Non-fatal Bihemispheric Penetrating Brain Injury from a Crossbow Arrow with Good Clinical Outcome: Case Report

Crossbow injuries to the head have seldom been reported in the literature, and they represent a unique type of penetrating brain injury (PBI) in which a low-velocity arrow results in an intracranial fragment larger than most high-velocity projectiles, usually with a lethal outcome.We present the case of a 34-year-oldman who attempted suicide with a self-inflicted cranial injury from a crossbow arrow, with a right parietal point of entry and a palpable subcutaneous tip in the left parietal region. The emergency team reported a Glasgow coma scale (GCS) score of 15, and the patient was brought sedated and intubated. Computed tomography (CT) imaging scans showed that the arrow crossed both parietal lobes, with mild subarachnoid hemorrhage and small cerebral contusions adjacent to its intracranial path. Careful retrograde removal of the penetrating arrow was performed in the CT suite, followed by an immediate CT scan, which excluded procedure-related complications. The patient woke up easily and was discharged 3 days later withmild left hand apraxia and no other neurologic deficits. To the best of our knowledge, there are no similar case reports describing both good clinical outcome and rapid discharge after a bihemispheric PBI. Individualizing the management of each patient is therefore crucial to achieve the best possible outcome as PBI cases still represent a major challenge to practicing neurosurgeons worldwide.

Uso do doppler colorido das carótidas no diagnóstico de um paciente com fístula carotideocavernosa direta / Use of color doppler of carotids in the diagnosis of a patient with direct carotid-cavernous fistula

Adulto jovem de 18 anos que evoluiu após traumatismo craniencefálico leve com fístula carotídea direta. Apresentou zumbido e exoftalmia, ambos de característica pulsátil e à esquerda. Foi submetido a estudo com Doppler das carótidas, que mostrou elevadas velocidades do fluxo sanguíneo e índices de resistência reduzidos nas artérias carótidas comum e interna esquerdas, compatíveis com fístula carotídea direta. A angiotomografia computadorizada cerebral confirmou a fístula carotídea. Foi encaminhado para tratamento endovascular por embolização, com sucesso. O Doppler de carótidas pode ter papel importante no diagnóstico das fístulas carotídeas diretas e acompanhamento de pacientes submetidos à terapêutica endovascular.(AU)

Microsurgical Cisternostomy for Treating Critical Patients with Traumatic Brain Injury - An alternative Therapeutic Approach

Introduction Traumatic brain injury (TBI) is a major cause of mortality around the world. Few advances regarding surgical approaches have been made in the past few years to improve its outcomes. Microsurgical cisternostomy is a well-established technique used in vascular and skull base surgery and recently emerges as a suitable procedure with lesser costs and morbidity when compared with decompressive craniectomy in patients with diffuse TBI. This study aims to describe the technique, indications, and limitations of cisternostomy and to compare it with decompressive craniectomy (DC). Methods A prospective study is being conducted after obtaining approval of the local human ethics research committee. Once the inclusion and exclusion criteria are applied, the patients are submitted to microsurgical cisternostomy, pre and postoperative neurological status and brain computed tomography (CT) evaluation. A detailed review was also performed, which discusses diffuse TBI, DC, and cisternostomy for the treatment of TBI. Results Two patients were submitted to cisternostomy after TBI and the presence of acute subdural hematoma and hugemidline shift at admission computed tomography. The surgery was authorized by the family (the informed consent form was signed). Both patients evolved with a good recovery after the procedure, and had a satisfactory control brain CT. No further surgeries were required after the initial cisternostomy. Conclusions Cisternostomy is an adequate technique for the treatment of selected patients affected by diffuse TBI, and it is a proper alternative to DC with lesser costs and morbidity, since a single neurosurgical procedure is performed. A prospective study is being conducted for a better evaluation and these were the initial cases of this new protocol.

Avaliação de pacientes vítimas de trauma cranioencefálico com sinais de intoxicação alcoólica / Evaluation of traumatic brain injury patients with signs of alcohol intoxication

