Iatrogenic traumatic brain injury: Penetration of Kirschner's knitting needle into the middle cranial cavity

Abstract

Traumatic penetrations of foreign objects into the craniocerebral cavity are often encountered in the department of emergency and traumatology. A 5-year-old child was brought to the department of pediatric neurosurgery with a severe headache and fatigue. On admission, the patient had initial neurologic examinations and radiologic scans. The consciousness assessment by Glasgow Coma Scale was 13. Neuroradiologic studies revealed a long hyperdense object extending from the extracranial cavity into the middle cranial fossa. A thorough history was obtained with attention to how and when the injury was sustained. Two weeks before the incident, the child had a blunt trauma of mandibular fractures with dislocation of the temporomandibular joint. Maxillomandibular surgery was performed with a Kirschner's knitting needle to fixate the temporomandibular articulation and simple interdental ligatures for mandibular fracture stabilization. The present radiologic film suggested that the mandibular fracture was not properly fixated allowing the mobilization of Kirschner's needle moving either externally or internally. A standard pterional access with frontotemporosphenoidal approach was performed according to the method of Yasargil and Oikawa-Miyazawa followed by an extradural approach method of Dolenc to the middle cranial structure at the skull base. Several stages of hemostasis were carried out with electrohemocoagulation on the penetrated Kirschner's needle during the needle extracting process at the extradural space of the middle cranial fossa. Two weeks postoperatively, computed tomography scan revealed the supratentorial and middle craniocerebral structures were in symmetric localization. The patient was free of neurologic deficits with no signs of excessive cerebrospinal fluid volume formation. In conclusion, the method of fixation requires appropriate application techniques to ensure adequate fracture fixation during the healing cascade. The neurosurgical approach also requires a specific measure on its management and rehabilitation for the maintenance of such a patient. ©2007Muntaz B. Habal, MD.