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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
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
• 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
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
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
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
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
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
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
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
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
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
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
Post-operative -
• To check retained fragment, edema,
infection and intracranial air
Low Velocity penetrating Head Injury
CT Scan
Angiography
• If there is doubt of possible
vascular injury, angiogram is
indicated
Low Velocity penetrating Head Injury
MRI
• It is more precise and informative.
However, its use is restricted in
metallic foreign bodies
Low Velocity penetrating Head Injury
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
• 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
•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
Assault by Battle axeAssault by Battle axe
Assault by Battle axe
During surgery holding arm of axe
Battle axe
Post operative CT
After 2-years
Assault by Sickle
Post operative CTPost operative CT
Homicide by scissor
Homicide by scissor
Alt. low velocity injury lecture lecture
Alt. low velocity injury lecture lecture
Post operative
Assault by caliperAssault by caliper
Fall over metal strip
Accidental injury by metal fragmentAccidental injury by metal fragment
Metal fragmentMetal fragment
Injury by wooden pieceInjury by wooden piece
Injury by wooden pieceInjury by wooden piece
Wooden piece
Post-Operative CT
Injury by fall of Stone
Pre-Operative CT
Post-Operative CT
Stone piece
Injury by Stone
Injury by Stone
Injury by Stone
Results
No. of cases 10
Good recovery - 10 100 %
Mortality - Nil 0 %
Low Velocity penetrating Head Injury
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
•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
Thanks

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Alt. low velocity injury lecture lecture

  • 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
  • 27. Post operative CTPost operative CT
  • 35. Accidental injury by metal fragmentAccidental injury by metal fragment
  • 37. Injury by wooden pieceInjury by wooden piece
  • 38. Injury by wooden pieceInjury by wooden piece
  • 41. Injury by fall of Stone
  • 47. Results No. of cases 10 Good recovery - 10 100 % Mortality - Nil 0 % Low Velocity penetrating Head Injury
  • 48. 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
  • 49. •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