Transnasal penetrating intracranial injury with a chopstick

Abstract

A 49-year-old Chinese man, who was a psychiatric in-patient, self-inserted a wooden chopstick into his A B S T R A C TWe report the first case of a transnasal penetrating intracranial injury in Hong Kong by a chopstick. A 49-year-old man attempted suicide by inserting a wooden chopstick into his left nose and then pulled it out. The chopstick caused a transnasal penetrating brain injury, confirmed by contrast magnetic resonance imaging of the brain. He was managed conservatively. Later he developed meningitis without a brain abscess and was prescribed antibiotics for 6 weeks. He enjoyed a good neurological recovery. This case illustrates that clinician should have a high index of suspicion for penetrating intracranial injury due to a nasally inserted foreign body, even though it had already been removed. In such cases left nose and then pulled it out in November 2012. He was subsequently assessed by an ear, nose and throat surgeon. No nasal foreign body was seen and there was no epistaxis. Brain computed tomography (CT) 6 hours after the injury showed a trace amount of haemorrhage over the right gyrus rectus and a small amount of pneumocephalus over the right anterior fossa (Fig 1), and hence the neurosurgical unit was consulted. Six hours after the incident his vital signs were stable and he was afebrile; his Glasgow Coma Scale score was E4M6V4. His speech appeared confused, as if in a premorbid state. There was no neurological deficit, and no cerebrospinal fluid (CSF) rhinorrhoea upon stress testing. Contrast magnetic resonance imaging (MRI) of the brain was performed on the next day, which showed a long haemorrhagic tract extending from right paramidline anterior skull base, coursing postero-superiorly across medial right frontal lobe, closely adjacent to the right frontal horn, and ending at the vertex region (Fig 2), and a trace of intraventricular haemorrhage. On the same day he developed fever. Lumbar puncture yielded turbid CSF, with the presence of Gram-positive cocci, as well as low CSF glucose and high CSF protein concentrations. Conservative management was adopted. On an empirical basis, intravenous ceftriaxone, vancomycin, and metronidazole were prescribed. Prophylactic anticonvulsant therapy (phenytoin) was also given. The CSF culture grew Staphylococcus aureus and Citrobacter koseri. The antibiotic regimen was switched to intravenous ceftriaxone and oral metronidazole. The patient's recovery was excellent, as reflected by normalisation of body temperature and inflammatory markers. On

Bacterial meningitis: a rare complication of an unrecognised nasal foreign body in a child

“…Single case reports of bacterial meningitis secondary to penetrating nasal foreign bodies can be found in the literature; however, to the best of our knowledge, this is the only reported case where an unrecognised non-penetrating nasal foreign body caused this serious complication 5 6…”

Incidentally Diagnosed Intracranial Sewing Needle in an Adult Patient: A Failed Infanticide Attempt?

“…Cranial CT is a method of scanning that is preferred for diagnosing the existence of a radio-opaque foreign body located in the brain [5]. In contrast-enhanced CT imaging, the relation between the foreign body and the vascular structure may be shown [6].…”

Neuroimaging in adult penetrating brain injury: a guide for radiographers

“…This can be better achieved using gadolinium-enhanced MRI, which can include a T2-weighted gradient-recalled echo (GRE) sequence 2,4. Cases have been reported where wooden foreign bodies may have been missed if contrast-enhanced MRI was not performed, as shown in Figure2 38,39…”

“…2,4 Cases have been reported where wooden foreign bodies may have been missed if contrast-enhanced MRI was not performed, as shown in Figure 2. 38,39 However, both CT and conventional MRI often lack the ability to determine long-term outcomes for patients and may miss subtle brain injuries, hence a number of alternative MR sequences are becoming increasingly useful in PBI imaging, with the benefit of increased sensitivity or faster scan times. 40 These alternatives each have their advantages and disadvantages but generally provide better evaluation of brain structures, in particular white matter.…”