2024-02-14 11:24:01
Key messages
Ophthalmologists recently reported a rare case occurring in the professional setting and published in the professional journal “Cureus”.
The patient and his story
According to the authors, a 30-year-old man with vision loss and hemorrhage in his left eye went to Sultanah Bahiyah Hospital, Malaysia after an accident at his workplace in the sector construction. As the patient reported, he used a pneumatic nail gun without wearing protective eyewear. When the nail gun jammed, he tested it through the barrel of the gun and accidentally shot it at his left eye.
Nail guns are popular tools in the construction industry because they significantly increase productivity. The firing speed of a nail gun ranges from 45.7 m/s (pneumatic nail gun) to 426.7 m/s (powder gun).
The results
- Fully oriented and cooperative male (Glasgow Coma Scale (GCS): 15), vital parameters stable, no paralysis
- Headache and painful left eye
- Apart from the injuries to the left eye and the swelling, the first and second examinations revealed no other injuries.
- X-rays and CT scan of the skull revealed the presence of a nail that had penetrated the roof of the left orbit. The nail was 3.2 cm long and located in the frontal lobe of the brain. The patient also had subdural and subarachnoid hemorrhages in the left frontotemporal region, as well as fractures of the roof and floor of the left orbit.
The treatment
- Emergency craniotomy and removal of the intracranial foreign body which had penetrated the parenchyma of both frontal lobes,
- Then surgical intervention of the injured eye immediately after the neurosurgical intervention,
- Patient discharged on the 5th postoperative day without neurological deficit (GCS score of 15)
- However, the patient did not perceive any light through the left eye.
It was not possible to monitor the situation as the patient, who was not from Malaysia, left the country.
Discussion
Penetration brain injuries are not common, accounting for only 0.4% of head injuries, according to the authors. Transorbital brain injuries by penetration are even rarer (24% of cranial injuries by penetration in adults and 45% in children).
Transorbital penetration brain injuries are often caused by shrapnel and pistol or rifle ammunition. Such injuries are also possible with metal materials like scissors, screwdrivers, knives or even wood. Although rare, transorbital penetrative brain injuries can cause serious and permanent neurological and ophthalmological damage.
Conventional skull x-rays do not always provide the desired information, particularly in the event of fractures or certain foreign bodies (wood, plastic and glass).
American worker Phineas Gage suffered one of the most significant transorbital brain injuries in the history of medicine. On September 13, 1848, the young man, then aged 25, prepared an explosion south of the village of Cavendish (Vermont). When the explosion was accidentally triggered, it threw a heavy iron bar through his skull, irreversibly destroying part of his frontal lobe. Subsequently, Phineas Gage’s survival prompted many doctors, brain researchers and psychologists to conduct research and debate, reports Professor Stephan Schleim of the University of Groningen in the specialist journal « Frontiers in Human Neuroscience ».
Because Phineas Gage not only survived the penetrating head trauma: but according to reports, he remained conscious and responsive when his colleagues took him home. He died in 1860, 12 years after the accident. This case became especially famous because the personality of Phineas Gage was greatly modified following frontal brain damage: the calm and confident young man became an impulsive and unreliable man. His medical history has provided neurologists and other neuroscientists with important and thought-provoking information about frontal brain function.
A few years ago, otolaryngologists at the Martin Luther University of Halle-Wittenberg also described a less famous but equally unusual case penetration injury. It was a 30 year old woman. According to the authors, the woman was injured by three shots from a revolver fired by her husband during a domestic dispute. She was first hit in the abdomen and back; the perpetrator then shot the patient who was on the ground a third time and hit her in the head.
According to the authors, the patient was awake upon arrival to the emergency room and the Glasgow Coma Score was 15. Left chest pain dependent on breathing was observed, as well as left leg weakness, with intact sensation. on both sides. According to the authors, a gunshot wound of approximately 8 mm in diameter was visible above the nasion, the nasal bone was mobile, and the woman had a bilateral spectacle-shaped hematoma. Inspection of the pharynx reportedly revealed a slightly hemorrhagic lesion in the mucosa of the posterior wall of the oropharynx.
After the shot in the face, the projectile would have presented “an unusual trajectory”: “After the entry of the projectile above the nasion, the firing channel passed through the ethmoid into the nasopharynx where the projectile penetrated the soft tissues pharyngeal and, due to the significantly reduced energy, bounced off the compact clivus and was deflected caudally toward the oropharynx and then apparently swallowed.”
The diagnosis: “intragastric position of a swallowed projectile after a head shot in the context of a multiple gunshot wound”.
This article was originally published on Univadis.de.
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