
requires immediate evaluation and treat-
ment of life-threatening injuries. It is
imperative to obtain preoperative appro-
priate imaging to assess for the extent of
injury and to make an operative plan. The
foreign object should be removed imme-
diately under direct visualization. Surgical
intervention should be personalized based
on the mechanism and extent of injury.
When feasible, minimal craniectomy is
recommended. Postoperative prophylactic
administration of antibiotics and anticon-
vulsants may minimize infectious and
epileptic complications, although some
 CASE REPORT
XI-SHENG LI ET AL. NONMISSILE PENETRATING HEAD INJURIES

Figure 9. Case 3. Preoperative photograph and imaging. (A)
Preoperative photograph shows a visible electric welding rod
impacted into the left orbit. (B, C) Computed tomography scans
show an electric welding rod in the brain involving the
brainstem. (D) Three-dimensional digital subtraction angiography
shows the relation of the electric welding rod with the left
internal carotid artery and the trajectory of the electric welding
rod. (E) An anteroposterior view on digital subtraction
angiography shows an interventional balloon in the left internal
carotid artery. (F) Balloon test occlusion was negative.

studies did not confirm the beneficial ef-
fect of prophylactic administration. Long-
term follow-up with imaging studies is
recommended to evaluate delayed trau-
matic injuries.
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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 25 August 2016; accepted 25 November 2016
Citation: World Neurosurg. (2017) 98:873.e9-873.e25.
http://dx.doi.org/10.1016/j.wneu.2016.11.125
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/ª 2016 The Authors. Published by Elsevier Inc.
This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 CASE REPORT
XI-SHENG LI ET AL. NONMISSILE PENETRATING HEAD INJURIES

Figure 10. Case 3. Postoperative computed tomography and computed tomography angiography
imaging. (A, B) Postoperative brain computed tomography shows the brainstem edema without
delayed intracerebral hemorrhages on the first postoperative day. (C, D) Computed tomography
angiography shows a narrow left internal carotid artery.

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 CASE REPORT
XI-SHENG LI ET AL. NONMISSILE PENETRATING HEAD INJURIES

Figure 11. Case 4. Preoperative and postoperative photograph
and imaging. (A) Preoperative photograph shows the entry site
of a metallic chopstick. (B, C) Computed tomography (CT) scans
show a metallic foreign body impaling the middle skull base into
the pituitary fossa through the mouth and the sphenoid sinus.
(D) CT scan with skull reconstruction shows the trajectory of the
electric welding rod. (E) CT angiography scan shows the relation
between the chopstick and the vessels. (F) A postoperative CT
scan confirmed no delayed intracerebral hemorrhages.

Figure 12. Case 5. Preoperative computed tomography imaging. (AeC) Preoperative brain computed
tomography shows the intracranial position of a sewing needle. (DeF) Head computed tomography
scan with skull and angiography reconstruction shows the trajectory of the sewing needle and the
penetration through the sagittal sinuses.

873.E24 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.11.125

 CASE REPORT
XI-SHENG LI ET AL. NONMISSILE PENETRATING HEAD INJURIES

Figure 13. Case 5. Operative photographs of needle removal. (A) Intraoperative fluorescein
angiography of the sagittal sinus. (B, C) Intraoperative process of needle removal. (D) The length of
the removed needle.

Figure 14. Case 5. Postoperative computed tomography imaging and follow-up photograph. (AeC)
Computed tomography scan showed that there were few intracerebral hemorrhages along the tract
with pneumocephalus on the first postoperative day. (D) The patient after postoperative follow-up.

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