gms | German Medical Science

To date, very few cases of penetrating head injuries by means of pointed objects, accounting for 0.4% of all head injuries, have been reported. Different tools have been described in causing the penetrating head injuries but, in only 10 cases was the tool reported to have been a screwdriver [Ref. 1], [Ref. 2], [Ref. 4], [Ref. 5], [Ref. 7]. Only five patients in total survived injury, but literature documents that four of these patients were left with permanent anatomical or functional deficits.

This paper reports the case of a patient who, despite the severity of the skull base penetrating injury, not only survived surgery, but is still alive and found to be neurologically intact at the last follow-up after two years.

A 20-year-old male patient suffered an accidental skull base penetrating injury by means of a cross-tipped screwdriver (Figure 1 a [Fig. 1]). The tool penetrated into the right maxillary bone and through the skull base for more than ten centimetres. The handle of the screwdriver had impeded the tool from running any deeper and it could be observed exiting from the right maxillary region .

On admission, the patient was in GCS 13: a CSF leak, diplopia, and a positive scotoma in the left eye were demonstrated.

An emergency CT and three-D CT scans revealed an oblique trajectory of the screwdriver through the right maxilla and the ethmoidal bone to the left sphenoid wing, penetrating into the brain (Figure 1 b–c [Fig. 1]). A frontal lobe laceration was present without severe intra-cerebral bleeding. The severe CSF leak and the close position of the tool to the left optic nerve, associated with a rapidly progressive visual loss, prompted immediate surgery.

A left supra-orbital craniotomy was performed obtaining secure exposure of the neurovascular basal structures. The screwdriver had passed over the left optic nerve and the carotid siphon stopping next to the left middle cerebral artery. Studying the screwdriver’s trajectory, it was deemed opportune to drill the skull base entry hole to raise the tip of the tool, thereby decompressing the arteries and the optic nerve. This procedure facilitated the gentle extraction of the screwdriver by its handle, without causing any complications. After this procedure, a dural laceration was detected and repaired and a piece of temporal muscle and fibrin glue were used to close the skull base fracture.

A lumbar drainage was positioned for nearly two days and continuous antibiotic therapy was administered.

After surgery, an initial recovery of the left visual acuity was observed without any local or general infections or complications. Six weeks following the injury, the patient completely recovered without any neurological deficits (Figure 1 d [Fig. 1]).

In the history of penetrating head injuries by means of sharp objects, the most famous patient was Henry II of France: the King was struck by the broken shaft of a lance in a joust with Gabriel de Lorges. He died on the 11^th day post-injury. Smrkolj [Ref. 4] reported two cases in which the screwdriver had remained lodged in the skull: both patients died in spite of surgical treatment [Ref. 4]. Evans and Richmond [Ref. 2] described the case of a patient falling down the ladder while holding a screwdriver between his teeth. Upon hitting the pavement, the shaft of the screwdriver was driven through the hard palate into the brain [Ref. 2]. Anderson et al. presented a case of a self-inflicted right eye screwdriver injury, treated conservately; the patient had no residual effects 3 years later [Ref. 1]. Li T et al. [Ref. 3] published a report of a 19-year old boy with a left temporal region screwdriver injury who presented, 4 weeks later, with an MRI evidence of basilar-cavernous fistula and saccular aneurysm of the basilar artery. The patient was successfully treated with endovascular embolization [Ref. 3]. Tutton et al. [Ref. 5] analyzed four homicide attempt cases with a screwdriver. Two patients, with brain stem lesions, died, while two others, with intracranial haematomas, improved [Ref. 5].

Wong et al. [Ref. 7] described an unusual left temporal fossa injury by a screwdriver. The screwdriver had penetrated into the temporal squama, pointing anteriorly and entering the orbital apex, the ethmoid sinus and contralateral orbital apex, induced a total loss of vision and reduced ocular motility of the left eye. The patient was treated with antibiotics with impairment of ocular motility [Ref. 7].

In literature, the neurological status of these patients at the admission at hospital represents the most significant indicator, particularly in terms of survival [Ref. 6].

In the reported case, given the length of the screwdriver shaft, the oblique trajectory through the skull base avoided a lethal brain tissue damage or vascular lesions.

On the basis of the CT findings, together with consideration of the good clinical status of the patient at admission, as well as the rapid progression of the visual loss, helped us to decide for the immediate removal of the screwdriver by means of an aggressive surgical approach. The simple extraction of the screwdriver shaft by the handle was not considered in order to avoid any iatrogenic lesions to the left optical nerve and artery which had already been injured by the primary insult.

The postoperative course was complication-free; in particular, neither signs of infections nor new neurological deficits were detected. In order to avoid infections it was essential to repair the dural lacerations and the bone fractures, after the removal of the devitalized brain tissue.

Among 11 described cases of patients with severe skull base penetrating injuries caused by screwdriver, the reported patient represents the only survived patient without residual neurological deficits after surgery. Certainly, some important variables conditioned this clinical result and played a determinant role in the positive outcome of this patient: that is the early and intensive medical management, the emergency surgery, the selected surgery procedure and the early prevention of the local infections and general complications.