1.
Unusual Cranio Cerebral Low Velocity
Penetrating Injury with Impacted Weapon
or Foreign Bodies
Sinha V.D.
Head of Depratment
Department of Neurosurgery,
SMS Medical College,
Jaipur

2.
Low Velocity penetrating Head Injury
Introduction
• Penetrating injuries of the brain so
common in warfare, are less common
in peace time
• Gunshot penetrating skull injuries are
common especially in war time and
developed countries
• Low velocity penetrating injuries are
commonly seen in developing and
under developed countries

3.
• In our state Rajasthan (India) assault
by bamboo stick, battle-axe, axe
and other sharp weapons are not
uncommon
• The patient presenting with the
impacted assault weapon or foreign
bodies are extremely uncommon
Low Velocity penetrating Head Injury

4.
This gruesome method of killing a person
is mentioned in Holy Bible, where it is
described in Book of Judges. This
method recruited in middle ages in
England, when professional “pickers”
stuck pins into suspected spots including
scalp, to find the branding by Satan
Low Velocity penetrating Head Injury

5.
Type of penetrating injury
Low velocity penetrating head injury
- fall and hitting of head against sharp
object
- assault by sharp weapon
High velocity penetrating head injury
- gun shot, missiles injury
Low Velocity penetrating Head Injury

6.
The velocity is critical factor
determining the tissue destruction. Low
velocity below 300 m/sec. result direct
disruption and laceration of tissue
K = 1/2 mv2
Low Velocity penetrating Head Injury

7.
Dynamics
Low velocity injury
In the low velocity penetrating injury,
there is absence of the significant impact
force and its deleterious secondary
consequence, result in good recovery
High velocity injury
While in high velocity penetrating injury
tissue cavitation and shock waves are
main cause of cerebral damage and
poor prognosis
Low Velocity penetrating Head Injury

8.
Incidence
• Incidence of gun shot injury is rising due
to increase in crime and terrorist activity
• In developed countries high velocity
penetrating injuries are more common
than developing countries
• In developing countries low velocity
penetrating injury are more common as a
result of inter personal assault or accident
Low Velocity penetrating Head Injury

9.
Low Velocity penetrating Head Injury
• In Kerala (India), such injury due to
fall of coconuts rom tree constitutes
1.6% of all head injuries
• Injury due to axe, battle axe and
sharp weapons are common in our state
Rajasthan (India)
Incidence

10.
Few facts
• The extent of damage depends on size,
shape, site, depth of penetration and
velocity
• An interesting facts to subject penetrating
injury is that often cases, where object has
been removed by assailant have poor
prognosis than where object is still in situ.
As removal of object may causes further
damage to the underlying brain tissue
Low Velocity penetrating Head Injury

11.
Low Velocity penetrating Head Injury
• Usual complication are due to vascular
injury 30% with mortality rate 17%.
Their incidence of vascular injury
increase with trans orbital stab up to 50%
and mortality 30%
(TAYLOR)
Few facts

12.
Investigation
X-ray skull
• Good x-ray skull is essential to
assess the nature of injury, size and
location of in driven bone fragment,
foreign body within the brain and for the
planning of proper surgical approach
Low Velocity penetrating Head Injury

13.
CT Scan
Pre-operative -
Allows the visualization of entire head and
demonstrates even small lesions which may
or may not produce mass effect or symptoms
- Nature of intracranial injury,
haemorrhage, edema, tract of lesion,
intracranial bony and metallic
fragments, intracranial air
- Some time CT scan not possible and
difficult to interpretrate
Low Velocity penetrating Head Injury

14.
Post-operative -
• To check retained fragment, edema,
infection and intracranial air
Low Velocity penetrating Head Injury
CT Scan

15.
Angiography
• If there is doubt of possible
vascular injury, angiogram is
indicated
Low Velocity penetrating Head Injury

16.
MRI
• It is more precise and informative.
However, its use is restricted in
metallic foreign bodies
Low Velocity penetrating Head Injury

17.
Treatment
• Cranio-cerebral injury allocated a
special priority requiring urgent
transfer to a centre where full facilities are
available for definitive
management of such cases
• Prophylactic antibiotic and anti-
convulsant is instituted right from start
Low Velocity penetrating Head Injury

18.
• Craniectomy around the foreign body,
debriment and removal of foreign body
without zigzag motion is needed
• Proper wound debriment, craniectomy,
decompression of bone, evacuation of
intracranial haematoma, contused pulpy
brain, contaminated material like hair, bone,
fragment, foreign body complete
haemostatic, water tight closer to dura and
wound
Low Velocity penetrating Head Injury

19.
•One has to be very careful not to
produce further damage to the
underlying brain by movement of
instrument while removing the
surrounding bone with instrument
Low Velocity penetrating Head Injury

20.
Assault by Battle axeAssault by Battle axe

21.
Assault by Battle axe

22.
During surgery holding arm of axe

23.
Battle axe

24.
Post operative CT

25.
After 2-years

26.
Assault by Sickle

27.
Post operative CTPost operative CT

28.
Homicide by scissor

29.
Homicide by scissor

30.
Post operative

31.
Assault by caliperAssault by caliper

32.
Fall over metal strip

33.
Accidental injury by metal fragmentAccidental injury by metal fragment

34.
Metal fragmentMetal fragment

35.
Injury by wooden pieceInjury by wooden piece

36.
Injury by wooden pieceInjury by wooden piece

37.
Wooden piece

38.
Post-Operative CT

39.
Injury by fall of Stone

40.
Pre-Operative CT
Post-Operative CT

41.
Stone piece

42.
Injury by Stone

43.
Injury by Stone

44.
Injury by Stone

45.
Results
No. of cases 10
Good recovery - 10 100 %
Mortality - Nil 0 %
Low Velocity penetrating Head Injury

46.
Conclusion
•The patient presenting with the impacted assault
weapon or foreign bodies are extremely
uncommon
In the low velocity penetrating injury, there is absence of the
significant impact force and its deleterious secondary
consequence, result in good recovery
•Good x-ray skull is essential to assess the
nature of injury, size and location of in
driven bone fragment, foreign body within the
brain and for the planning of proper surgical
approach

47.
•The extent of damage depends on size,
shape, site, depth of penetration and
velocity
-Allows the visualization of entire head - Nature of
intracranial injury, haemorrhage, edema, tract of
lesion, intracranial bony and metallic fragments,
intracranial air
- Some time CT scan not possible and difficult to
interpretrate
•Craniectomy around the foreign body,
debriment and removal of foreign body
without zigzag motion is needed

48.
Thanks