Refer to: Dempsey LC, Winestock DP, Hoff JT: Stab wounds ofthe brain. West J Med 126:1-4, Jan 1977

THE WESTERNJournal of Medicine

Stab Wounds of the Brain

LAWRENCE C. DEMPSEY, MD; DAVID P. WINESTOCK, MD, and JULIAN T. HOFF, MDSan Francisco

Unlike the penetratng injuries to the brain caused by missiles, injuries bystabbing are largely restricted to the wound tract. Early recognition, debride-ment and judicious antibiotic therapy can limit or prevent complications in themanagement of stab wounds. Among the common sequelae of stab wounds ofthe brain are pneumocephalus, meningitis, intracerebral hemorrhage anddirect blood vessel or nerve injury.

LOW-VELOCITY PENETRATING WOUNDS of thebrain are uncommon because the skull usuallyprovides an effective protective barrier. The skullcan be penetrated easily, however, through itsforamina and in areas of thin bone. Dujovny re-cently emphasized the vulnerability of the brainto penetrating wounds of the orbit and the thincalvarium of children' and Dolling and co-workers pointed out the relative ease with whichthe squamous portion of the temporal bone canbe perforated in a child.2 The adult calvarium isless easily traversed, yet stab wounds and theircomplications continue to be clinical problems.The case reports to follow exemplify not only thepenetrability of the adult calvarium, but also earlyand delayed sequelae resulting from stab woundsof the brain.

Reports of CasesCASE 1. A 43-year-old man lost consciousness

minutes after having been stabbed with a screw-driver in the right temporal area. The 7 mmpuncture wound extruded hematoma but not cere-

From the Departments of Neurological Surgery (Drs. Dempseyand Hoff) and Radiology (Dr. Winestock), San Francisco Gen-eral Hospital, University of California School of Medicine, SanFrancisco.

This work was supported In part by NINCDS Training Grant05593 and Trauma Center Program Project Grants GM18470 (Dr.Hoff) and NS11539-2.

Dr. Hoff is the recipient of Teacher-Investigator Award NS11051.Submitted April 14, 1976.Reprint requests to: Editorial Office, Department of Neurological

Surgery, University of California School of Medicine, San Fran-cisco, CA 94143.

bral tissue. On neurological examination the pa-tient was comatose and responded to pain withdecerebrate posturing. Conjugate deviation ofgaze to the left could not be overcome with thedoll's eye maneuver. There were bilateral iri-dectomy residua, intact corneal reflexes, absentgag reflex and a flaccid left hemiplegia. An arte-riogram showed right temporal lobe swelling butno abnormalities in the posterior fossa. Debride-ment by temporal craniectomy showed a narrowhemorrhagic tract with a few superficial bonefragments. Postoperatively the complete rightgaze palsy resolved to a "one and a half" syn-drome.8 On an arteriogram done 16 days afterinjury a traumatic aneurysm was noted which haddeveloped from the right superior cerebellarartery (Figure 1). The patient regained fullalertness and comprehension over two weeks buthad residual right pontine deficits including: lefthemiplegia, right trochlear palsy, right internu-clear ophthalmoplegia, ocular bobbing, palataland pharyngeal myoclonus, and aphonia.

CASE 2. A 22-year-old man was admitted tohospital in an obtunded state after having beenfound in his bed in vomitus. Body temperaturewas 103.2°F (39.6°C), blood pressure was150/90 mm of mercury and his neck was rigid;he responded to pain with nonpurposeful thrash-ing movements. Respirations were Cheyne-Stokestype. Fundi were normal, pupils were 4 mm indiameter and briskly reactive to light. Conjugate

rHE WESTERN JOURNAL OF MEDICINE 1

STAB WOUNDS OF THE BRAIN

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W _ -x~~~~~~11W_-.."Figure 1.-Left, right vertebral angiogram on the day of iangiogram 16 days after injury. An aneurysm of the right

deviation of gaze to the right was present, butcould be overcome by doll's eye maneuver. Re-flexes were 4 + throughout with bilateral Babinskisigns. A lumbar puncture yielded bloody fluidwith an opening pressure of 500 mm of water.The patient became apneic during an arterio-

