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Brain Injury

ISSN: 0269-9052 (Print) 1362-301X (Online) Journal homepage: http://www.tandfonline.com/loi/ibij20

Impalement brain injury from steel rod causinginjury to jugular bulb: Case report and review ofthe literature

Andrew J. Grossbach, Taylor J. Abel, Janel Smietana, Nader Dahdaleh, MerylA. Severson III & David Hasan

To cite this article:Andrew J. Grossbach, Taylor J. Abel, Janel Smietana, Nader Dahdaleh, MerylA. Severson III & David Hasan (2014) Impalement brain injury from steel rod causing injury to

jugular bulb: Case report and review of the literature, Brain Injury, 28:12, 1617-1621

To link to this article: http://dx.doi.org/10.3109/02699052.2014.934284

Published online: 14 Jul 2014.

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http://informahealthcare.com/bijISSN: 0269-9052 (print), 1362-301X (electronic)

Brain Inj, 2014; 28(12): 16171621! 2014 Informa UK Ltd. DOI: 10.3109/02699052.2014.934284

CASE STUDY

Impalement brain injury from steel rod causing injury to jugular bulb:

Case report and review of the literature

Andrew J. Grossbach1, Taylor J. Abel1, Janel Smietana1, Nader Dahdaleh2, Meryl A. Severson III3 & David Hasan1

1Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA, 2Department of Neurosurgery, Northwestern University,

Chicago, IL, USA, and 3Division of Neurosurgery, National Capitol Consortium, Walter Reed National Military Medical Center, Bethesda, MD, USA

Abstract

Background: The management of impalement penetrating brain injuries (IPBI) from non-missileobjects is extremely challenging, especially when vascular structures are involved. Cerebral

angiography is a crucial tool in initial evaluation to assess for vascular injury as standardnon-invasive imaging modalities are limited by foreign body artifact, especially for metallic

objects.

Case study: This study reports a case of an IPBI caused by a segment of steel rebar resulting ininjury to the left jugular bulb and posterior temporal lobe. It describes the initial presentation,

radiology, management and outcome in this patient and reviews the literature of similar

injuries.

Keywords

Angiogram, rebar, traumatic brain injury,

vascular

History

Received 6 November 2013Revised 28 January 2014Accepted 6 June 2014

Published online 14 July 2014

Introduction

Penetrating brain injuries (PBIs) are a type of traumatic brain

injury that can be separated into two categories, missile and

non-missile injuries [1]. Missile injuries result from an object

penetrating the brain travelling at4100ms1 and results in

brain injury from both kinetic and thermal energy [1, 2].

Non-missile PBIs are relatively uncommon injuries in the US

that result from various causes including motor vehicle

accidents, falls, violence, self-inflicted trauma and work

accidents [3, 4]. Although these injuries are often fatal [5],

patients who do survive the initial injury pose a unique set of

problems that must be addressed during management [3, 4].

There have been several reports of non-missile PBIs in the

literature resulting from impalement by various objects, most

commonly metallic objects [1, 3, 4, 6, 7]. This manuscript

describes the presentation and management of a patient

who was impaled by a segment of steel bar and reviews the

management of impalement penetrating brain injuries.

Case reportHistory and physical

A 22-year-old male presented to the University of Iowa

Hospitals and Clinics after a 12 foot fall from a ladder while

working at a construction site. The patient landed upright

on a piece of steel reinforcing bar (rebar) that penetrated

his neck and extended intracranially. Emergency services

responded at the scene and cut the rebar from the concrete

from which it was imbedded. The patient was taken to the

emergency department with the rebar in place. He was

intubated en route after becoming combative. Upon arrival

in the emergency department, the patient was noted to be

stuporous. His pupils were equal and reactive. The patient was

moving all extremities spontaneously, but not following

commands. The rebar was noted to be piercing the left neckand extending cranially (Figure 1).

A non-contrast computed tomography (CT) scan of the

head was obtained that showed the rebar had punctured the

soft tissues of the neck, travelled posterior to the mandible

and penetrated the skull base, traversing the medial mastoid

air cells and jugular fossa on the left (Figures 1 and 2).

The bar also pierced the left posterior temporal lobe with

termination in the left temporoparietal region. There was

intraparenchymal haemorrhage along the tract of the rebar,

ventricular haemorrhage in the left lateral ventricle and a

left subdural haemorrhage causing midline shift (Figure 1).

A CT angiogram (CTA) of the head and neck was performed

and did not show any evidence of injury to the intracranial

arteries; however, the scan was severely limited by metallic

artifact.

