Surg Neurol 471 1992;38:471-2

Unusual Craniocerebral Penetrating Injury by a Power Drill: Case Report

A.J. Kelly, M.B., B.Ch., I. Pople, F.R.C.S., and B.H. Cummins, Ch.M., F.R.C.S. Department of Neurosurgery, Frenchay Hospital, Bristol, United Kingdom

Kelly AJ, Pople I, Cummins BH. Unusual craniocerebral penetrating injury by a power drill: case report. Surg Neurol 1992;38:471-2.

Craniocerebral penetrating injuries due to foreign bodies are rare in British civilian practice. Most cases result from industrial accidents, criminal assaults, and self-inflicted injury [2]. We report the case of a man who attempted suicide by drilling through his skull with an electric power drill.

Case Report A 53-year-old man with a history of depression and previous parasuicide presented to an Accident and Emergency Department stating that he had just at- tempted suicide with an electric power drill (Figure 1). At this stage, he was alert and oriented, and neurological examination was normal. Two circular wounds 6 mm in diameter were noted over the vertex of the skull. Anteroposterior and lateral plain skull radiographs were reported as showing no bony injury. It was concluded that the wounds were superficial, and the patient was admitted to a psychiatric hospital.

Eight days after the injury, a fluctuant swelling devel- oped around the scalp wounds. Following the removal of some matted hair, frank pus was released, revealing two drill holes in the skull (Figure 2). The patient was transferred to a general hospital and he remained alert and oriented, with no focal deficit. Oral antibiotic ther- apy (floxacillin 500 mg daily) was started, and a sample of pus taken for culture. This grew a mixture of Staphylo- coccus aureus, Streptococcus sanguis, and mixed coliforms, all sensitive to floxacillin.

This treatment was continued for a further 3 days,

Address reprint requests to: Dr. A.J. Kelly, Department of Neurosur- gery, Frenchay Hospital, Bristol, BS16 1LE, UK.

Received December 30, 1991; accepted April 13, 1992.

Figure 1. Photograph of drill.

when he complained of a progressive weakness of his right arm and leg. Examination revealed a right hemipa- resis with no sensory deficit, and no change in level of consciousness. A computed tomographic (CT) brain scan revealed a left parasagittal ring-enhancing lesion with surrounding edema (Figure 3). Peripheral while blood cell count was 10.2 × 109/L (66% neutrophils), and C- reactive protein level was 42 ng/L (normal < 10).

The patient was transferred to Frenchay Hospital and underwent a craniectomy at the site of the drill holes. Lumps of hair were found in a 3-cm radius around the drill holes in the extradural and subdural spaces and along a 5- to 6-cm track leading to an abscess cavity within the left parietal lobe. The diameter of the drill holes was 6 mm each, so that the hair had expanded

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472 Surg Neurol Kelly et al 1992;38:471-2

laterally 10 times the extent o f the original hole. The hair was removed, and the wounds were debrided, irri- gated, and closed primarily.

Postoperat ive antibiotics were continued on the basis o f culture sensitivities, and the C-reactive protein level declined to the normal range on the 12th day. On clinical examination at follow-up, the patient had made an almost complete recovery f rom his hemiparesis and exhibited none o f the psychological disturbances associated with frontal lobotomy. His depressive state had responded well to psychiatric counseling and tricyclic antidepres- sants, and he was planning a return to full-time em- ployment .

Conclusions

Deliberate self-harm may present as bizarre craniocere- bral penetrat ing injury. Repor ted implements include nails [4], metal wire [1], ice picks [2], keys [5], pencils [3], and chopsticks [6].

In this case, the extent o f the injury was not appreci- ated initially, and the diagnosis o f craniocerebral pene-

Figure 2. Debrided scalp wound showing drill holes in skull. Figure 3. CT brain scan showing intracranial air and ring-enhancing lesion with surrounding area of edema.

trating injury was delayed until the development of mo- tor signs with abscess formation 11 days later. Adequate exploration of scalp wounds is essential to exclude un- derlying injury. CT brain scanning may provide useful information about the extent o f cerebral injury and the presence of foreign bodies, intracranial hemorrhage, and gas. Power drill injury causes surface material such as hair to be dragged into the wound and spread over some distance f rom the drill track. This foreign material is likely to act as a nidus for infection.

R e f e r e n c e s

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2. Bakey L, Glasauer FE, Drand W. Unusual intracranial foreign bod- ies. Acta Neurochir (Wien) 1977;39:219-31.

3. Miller CF, BrodkeyJS, Colobi BJ. The danger ofintracranial wood. Surg Neurol 1977;7:95-103.

4. Reeves DL. Penetrating craniocerebral injuries: report of two un- usual cases. J Neurosurg 1965;23:204-5.

5. Tiwari SM, Singh RG, Dharker SR, Chaurasia D. Unusual cranio- cerebral injury by a key. Surg Neurol 1978;9:267.

6. Yamamoto I, Yamada S, Sato O. Unusual craniocerebral penetrat- ing injury by a chopstick. Surg Neurol 1985;23:396-8.