Management of screwdriver-induced penetrating brain injury: a case report
Shi et al. BMC Surgery
Management of screwdriver-induced penetrating brain injury: a case report
Jia Shi 0
Yumin Mao 0
Jiachao Cao 0
Bo Dong 0
0 Department of Neurosurgery, The Third Affiliated Hospital of Soochow University , Changzhou City 213003 , China
Background: Penetrating brain injury (PBI) can be caused by several objects ranging from knives to chopsticks. However, an assault with long and electric screwdriver is a peculiar accident and is relatively rare. Because of its rarity, the treatments of such injury are complex and nonstandardized. Case presentation: We presented a case of a 54-year-old female who was stabbed with a screwdriver in her head and accompanied by loss of consciousness for 1 h. Computer tomography (CT) demonstrated that the screwdriver passed through the right zygomatic bone to posterior cranial fossa. Early foreign body removal and hematoma evacuation were performed and the patient had a good postoperative recovery. Conclusions: In this study, we discussed the clinical presentation and successful management of such a unique injury caused by a screwdriver. Our goal is to demonstrate certain general management principles which can improve patient outcomes.
Screwdriver; Penetrating brain injury; Right zygomatic bone; Cranitomy
Intracranial injuries caused by penetrating foreign bodies
are associated with high risks of morbidity and mortality
due to relevant infection, seizures, vascular injury and
cerebrospinal fluid leakage [1, 2]. Penetrating brain injury
(PBI) in civilian population can be caused by almost all
sharp and blunt objects, ranging from knives and scissors
to chopsticks and screwdrivers . To date, PBI with a
screwdriver is a peculiar accident and is relatively rare .
Screwdriver-induced PBI is severe and neglected [4, 5].
First, due to their length and spiral force, the tip of rigid
screwdrivers may be enable to penetrate into the calvarium,
and once through the bone, the screwdrivers may pivot
around the entry point in the skull and then cause curved
intracranial injuries, which are far more serious than the
damage of skin surface. Second, if the screwdriver is
withdrawn, the small entry wound may be missed by clinical
examination, and the seriousness of intracranial injuries
may also be overlooked . Therefore, it is relatively
complex to manage such injuries owing to their rarity and
In this study, we discussed the clinical presentation
and successful management of such an unique injury
caused by screwdriver. Our goal is to demonstrate
certain general management principles which can improve
patient outcomes. It is worth mentioning that this case
report strictly adhered to care guidelines.
A 54-year-old-female patient, without addictions or
comorbidities, was admitted in our emergency department
due to assault with a screwdriver in her head and loss of
consciousness for 1 h. Her colleagues explained that she
suffered the injury hit by shedding electric screwdriver
when working in a factory, and the screwdriver penetrated
the right zygomatic bone (Fig. 1a). The injury was
associated with an immediate coma and bleeding of the right
ear. The patient had no history of vomiting or seizures.
Owing to the disorder of vital signs, the patient underwent
tracheal intubation in emergency department.
Neurological examination revealed a Glasgow Coma Scale
(GCS) of 3/15. A screwdriver was seen partially
penetrating the right cheekbone through a lacerated horizontal
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Fig. 1 a. Clinical picture showing a strewdriver penetrating the right cheekbone. b. Computed tomogram (CT) of brain showing the metallic
foreign body with metal artefacts. c-d. CT of head-brain window showing a metallic foreign body passed through the right cheekbone to
posterior cranial fossa. e-f. CT scan showing left cerebellar hematoma and subarachnoid hemorrhage
wound of 10 mm × 10 mm. The injury was accompanied
by left pupillary dilatation (5 mm) with disappeared
responsive to light, right pupillary dilatation (3 mm) and
unresponsive to light, and bleeding of right ear. There was
no evidence of any other injury.
A noncontrast axial computed tomographic (CT) scan
showed a metallic foreign body passing through the right
cheekbone to posterior cranial fossa, and a linear
structure extending from right temporal bone, petrous bone,
middle cranial fossa, posterior fossa to left occipital
bone (Fig. 1b-c). Meanwhile, left cerebellar hematoma
and subarachnoid hemorrhage were also demonstrated
in CT scan (Fig. 1e-f ). Because of the clinical status of
the patient, a digital subtraction angiogram could not
The patient was emergently taken to the operating room
(OR) and immediately given broad-spectrum antibiotic
coverage with penicillin (3.75 g, ivgtt). The patient was
given a right cheekbone craniectomy and removal of the
foreign body at supine position. 6 cm long straight
incision was adopted with the entry point as the center.
Craniotomy was performed along the skin incision, during
which the screwdriver came along and was removed
(Fig. 2a). Afterwards the wound was debrided, cleaned,
and closed. Brain CT scan was made again and revealed
little hematoma of screwdriver tract, a left cerebellar
contusion with about 15 ml hematoma, obvious compression
of the fourth ventricle and brain stem, and intraventricular
hemorrhage (Fig. 2b-d). Then right frontal puncture was
Fig. 2 a. Clinical picture showing the strewdriver removed surgically. b. CT of head-brain window showing hematoma of strewdriver tract. c. CT
scan showing a left cerebellar contusion with hematoma and obvious compression of the fourth ventricle and brain stem. d. CT scan showing
high density corrosion cast of the ventricular system
immediately performed, followed by drainage of
cerebrospinal fluid (CSF), which was as higher as 20 mmHg, to
achieve maximum brain relaxation. The patient was then
repositioned, placed in prone position and given
evacuation of posterior fossa hematoma. The incision was made
along the median line, about 16 cm, then skin and muscle
flap were separated and the skull was exposed. A 6 cm ×
5 cm flap was removed from occipital bone and about
15 ml of subdural hematoma was evacuated. Contusive
cerebellar tissues and sutured dura were removed. The
patient was then transferred to the neurosurgery intensive
care unit (NICU) for postoperative management.