Operation

The patient was taken emergently to the operating room

where a right-sided ventriculostomy was placed for ICP

monitoring and drainage of cerebrospinal fluid (CSF). Given

the injury to the soft tissues of the neck and concern for

swelling, a tracheostomy was performed. An emergent

diagnostic cerebral angiogram was performed prior to crani-

otomy, given the high concern for injury to the cerebral

Correspondence: Andrew J. Grossbach, MD, Department ofNeurosurgery, University of Iowa Hospitals and Clinics, 200 HawkinsDrive, Iowa City, IA, 52245, USA. Tel: 206-679-2197. E-mail: [email protected]
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vasculature due to the trajectory of the rebar despite the

negative CTA. The angiogram showed no injury to the

intracranial or cervical arteries (Figure 3), however, extrava-sation of the contrast dye was seen from the left jugular bulb

(Figure 4A). A SynchroSoft microwire and SL10 micro-

catheter were used to perform a coil embolization of the

left sigmoid sinus along with coil embolization and onyx

embolization of the left jugular bulb (Figure 4B). The patient

was then repositioned and underwent a left hemicraniectomy.

A mastoidectomy was performed to expose the transverse

sinus, sigmoid sinus and cervical internal jugular vein,

which was ligated. The dura was then opened to remove the

SDH. Once proximal control of the sigmoid sinus was

obtained and the jugular bulb visualized, the segment of rebar

was carefully removed. The rebar could be seen disrupting

the jugular bulb. There was minimal haemorrhage after

rebar removal and hemostasis was achieved using standard

techniques. A second diagnostic cerebral angiogram wasperformed to confirm that there was no dissection and

satisfactory occlusion of the left sigmoid sinus and jugular

bulb (Figure 4).

Post-operative course

Post-operatively, the patient was admitted to the ICU for

monitoring. The ventriculostomy was slowly weaned and was

removed on post-operative day 11. The patient was initially

comatose; however, made a steady recovery. He initially

exhibited a Wernickes aphasia; however, by discharge on

post-operative day 15 to a rehabilitation facility, the patient

Figure 1. (A) Pre-operative photograph demonstrating entry site and trajectory of rebar. (B) Lateral XR showing the relationship of the rebar to thecranium. There was haemorrhage along the tract of the rebar, intraventricular haemorrhage and a subdural haematoma evident on non-contrast CT (C).

The position of the rebar is depicted on coronal (D), sagittal (E) and axial (F) CT scans.

Figure 2. 3-D CT reconstruction demonstrating the entry point of the rebar in relation to the cranial bones.

1618 A. J. Grossbach et al. Brain Inj, 2014; 28(12): 16171621


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was able to follow simple commands, speak a few short

sentences and was oriented to self. He was ambulatory,

although he had a mild right-sided hemiparesis. He also had

a dense right hemianopia. Upon follow-up 6 weeks

after injury, the patient was oriented to person and place.

His aphasia had resolved and he was full strength in allfour extremities. His right hemianopia persisted. It was

noted that he had some build-up of fluid under his cranial

incision and a head CT revealed a CSF fluid collection. The

patient underwent placement of a ventriculo-peritoneal shunt

and a left-sided native bone cranioplasty without complica-

tion. One year after injury, the patient underwent formal

neuropsychological evaluation that demonstrated deficits in

attention, complex organization, verbal memory and process-

ing speed. On the most recent follow-up, 18 months post-

injury, the patient exhibited significant improvement in many

of his baseline functions, with the exception of his dense right

hemianopia and seemingly mild cognitive slowing.

Discussion

Impalement brain injuries pose unique challenges to surgeons

[3, 68]. These injuries often involve the orbit or temporal

areas, as these areas have thinner calvarium that is more

susceptible to penetration [1]. Several factors need to be takeninto account including associated trauma, the characteristics

of the penetrating object, the location of the penetration and

structures that could be involved, as well as the possibility

of vascular injury [4]. When dealing with PBIs, as with any

traumatic brain injury, secondary injury can be common from

mechanisms including increased ICP, hypotension, respira-

tory distress and coagulopathy, all of which have been

associated with increased mortality in PBI patients [3, 5].

Additionally, PBI management can be complicated by infec-

tion, cerebrospinal fluid leak and cerebral vasospasm [9].

Pre-hospital care should focus on standard Advanced

Trauma Life Support (ATLS) principles, the ABCs,

Figure 3. Cerebral angiogram demonstrating position of rebar (arrows in (A) and (B)) in relation to the cerebral vasculature. (A) AP left internal carotidartery injection and (B) lateral left internal carotid artery injection.

Figure 4. Cerebral angiogram demonstrating extravasation of contrast dye from left jugular bulb during angiogram (vertical arrow, horizontal arrowsdepict rebar). (D) Coil and onyx embolization of the left sigmoid sinus and jugular bulb (arrows).

DOI: 10.3109/02699052.2014.934284 Penetrating brain injury from rebar 1619


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including airway, breathing and cardiovascular support [10].

