Traumatic brain injury with carotid canal penetrating wound

Traumatismo cranioencefálico com lesão penetrante do canal catotídeo

Patient male, victim of aggression, comatose, with a screwdriver in his ear canal (Figure 1). CT scan showed a route of the screwdriver through the temporal petrous portion, through the internal carotid artery (ICA) course and a subdural hematoma (Figure 2).

Figure 1
. Photograph showing the screwdriver in the ear canal of the patient before surgery.

Figure 2
. Computed tomography (CT) showing significant brain swelling with large acute subdural hematoma (arrow) (A). Multiplanar Reconstruction (MPR) of the CT on the axial plane with bone window shows the screwdriver reaching the carotid canal (B). MPR of the CT on the coronal plane with bone window showing the route of the screwdriver in the carotid canal attached to the petrous portion of the temporal bone (C).

We performed hematoma evacuation, with subsequently intracranial and cervical ICA temporary clipping. We removed the screwdriver without bleeding (Figure 3). A postoperative angiography showed no vascular lesions (Figure 4). In the patient discharge, he had severe disability (Glasgow outcome scale 3).

Figure 3
. Postoperative CT scan shows a left frontotemporoparietal craniotomy with a good radiological result, absence of ischemia or large hematomas, and improvement of brain swelling (A). 3D reconstruction of the CT scan highlights the large craniotomy performed (B).

Figure 4
. A postoperative angiography showed no vascular lesions. Left anteroposterior internal carotid artery image (A). Internal carotid artery in the petrous segment without injury (B).

In these cases there is high risk for bleeding^1,2,3. So, we believe that combined approach should be performed for safe removal of this penetrating body.

References

• ¹
  Paiva WS, Monaco B, Prudente M, et al. Surgical treatment of a transorbital penetrating brain injury. Clin Ophthalmol 2010;4:1103-1105.
• ²
  Paiva WS, Saad F, Carvalhal ES, De Amorim RL, Figuereido EG, Teixera MJ. Transorbital stab penetrating brain injury. Report of a case. Ann Ital Chir 2009;80:463-465.
• ³
  Bozzeto-Ambrosi P, Costa LF, Azevedo-Filho H. Penetrating screwdriver wound to the head. Arq Neuropsiquiatr 2008;66:93-95.

Publication Dates

• Publication in this collection
  May 2014

History

• Received
  24 Sept 2013
• Reviewed
  19 Feb 2014
• Accepted
  11 Mar 2014