Management of screwdriver-induced penetrating brain injury: a case report

PBI involving foreign bodies is less prevalent than closed head injuries but often causes a worse prognosis. To date, there is no standardized management for such injuries because different injury patterns share with each scenario. However, some general management principles can be applied to almost any case to improve patient outcomes.

First is the preoperative examination. Head CT is the most sensitive imaging modality for PBI, to identify the extent of bone and parenchymal injuries and formulate operation plan [7]. In case of suspicion for vascular injury, CT cerebral angiography is also needed to evaluate traumatic aneurysm, which may rapidly develop after PBI [8].

Second is the operative management. In this study, the patient had severe low GCS of 3/15, which could be attributed to 2 points: 1) The characteristics of PBI caused by a screwdriver. 2) The patient presented with posterior fossa hematoma in the early stage, which might oppress brainstem, leading to disorder of vital signs. However, timely and effective surgical interventions made the patient have a good prognosis [9, 10]. Generally, the goals of surgical intervention for such injury are to: 1) Remove the penetrating object and accompanying necrotic debris around the injury site. According to our study, we recommended removal of the screwdriver through its trajectory with minimum injury. However, in some cases, foreign bodies were removed roughly on the spot, which would lead to bleeding of puncture and poor prognosis [6, 11]. 2) Eliminate any hematomas developed from the injury. 3) Ensure watertight closure of the dura and prevent CSF leakage [12].

Third is the postoperative management. 1) Prophylactic antibiotics and antiseizure medications are recommended to be applied for the first week [13, 14]. In this case, we prolonged the use of antibiotics owing to deep penetrating tract and pulmonary infection. 2) For severe PBI patient with postoperative coma and pulmonary infection, tracheotomy could be help to prevent the damage of chronic hypoxia on brain tissue and strengthen the management of respiratory tract. 3) Postoperative imaging and follow-up are important to evaluate complications such as pulmonary infection, delayed intracranial hematoma and posttraumatic hydrocephalus, which can be presented in a delayed mode [8].

However, there are still some limitations in this case report. First, the patient with a metallic foreign body in her head was unable to perform magnetic resonance imaging (MRI). Meanwhile, because of obvious CT imaging artifacts, computed tomography angiography (CTA) imaging and three-dimensional reconstruction could not be used to identify the relationship between metallic foreign body and intracranial vessels or skull. Second, the patient’s GCS score on arrival was 3/15 with unstable vital signs and formation of traumatic cerebral hernia. Thus immediate surgical decompression was needed, which kept us from digital subtraction angiography and made us unable to clear intracranial vascular injury. Third, the would tract induced by screwdriver was deep and long, involving multiple lobes,which made it difficult to thorough debridement. Therefore, it may result in residues of foreign bodies or necrotic tissue and increase the risk of infection.