The penetrating object should not be removed in the field

if it can be avoided. Cutting the penetrating object can be

considered to make the object and patient more mobile.

Care should be taken to disturb the object as little as possible

during transport.

Initial pre-operative imaging should be performed with

a non-contrast computed tomography (CT) scan [7]. This is

especially true when dealing with a metallic object.

Magnetic resonance imaging (MRI) may be useful to identifypenetrating objects made of wood [1, 7]; however, it is

contraindicated when dealing with potentially ferromagnetic

objects. Pre-operative cerebral angiography should be per-

formed if there is any concern for intracranial vascular injury

[4, 6, 7, 9, 11]. In their series on intracranial stab wounds,

Kieck and de Villiers [6] report intracranial vascular injury

in 20% of their total patients and 33% of the patients

who underwent angiography [6]. Intracranial vascular injuries

can range from carotid-cavernous and other arteriovenous

fistulas, aneurysms, pseudoaneurysms, arterial transections

or occlusions and vasospasm [9, 12, 13]. The use of CT-

angiography (CTA) or MR-angiography (MRA) has been

increasing; however, conventional cerebral angiographyremains the gold standard [4, 14]. CTA and MRA may

exhibit artifact, making accurate interpretation difficult or

impossible [4]. This study recommends digital subtraction

angiography in all cases of penetrating brain injury, as the

possibility of cerebrovascular injury exists by the very nature

of the injury. Delayed follow-up angiography is also recom-

mended as pseudoaneurysms can frequently present in a

delayed fashion [6, 9, 1517]. Early post-operative CT is

important to identify possible intracranial haemorrhage

obscured by artifacts from the foreign body during initial

scanning [11].

Removal of the offending object should be done under

direct visualization in a controlled manner in the operating

room using a craniotomy due to risk of potentially fatal

haemorrhage [1, 4, 7, 8]. Angiography should be used to

evaluate for vascular injury and vascular control should be

obtained prior to removal via endovascular techniques [15];

however, some authors recommend craniotomy for direct

hemostasis of vascular injuries due to possible delay in

obtaining angiography [11]. When removing embedded

penetrating foreign objects the standard goals of surgery in

these institutions are removal under direct vision with

proximal and distal vascular control; cerebral decompression;

evacuation of mass lesions (EDH, SDH, IPH); debridement

of necrotic tissue; hemostasis; and CSF diversion for ICPmonitoring and to reduce the risk of CSF leak [9,18]. While

the literature is lacking with regard to ICP monitoring in

PBI patients, this practice is the standard in accordance with

the head injury management guidelines [8,9, 11, 18]. Dural

closure should be attempted if a craniectomy is not performed

to reduce the risk of post-operative cerebral spinal fluid (CSF)

leak [11]. The use of ICP monitoring is relatively uncommon

in PBI patients, likely due to high initial mortality and lack

of reporting in the literature, but elevated ICPs have been

associated with increased mortality [5].

The use of antibiotics in the context of PBI is controversial

in terms of antibiotic selection and time course of therapy,

however, it is generally recommended that broad-spectrum

antibiotics with good CNS penetration be used for 714 days

[9], as meningitis and cerebral abscesses may be complica-

tions resulting from low-velocity penetrating brain injuries

[1, 4, 11, 14]. Currently, there are no evidence-based

guidelines to dictate duration of antibiotic use. Potential

contamination from the penetrating object must be taken into

account on a case-by-case basis.

Post-traumatic epilepsy (PTE) is also a common compli-

cation of PBI [8, 19]. PTE after penetrating brain injury ismore common than in blunt TBI and is reported in up to 50%

of patients and can occur decades after injury [20, 21].

Prophylactic anti-epileptic medications are frequently used,

although none has been demonstrated to prevent post-

traumatic epilepsy and recommended duration of therapy

varies significantly [2, 8, 12, 14]. The Brain Trauma

Foundation Guidelines offer a Level II recommendation that

prophylactic use of phenytoin or valproate are not recom-

mended to prevent late post-traumatic seizures while anti-

convulsant use is indicated to prevent early seizures within 7

days of injury [22]. In practice, the authors typically employ

either phenytoin or levetiracetam for 7 days post-injury.

When dealing with PBIs, low initial Glasgow Coma Scale(GCS) and advanced age are associated with poor outcomes

[3, 5]. Suicide as a mechanism of injury is also correlated

with a higher mortality [5]. Despite the high mortality

rate for penetrating brain injuries, this case illustrates that,

if properly managed, these patients have the ability to

significantly recover from their severe injuries. Further

study is needed to determine appropriate PBI seizure

prophylaxis as well as antibiotic therapy.

Declaration of interest

The authors report no conflicts of interest. The authors alone

are responsible for the content and writing of the paper.

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