gram. The angiographs disclosed a very largeposterior temporal mass (Figure 2). Angiographicsigns of ventricular enlargement were present. Apreviously unrecognized 5 mm puncture woundwas discovered 5 cm above and behind the meatusduring head preparation for craniotomy. Thelarge hematoma was evacuated. Tiny fragmentsof bone and hair were removed from the laceratedcortex and white matter. Postoperatively Cheyne-Stokes respirations returned, but the patient be-came apneic and died 24 hours later.On autopsy an intraventricular clot and ex-

tensive hemorrhagic laceration of brain werenoted.

CASE 3. A 27-year-old schizophrenic manentered the hospital after stabbing a paring knifewith a 4-inch blade into his forehead. Findingson examination were normal except for delusionalideation, and a 3 cm by 2 mm horizontal gash inthe midline just above the nasion. Body tempera-ture was normal. X-ray films of the skull showed

injury. No abnormality is identified. Right, right vertebral

superior cerebellar artery is present (arrow).

a fracture through the right frontal sinus and

pneumocephalus (Figure 3). Antibiotic therapy

was begun. The wound was debrided and the dura

closed. The patient remained afebrile until the

sixth postoperative day when his temperature

rose to 101.80F (38.80C) and he became inco-

herent. Findings on lumbar puncture showed

Enterobacter meningitis which was eliminated by

adding chloramphenicol to the antibiotic regimen.

The patient recovered completely.

CASE 4. A 22-year-old man was admitted to

San Francisco General Hospital after having

been assaulted. On physical examination an ir-

regular 3 cm laceration in the superior posterior

frontal area was found. Results of neurological

examination were normal except for obtundation

with preserved purposeful movements and a mild

right hemiparesis. On radiographs of the skull a

3 cm linear skull fracture beneath the laceration

was seen. Within 30 minutes of admission the

patient's left pupil dilated and reacted poorly to

light. Burr holes showed there to be intracranial

hypertension without an extracerebral hematoma.

An arteriogram done immediately after trephina-

tion confirmed temporoparietal swelling without

a localized parenchymal hematoma. Intracranial

pressure was monitored after operation by a sub-

2 JANUARY 1977 * 126 * 1

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STAB WOUNDS OF THE BRAIN

Figure 2.-Upper, right common carotid angiogram.Lateral projection. The posterior branches of the rightmiddle cerebral artery are displaced anterosuperiorly(arrow) leaving a hypovascular area in the posteriortemporal lobe. The anterior cerebral artery is straight-ened and elevated as a result of ventricular enlarge-ment. Lower, right common carotid angiogram. Frontalprojection. The sylvian point (arrow) is elevated. Ven-triculomegaly is suggested by the increased distancebetween the anterior and middle cerebral arteries andthe straightening of the anterior cerebral artery.

_.- d

Figure 3.-Skull, lateral projection, brow up. There is afracture through the frontal bone (open arrow) whichinvolved the right frontal sinus. Air is present withinthe subarachnoid space (closed arrows) and the rightventricle (V).

dural catheter and managed with administrationof mannitol and glycerol, and with controlledhyperventilation. A week later intracranial pres-sure rose to 50 mm of mercury, and both pupilsbecame dilated and fixed. Increased serumosmolality prevented further therapy with osmoticagents. The patient became - bradycardic andarrested while being ventilated.On autopsy no infection was found but there

was massive cerebral edema surrounding a deeplaceration beneath the frontal fracture. Smallbone fragments within brain tissue confirmed thepenetrating nature of the injury.

