Craniocerebral injury by penetration of a T-shaped metallic spanner: A rare presentation
A 22-year-old Chinese male presented with an intracranial T-shaped metallic spanner to the Aga Khan Hospital, Dar es Salaam, Tanzania. The patient was a mechanic by profession. While working in a garage, he had a quarrel with a fellow mechanic who attacked him with a T-shaped metallic spanner. He presented to the hospital approximately 2 hours after the injury, and was still bleeding profusely from the scalp. Necrotic brain tissue was evident at the point of entry of the retained short arm of the spanner []. His vitals were stable on arrival with a blood pressure of 130/80, heart rate of 69 beats/minute, and temperature of 37°C. However, he was irritable and restless. He gradually became drowsy, with spontaneous eye opening initially and later to command and mild pain only. He had confused speech, however, he was localizing well. The speech deficits were difficult to document because of the language barrier. He became unconscious approximately 2 hours after admission. As digital subtraction angiography (DSA) is not available in the whole country (to the best of our information), there was no way to assess the potential involvement of major sinuses. Magnetic resonance imaging (MRI) was not possible due to the presence of the intracranial metallic rod. Skull X-ray and head computerized tomography (CT) scan were done, which revealed the short arm of the T-shaped spanner penetrating the left parieto-occipital lobe of the brain, extending into the contralateral occipital lobe []. The situation was explained to the attendants and the patient was brought to the operating room with the retained spanner approximately 3 hours after admission and the intervention was designated as high risk. Perioperatively, the brain was severely edematous and necrotic brain with foreign debris was present in the track. Owing to the nonavailability of a craniotome or a Gigli saw chain (risk of any movement of retained foreign body leading to further cortical/vascular injury precluded the transfer of the patient to a better-equipped neurosurgical facility), a decompressive craniectomy was done with multiple burr holes. The intracranial part of the metallic spanner was slowly removed followed by debridement and irrigation of the track with normal saline and hydrogen peroxide [Figure –]. The perioperative course was uneventful; surgery lasted for 3 hours. The patient was successfully extubated in the intensive care unit (ICU) approximately 6 hours after surgery. He initially showed mutism, followed by disoriented and confused speech till postoperative day 3. He was, however, moving all four limbs, and no seizure activity was noted. The patient was suspected to have some visual field abnormality; however, a complete visual field examination could not be done by an ophthalmologist because of the language barrier. Mannitol (0.5 g/kg/dose) and furosemide (40-80 mg/dose) were given pre-, intra-, and postoperatively for the control of intracranial pressure (ICP). Postoperatively, mannitol was continued for 48 hours tapering the dose down to 25 g per i.v. infusion every 4 hours. Intravenous augmentin (1 g every 8 hours), amikacin (15 mg/kg/day divided into 3 equal dosages), and metronidazole (single preoperative dose of 15 mg/kg, and 2 doses of 7.5 mg/kg 6 and 12 hours after surgery) were given pre- and postoperatively during the first week; antibiotic regimen was changed to oral second-generation cephalosporin for the second week (based on empirical evidence). No seizure prophylaxis was given. Postoperative CT scan (day 3) revealed the hyperdense track of the removed short arm of the spanner. No residual foreign body was noted. The patient was discharged on postoperative day 6. On day 12, stitches were removed. At that time, he was speaking fluently. He did not have any infectious complication or seizure activity until his last follow up, approximately 6 months after the surgery, at which point he was fully functional. Afterwards, the patient returned to China and a cranioplasty was done there. Follow-up information was obtained from the family by telephone with the help of a translator. No clinical deficits or symptoms resembling syndrome of the trephined were reported.