RESUMO Objetivo: avaliar, em vítimas de traumatismo cranioencefálico, a influência da intoxicação alcoólica no tempo para submissão destes pacientes à tomografia de crânio, comparando também os achados tomográficos nos pacientes alcoolizados e não alcoolizados. Métodos: estudo retrospectivo de 183 pacientes com traumatismo cranioencefálico, divididos em dois grupos: 90 alcoolizados e 93 não alcoolizados. Foi calculado o intervalo de tempo desde a chegada do paciente ao pronto socorro até a realização da tomografia para comparação entre os grupos, e analisados os achados tomográficos. Resultados: no grupo alcoolizado, o percentual de pacientes do sexo masculino foi maior, a idade predominante situava-se entre os 31 e os 40 anos, a agressão foi o mecanismo de trauma mais frequente e estes pacientes apresentaram valores mais baixos na escala de coma de Glasgow. Observou-se que não houve diferença estatística entre os dois grupos quanto ao intervalo de tempo para realização de tomografia, bem como, em relação aos achados tomográficos. Além disso, nos pacientes alcoolizados, quando correlacionados os valores da escala de coma de Glasgow com o intervalo de tempo, não houve diferença entre valores de 13 a 15 (traumatismo cranioencefálico leve) e os iguais ou menores do que 12 (traumatismo cranioencefálico moderado e grave). Conclusão: os sinais de intoxicação alcoólica não influenciaram no intervalo de tempo para realização da tomografia. Os pacientes alcoolizados apresentaram escores mais baixos na escala de coma de Glasgow por efeito direto do álcool e não por uma maior prevalência de achados tomográficos.

ABSTRACT Objetive: to evaluate the influence of alcohol intoxication in the time to perform head computed tomography and tomographic findings in traumatic brain injury patients. Methods: a retrospective study of 183 traumatic brain injury patients, divided into two groups: 90 alcoholics and 93 non-alcoholics. Time interval from patient's arrival at emergency room to tomography was calculated for comparison between the groups, and tomographic findings were analyzed. Results: in the alcoholic group, the percentage of male patients was higher, the predominant age was between 31 and 40 years, aggression was the most frequent trauma mechanism, and these patients showed lower values on the Glasgow coma scale. It was observed that there was no statistical difference between the two groups regarding the time interval for tomography execution, as well as regarding the tomographic findings. In addition, in the alcoholic patients, when the Glasgow coma scale values were correlated with the time interval, there was no difference from scores 13 to 15 (mild traumatic brain injury) and those equal to or inferior than 12 (moderate and severe traumatic brain injury). Conclusion: signs of alcoholic intoxication did not influence the time interval for tomography execution. Patients under alcohol influence showed lower scores on the Glasgow coma scale due to the direct effect of alcohol and not due to a higher prevalence of tomographic findings.

Devemos monitorar a pressão intracraniana de pacientes com TCE grave Marshall II? / Should we monitor ICP in severe brain trauma injury Marshall II patients?

Objetivos: Avaliar a relação da PIC com o crescimento de lesões e morbimortalidade em pacientes Marshall II e determinar a necessidade de sua monitorização. Método: Estudo de coorte observacional prospectivo em pacientes com TCE grave classificados como Marshall II. Resultados: Setenta pacientes foram divididos em dois grupos baseados na PIC; G1: PIC ≤ 20 mmHg (49 pacientes) e G2 PIC > 20 mmHg (21 pacientes). Os achados mais comuns foram hemorragias subaracnóideas e contusões.A mortalidade foi maior em G2 que em G1 (OR: 11,7) (IC 95%: 2,2 a 63,1). A mediana da Escala de Desfecho de Glasgow após 90 dias foi de 2 para o G2 e de 5 para o G1. O surgimento ou progressões de lesões ocorreram em 71% dos pacientes no G2 contra 10% no G1 (p < 0,05). Em comparação ao G1, o OR de um novo achado na TC foi 22 vezes maior no G2 (IC 95%: 5,02 a 106,9). Dois pacientes do G2 precisaram de cirurgia e nenhum do G1. Conclusões: Pacientes Marshall II, com hipertensão intracraniana, apresentam maior risco para crescimento de lesões na TC de controle, pior prognóstico e maior mortalidade que aqueles sem hipertensão. A monitorização desses pacientes foi definitiva para determinar o prognóstico. Pacientes Marshall II devem ser monitorados.

Objectives: Evaluate the relationship of intracranial hypertension with an increase of brain lesions, morbimortality in Marshall II patients and determine whether these patients need to have ICP monitored. Method: Prospective observational cohort study on severe TBI patients (GCS ≤ 8), Marshall CT classification II. Results: A total of 70 patients were divided into two groups based on ICP; G1: ICP ≤ 20 mmHg (49 patients) and G2 ICP > 20 mmHg (21 patients). The most common CT findings were: subarachnoid hemorrhages and contusions. Mortality was higher in G2 than in G1 (OR: 11.7) (95% CI: 2.2 to 63.1). The median Glasgow Outcome Score after 90 days was 2 for G2 and 5 to G1. The onset or progression of lesions occurred in 71% of patients in G2, against 10% in G1 (p < 0.05). Compared toG1, the OR for a new finding on CT was twenty-two times higher in G2 (95% CI: 5.02 to 106.9). Two G2 patients needed surgery and none of the G1. Conclusions: Severe TBI patients with Marshall score II and intracranial hypertension, are at greater risk for new CT abnormalities, worse prognosis, and higher mortality than those with no hypertension. ICP monitoring was crucial to define prognosis. Severe TBI Marshall II patients should be monitored.