DiscussionMedical reports of stab wounds of the brain

date from as early as 1806.4 Penfield5 describedthe pathological features of experimental stabwounds with cannulas. Pilcher6 compiled alengthy list of objects known to have penetratedthe brain that included knives, pitchforks, cro-chet hooks, knitting needles, breech pins, umbrellabibs, crowbars and iron rods. More recently,Markham7 added car antennas to the list andDolling added pairs of scissors.2

Nonmissile penetrating craniocerebral injuriesare more amenable to treatment than are missileinjuries. A stab wound creates a narrow hemor-rhagic infarction which is largely restricted tothe wound tract.8 Concentric zones of coagula-tive necrosis do not result from stab wounds asthey do from explosives and the cavitating forcesof missiles.8'9 Similarly contre coup injuries rarelyoccur, if at all, from stab wounds.8 Unless thestabbing instrument is swept across the brain be-fore withdrawal (as in case 4), the resultantlesion is focal. Therefore, in the absence of adirect injury to the brain stem or direct lacera-tion of a major vessel, the prognosis for re-covery may be good.The reported stab wounds have usually pene-

trated the skull either in the vicinity of the orbitsor in the temporal areas where the vault is thin.2Even full-thickness skull, however, will not stopa forcefully thrust sharp object. Although radiat-ing fractures from the entry wound are common,the skull fracture often corresponds to the di-mensions of the penetrating object.8

Early recognition of stab wounds of the brainis essential to ensure early treatment and a goodoutcome. Nonetheless, recognition remains diffi-cult; neither the usual sites nor the appearancesof entry wounds are characteristic of stab wounds

THE WESTERN JOURNAL OF MEDICINE 3

STAB WOUNDS OF THE BRAIN

alone. Puncture wounds from screwdrivers andicepicks inside the hairline are especially easy tomiss (case 2 provides an example). Congruentscalp lacerations and underlying fractures shouldalways arouse suspicion.Once recognized, treatment is straightforward,

consisting of hemostasis, debridement and duralclosure. The surgical approach is essentially thatused for missiles'0-debridement and dural repair.

REFERENCES

1. Dujovny M, Osgood CP, Maroon JC, et al: Penetrating intra-cranial foreign bodies in children. J Trauma 15:981-986, 1975

2. Dooling JA, Bell WE, Whitehurst WR: Penetrating skullwound with a pair of scissors: Case report. J Neurosurg 26:636-638, 1967

3. Fischer CM: Some neuro-ophthalmological observations. INeurol Neurosurg Psychiat 30:382-392, 1967

4. Mason F: Case of a young man who had a pitchfork driveninto his head four inches who speedily got well. Mar 10, 1806.Lancet 1:700-701, 1870

5. Penfield W, Buckley R: Punctures of the brain. Arch NeurolPsychiat 20:1-13, 1928

6. Pilcher C: Penetrating wounds of the brain. Ann Surg 103:173-198, 1936

7. Markham JW, Mccleve PE, Lynge HN: Penetrating cranio-cerebral injuries. J Neurosurg 21:1095-1097, 1964

8. Lindenberg R: Trauma of meninges and brain, In MincklerJ: Pathology of the Nervous System, Vol 2. New York, McGraw-Hill, 1971, p 1721

9. Campbell E, Kuhlenbeck H: Mortal brain wounds: A patho-logic study. J Neuropath Exp Neurol 9:139-149, 1950

10. Merirowsky AM: Penetrating craniocerebral trauma. ClinNeurosurg 12:254-265, 1965

Diagnosing Acute IntussusceptionThe diagnosis of acute intussusception is suspected on the basis of age (80 per-cent of cases are in the first two years of life); sex (three boys to one girl);symptoms of intermittent colicky, severe, "labor" pains-even going into theknee-chest position; and appropriate signs of a palpable, sausage-shaped mass,frequently in the right upper quadrant under the liver where it is most difficultto feel. With family doctors taking particular note when a mother says somethinglike "My child is having labor pains," we are picking up the diagnosis earlier.And, in 70 percent of these cases, a barium enema is effective and surgical opera-tion is not required.

-TAGUE C. CHISHOLM, MD, MinneapolisExtracted from Audio-Digest Family Practice, Vol. 23, No. 46,in the Audio-Digest Foundation's subscription series of tape-recorded programs. For subscription information: 1930 WilshireBlvd., Suite 700, Los Angeles, CA 90057.

4 JANUARY 1977 * 126 * 1