Brain Injury

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

Impalement brain injury from steel rod causing

injury to jugular bulb: Case report and review of
the literature
Andrew J. Grossbach, Taylor J. Abel, Janel Smietana, Nader Dahdaleh, Meryl
A. Severson III & David Hasan
To cite this article: Andrew J. Grossbach, Taylor J. Abel, Janel Smietana, Nader Dahdaleh, Meryl
A. 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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Date: 28 September 2015, At: 00:51

http://informahealthcare.com/bij
ISSN: 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
Downloaded by [Complexo Hospitalario Universitario A Coruna] at 00:51 28 September 2015

Department 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

Keywords

Background: The management of impalement penetrating brain injuries (IPBI) from non-missile
objects is extremely challenging, especially when vascular structures are involved. Cerebral
angiography is a crucial tool in initial evaluation to assess for vascular injury as standard
non-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 in
injury 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.

Angiogram, rebar, traumatic brain injury,

vascular

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 at 4100 m s 1 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 report
History 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
Correspondence: Andrew J. Grossbach, MD, Department of
Neurosurgery, University of Iowa Hospitals and Clinics, 200 Hawkins
Drive, Iowa City, IA, 52245, USA. Tel: 206-679-2197. E-mail: andrewgrossbach@uiowa.edu

History
Received 6 November 2013
Revised 28 January 2014
Accepted 6 June 2014
Published online 14 July 2014

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 neck
and 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 craniotomy, given the high concern for injury to the cerebral

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A. J. Grossbach et al.

Brain Inj, 2014; 28(12): 16171621

Figure 1. (A) Pre-operative photograph demonstrating entry site and trajectory of rebar. (B) Lateral XR showing the relationship of the rebar to the
cranium. 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.

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, extravasation of the contrast dye was seen from the left jugular bulb
(Figure 4A). A SynchroSoft microwire and SL10 microcatheter 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 was
performed 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

Penetrating brain injury from rebar

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DOI: 10.3109/02699052.2014.934284

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Figure 3. Cerebral angiogram demonstrating position of rebar (arrows in (A) and (B)) in relation to the cerebral vasculature. (A) AP left internal carotid
artery 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 arrows
depict rebar). (D) Coil and onyx embolization of the left sigmoid sinus and jugular bulb (arrows).

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 all
four 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 complication. One year after injury, the patient underwent formal
neuropsychological evaluation that demonstrated deficits in
attention, complex organization, verbal memory and processing speed. On the most recent follow-up, 18 months postinjury, 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 taken
into 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, respiratory distress and coagulopathy, all of which have been
associated with increased mortality in PBI patients [3, 5].
Additionally, PBI management can be complicated by infection, cerebrospinal fluid leak and cerebral vasospasm [9].
Pre-hospital care should focus on standard Advanced
Trauma Life Support (ATLS) principles, the ABCs,

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A. J. Grossbach et al.

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 identify
penetrating objects made of wood [1, 7]; however, it is
contraindicated when dealing with potentially ferromagnetic
objects. Pre-operative cerebral angiography should be performed 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 CTangiography (CTA) or MR-angiography (MRA) has been
increasing; however, conventional cerebral angiography
remains 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 recommended 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 ICP
monitoring 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,

Brain Inj, 2014; 28(12): 16171621

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 complications 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 complication of PBI [8, 19]. PTE after penetrating brain injury is
more 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 posttraumatic 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 recommended to prevent late post-traumatic seizures while anticonvulsant 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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