Phineas Gage Revisited: An “Indian Crowbar Case”

Objective: To review the mode of injury, the clinical sequelae, complications, and management of perforating head injury.

Methods: We present a case of perforating head injury in a 17-year-old boy a la Phineas Gage. We report on the management of an extremely rare perforating head injury. The range of complications that occurred with this unusual form of trauma, the stormy clinical course, and the unique management concerns have been discussed.

Results: This Engineering student sustained head injury from a high speed motor vehicle accident in February 2007. A hollow metallic rod, from the window side rail of the bus perforated his skull traversing a frontal to occipital trajectory. On arrival he was conscious and complaining of neck pain and had a right LMN type 12th nerve palsy. After imaging, he was tracheostomized and an “in line” extirpation of the rod was accomplished. The screw was left behind and could not be retrieved. The entry and exit wounds were free of significant bleed and were debrided and sutured primarily. He was put on anti meningitic doses of antibiotics . During the postoperative course, he developed CSF rhinorrhea and expansion of the frontal contusions requiring a second surgery. The frontal contusions were decompressed. The cranial base defect was reinforced by an intradural fascia lata graft sutured to the dura and calvarial repairs were done with split calvarial grafts. He subsequently developed ventriculitis and gross communicating hydrocephalus for which an external ventriculostomy drainage was done. Ventriculitis was treated with antibiotics. On the 20th day, Imaging showed the screw had migrated posteriorly along the track, to the occipital condyle which was retrieved through the occipital exit wound. He underwent a Ventriculoperitoneal shunt once the CSF cultures were sterile. Dynamic CT and X-rays of his CVJ showed no instability. He steadily improved, and at discharge on day 116 after injury, he was able to walk with minimal support. He went back to Engineering College and was doing well at his last follow up, 9 years after discharge. The distinctive steps in management that need consideration are as follows: (1) Minimal manipulation with in line extirpation of the projectile to reduce further damage of nervous tissue. (2) Contaminant debris within a lengthy and narrow track is difficult to retrieve safely and one must weigh the risks and benefits of attempting to remove all the intracranial fragments. (3) Successful surgical occlusion of the CSF fistula to reduce CSF contamination could potentially unmask latent hydrocephalus and this should prompt surveillance for early CSF diversion. (4) Frequent monitoring and neuroimaging are essential in anticipation of delayed complications like hydrocephalus and meningitis. (5) Infection should be addressed with prolonged culture guided parenteral antibiotic usage of 6 to 8 weeks.

Conclusion: Perforating head injuries are rare requiring unique management paradigms. The need of prolonged surveillance for delayed complications and their prompt management are essential.

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