Case Report
The patient was 24 years old man. When he was working on bend down position at the construction site, a reinforcing steel bar fall down from 12 meters high and the bar penetrated his safe helmet and penetrated from occipital to left frontal head and 1.5 meters long outside his head. The steel bar was 6 meters in length and 12 millimeters in diameter. After the outside part of the bar was cut off, the man was transported to our emergency room in 15 minutes. The blood pressure was 13/9kpa, the heart rate was 90 p/min and the breath rate was 20 t/min. The patient was in an obscure state. The pupils of both sides were dilated in the same size. The light response existed. Weakness of right limb was found in grade III. There were no abnormal signs in the heart and the lung. The deep and superficial reflexes of right limb disappeared and those of the left were kept. The bar went in his head 3cm above the occipital tubercle and 1cm left to the midline. It came out 1cm left to the midline and 2cm above the eyebrow. The wound holes were bleeding. The X-ray of skull indicated that the bar was in the left frontal, parietal and occipital lobe.
The diagnose was severe brain trauma and cranial penetration injury.
An emergency operation was given. After general anesthesia, the expressive parts of the reinforcing bar outside the skull were cut shorter as possible. An incision of S-shaped was made between the two wound holes. The craniotomy was done 1cm left the midline with the bony window of 4cm in width and 20cm in length. After dehydrate agent was given, the dura mater was incised. Three incisions on the non-function cortical areas were made 1.5 cm to the sagittal sinus and deep to the bar from anterior to posterior. The debris of the hair and the skull and the dead brain tissues and blood clot were taken out from the wound channel, well hemostatics were wade. The wound channel was repeatedly washed with nature saline with gentamycin. The brain pulsation was well recovered. The drainage veins were not damaged. Scalp membrane was taken to repair the dura mater for releasing tension. Blood transfusion of 400ml was given during the operation. The man had aphasia and spastic hemiplegia in the right limb postoperatively. Large amounts of dehydrate agent, hormone and antibiotics were applied. Cerebral spinal fluid examination showed 3/mm in white blood cell and 250/mm in red blood cell 4 days after operation. No bacterium was found in CSF culture, the brain CT scanning showed the edema in the operated area. After well rehabilitation, the patient was discharged 30 day later. The man could walk in balance steps and speak some simple words. three months follow-up showed he could talk as usual. six years follow-up showed the strength and tension of his right limb recovered.
The cranial penetration caused by the reinforcing steel bar had not ever been reported. From this case we suppose the important thoroughly wound cleaning and well hemostatics . Watertight closure of dura mater may decrease the possibility of infection. During the operation well protection of the function cortex and avoidance of drainage veins damage were also essential for better outcome. |
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