On post-operative day (POD) 2, brain CT showed smaller
posterior fossa hematoma. Meanwhile, external ventricular
drainage tube was also placed to replace CSF and prevent
obstructive hydrocephalus (Fig. 3a-b). However, the patient
suffered persistent coma, with GCS of 4/15, complicated
with pulmonary infection in the subsequent 3 days.
Tracheotomy was performed to open the airway and control
infection. Meanwhile, the patient received aggressive
broadspectrum antibiotics which were maintained for 14 days.
Intravenous sodium valproate was given for prophylaxis
against posttraumatic seizures. No other serious
complications were reported after symptomatic supportive measures
such as anti-infection treatments and nerve nutrition. The
patient’s GCS score was improved to 12 on POD 42.
Postoperative brain CT scan (Fig. 3c-d) revealed favorable
findings. The patient was discharged on POD 60. Postoperative
6-month follow-up evaluation showed normal neurological
status of the patient, without further seizures.
PBI involving foreign bodies is less prevalent than closed
head injuries but often causes a worse prognosis. To date,
there is no standardized management for such injuries
because different injury patterns share with each scenario.
However, some general management principles can be
applied to almost any case to improve patient outcomes.
First is the preoperative examination. Head CT is the
most sensitive imaging modality for PBI, to identify the
extent of bone and parenchymal injuries and formulate
operation plan . In case of suspicion for vascular injury,
CT cerebral angiography is also needed to evaluate
traumatic aneurysm, which may rapidly develop after PBI .
Second is the operative management. In this study, the
patient had severe low GCS of 3/15, which could be
attributed to 2 points: 1) The characteristics of PBI caused by a
screwdriver. 2) The patient presented with posterior fossa
hematoma in the early stage, which might oppress
brainstem, leading to disorder of vital signs. However, timely and
Fig. 3 a-b. CT of brain taken on post-operative day 2, showing smaller posterior fossa hematoma and drainage of CSF. c-d. CT of brain taken on
post-operative day 42, showing complete absorption of haematomas and normal ventricular system
effective surgical interventions made the patient have a
good prognosis [9, 10]. Generally, the goals of surgical
intervention for such injury are to: 1) Remove the
penetrating object and accompanying necrotic debris around the
injury site. According to our study, we recommended
removal of the screwdriver through its trajectory with
minimum injury. However, in some cases, foreign bodies were
removed roughly on the spot, which would lead to bleeding
of puncture and poor prognosis [6, 11]. 2) Eliminate any
hematomas developed from the injury. 3) Ensure watertight
closure of the dura and prevent CSF leakage .
Third is the postoperative management. 1) Prophylactic
antibiotics and antiseizure medications are recommended to
be applied for the first week [13, 14]. In this case, we
prolonged the use of antibiotics owing to deep penetrating tract
and pulmonary infection. 2) For severe PBI patient with
postoperative coma and pulmonary infection, tracheotomy
could be help to prevent the damage of chronic hypoxia on
brain tissue and strengthen the management of respiratory
tract. 3) Postoperative imaging and follow-up are important
to evaluate complications such as pulmonary infection,
delayed intracranial hematoma and posttraumatic
hydrocephalus, which can be presented in a delayed mode .
However, there are still some limitations in this case
report. First, the patient with a metallic foreign body in her
head was unable to perform magnetic resonance imaging
(MRI). Meanwhile, because of obvious CT imaging
artifacts, computed tomography angiography (CTA) imaging
and three-dimensional reconstruction could not be used to
identify the relationship between metallic foreign body and
intracranial vessels or skull. Second, the patient’s GCS score
on arrival was 3/15 with unstable vital signs and formation
of traumatic cerebral hernia. Thus immediate surgical
decompression was needed, which kept us from digital
subtraction angiography and made us unable to clear
intracranial vascular injury. Third, the would tract induced by
screwdriver was deep and long, involving multiple
lobes,which made it difficult to thorough debridement.
Therefore, it may result in residues of foreign bodies or necrotic
tissue and increase the risk of infection.
In conclusion, this is a unique case of penetrating
screwdriver injury. Despite the removal of the screwdriver from
the intracranial tissue through the orbit, we achieved
positive outcomes in this challenging case due to the ability of
the neuro trauma unit and the cooperation of
multidisciplinary team, involving neurosurgeons, emergency
physicians, radiologists and anesthesiologists.
Availability of data and materials
All patient data and clinical approaches adopted are contained in the medical
files of The Third Affiliated Hospital of Soochow University. The bibliographic
data of reference are available on PubMed and the conclusions are based on
the opinion of the expert involved in the this case. The data supporting the
conclusions of this article are included within the article and its figures.
BD was a major contributor in writing and in a review of the manuscript. JS
collected patient data and was involved in writing and in a review of the
manuscript. YM and JC were involved in patient management and review of
the manuscript. All authors read and approved the final manuscript.
Consent for publication
Written informed consent was obtained from the patient for publication of
this case report and images. A copy of the written consent is available.
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