Penetrating brain injury after suicide attempt with speargun: case study and review of literature

Abstract

Penetrating cranial injury by mechanisms other than gunshots are exceedingly rare, and so strategies and guidelines for the management of PBI are largely informed by data from higher-velocity penetrating injuries. Here, we present a case of penetrating brain injury by the low-velocity mechanism of a harpoon from an underwater fishing speargun in an attempted suicide by a 56-year-old Caucasian male. The case raised a number of interesting points in management of low-velocity penetrating brain injury (LVPBI), including benefit in delaying foreign body removal to allow for tamponade; the importance of history-taking in establishing the social/legal significance of the events surrounding the injury; the use of cerebral angiogram in all cases of PBI; advantages of using dual-energy CT to reduce artifact when available; and antibiotic prophylaxis in the context of idiosyncratic histories of usage of penetrating objects before coming in contact with the intracranial environment. We present here the management of the case in full along with an extended discussion and review of existing literature regarding key points in management of LVPBI vs. higher-velocity forms of intracranial injury.

Keywords: ballistic injury; foreign body removal; intracranial antibiotic prophylaxis; neurovascular injury; operative timing; penetrating brain injury; seizure prophylaxis; traumatic brain injury.

Figure 1

3-dimensional computed tomography reconstruction of the spear’s tract through the oropharynx and skull.

Figure 2

View of the cut tail of the spear protruding from the patient’s neck before removal.

Figure 3

View of the spear tip protruding through the skin overlying the left parietal bone.

Figure 4

View of the large craniotomy through a left-sided question-mark-shaped trauma flap exposing the foreign object in the posterior parietal region and allowing for a pterional-type approach to the ICA within the intracranial cavity.

Figure 5

View of the second, smaller craniotomy was formed directly surrounding the tip of the harpoon, allowing the bone to be removed by sliding it upward and posteriorly along the path of the projectile.

Figure 6

The embedded portion of the spear after removal.

Figure 7

Pre-operative CT scan showing complete transection of the petrous portion of the left internal carotid artery.

Figure 8

Post-operative follow up CT scan showing lack of flow through the left ICA.