An Unusual Case of a Penetrating Skull-base Injury Caused by a Wild Deer's Antler

Abstract

Injuries relevant to neurosurgeons in central Europe are rarely caused by wild animal attacks, whereas dog bites in urban areas and farm-related attacks from cattle and horses are well-known to cause sometimes fatal head injuries. The authors describe the first case of a perforating frontobasal injury caused by a wild deer's antler. Associated lesions involved the endonasal area and the left orbit. A multidisciplinary approach was used to address all lesions in a one-stage operation resulting in a full recovery of the patient. Apart from the problem of a possible contamination of the head wound, injuries caused by wild animal attacks should be treated the same way as comparable “regular” cases. Adequate coverage of dural and bone defects with autologous material via a bifrontal intradural approach and meticulous debridement of the intracranial wound usually gives good functional and cosmetic results.

Zusammenfassung

Angriffe wilder Tiere sind in Mitteleuropa selten Ursache neurochirurgisch relevanter Schädel-Hirn-Verletzungen, während Verletzungen durch Haus- und Hoftiere (Hunde, Pferde, Rinder) gelegentlich einmal Ursache auch tödlich verlaufender Traumen sein können. Die Autoren beschreiben erstmals den ungewöhnlichen Fall einer Hirschgeweihdurchspießung als Ursache einer ausgedehnten frontobasalen Verletzung. Begleitverletzungen betrafen insbesondere das zentrale Mittelgesicht und die linke Orbita. Die operative Versorgung erfolgte direkt nach Klinikaufnahme interdisziplinär durch die Fachdisziplinen HNO, MKG und Neurochirurgie mit einem exzellenten klinischen Ergebnis nach 12 Monaten. Prinzipiell sollten derartige Verletzungen nach den gleichen chirurgischen Regeln (hier: Deckung über ein intradurales Vorgehen mittels autologem Material) wie „gewöhnliche” Frontobasisverletzungen vorgenommen werden. Besondere Aufmerksamkeit ist bei ausgedehnten Verletzungen auf ein sorgfältiges Wunddebridement und mögliche Frühkomplikationen (Pneumenzephalus, Meningitis, Hydrozephalus) zu richten.

head injury - skull base - animal attack - CSF leak - pneumencephalus

Schädel-Hirn-Trauma - Schädelbasis - Tier - Liquorrhoe - Pneumenzephalus

References

• 1 Abuabara A. A review of facial injuries due to dog bites.  Med Oral Patol Oral Cir Bucal. 2006;  11 E348-350
• 2 Bachert C, Verhaeghe B, Cauwenberge P van, Daele J. Endoscopic endonasal surgery (EES) in skull base repairs and CSF leakage.  Acta Otorhinolaryngol Belg. 2000;  54 179-189
• 3 Bahram R, Burke JE, Lanzi GL. Head and neck injury from a leopard attack: case report and review of the literature.  J Oral Maxillofac Surg. 2004;  62 247-249
• 4 Bayaux M. Clinical case of the month. Penetrating trauma of the thoracic aorta caused by a deer horn.  Rev Med Liege. 2003;  58 666-668
• 5 Bell RB, Dierks EJ, Homer L, Potter BE. Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma.  J Oral Maxillofac Surg. 2004;  62 676-684
• 6 Bjornstig U, Eriksson A, Ornehult L. Injuries caused by animals.  Injury. 1991;  22 295-298
• 7 Brawley BW, Kelly WA. Treatment of basal skull fractures with and without cerebrospinal fluid fistulae.  J Neurosurg. 1967;  26 57-61
• 8 Brisman R, Hughes JE, Mount LA. Cerebrospinal fluid rhinorrhea.  Arch Neurol. 1970;  22 245-252
• 9 Brogan TV, Bratton SL, Dowd MD, Hegenbarth MA. Severe dog bites in children.  Pediatrics. 1995;  96 947-950
• 10 Chibbaro S, Tacconi L. Orbito-cranial injuries caused by penetrating non-missile foreign bodies. Experience with eighteen patients.  Acta Neurochir (Wien). 2006;  148 937-941 , ; discussion 941–932
• 11 Cohle SD, Harlan CW, Harlan G. Fatal big cat attacks.  Am J Forensic Med Pathol. 1990;  11 208-212
• 12 Cooler JO, Kleiman MB, West K, Grosfeld J. Retained spur following a rooster attack.  Pediatrics. 1992;  90 106-108
• 13 Dietz H. Basal craniocerebral injuries.  Langenbecks Arch Chir. 1971;  329 528-543
• 14 Eden K. Traumatic cerebrospinal rhinorrhea: repair of the fistula by a transfrontal intradural operation.  Br J Surg. 1941;  290 299-303
• 15 Gandhi RR, Liebman MA, Stafford BL, Stafford PW. Dog bite injuries in children: a preliminary survey.  Am Surg. 1999;  65 863-864
• 16 Gates RL, Helmkamp JC, Wilson SL, Denning DA, Beaver BL. Deer stand-related trauma in West Virginia: 1994 through 1999.  J Trauma. 2002;  53 705-708
• 17 Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap.  Laryngoscope. 2006;  116 1882-1886
• 18 Healey DL, Kieser JA. Unusual fatal dog attack in Dunedin, New Zealand.  J Forensic Odontostomatol. 2005;  23 51-54
• 19 Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis.  Laryngoscope. 2000;  110 1166-1172
• 20 Hollander JE, Singer AJ, Valentine SM, Shofer FS. Risk factors for infection in patients with traumatic lacerations.  Acad Emerg Med. 2001;  8 716-720
• 21 Huiras CM, Cogbill TH, Strutt PJ. Hunting-related injuries.  Wis Med J. 1990;  89 573-576
• 22 Kadesky KM, Manarey C, Blair GK, Murphy 3rd JJ, Verchere C, Atkinson K. Cougar attacks on children: injury patterns and treatment.  J Pediatr Surg. 1998;  33 863-865
• 23 Ketai LH, Temes RT, Deis JL, Allen NL, Wernly JA. Rodeo related large animal injury: is protective head-gear warranted?.  Injury. 2000;  31 757-759
• 24 Kneafsey B, Condon KC. Severe dog-bite injuries, introducing the concept of pack attack: a literature review and seven case reports.  Injury. 1995;  26 37-41
• 25 Kountakis SE, Chamblee SA, Maillard AA, Stiernberg CM. Animal bites to the head and neck.  Ear Nose Throat J. 1998;  77 216-220
• 26 Kriss TC, Kriss VM. Equine-related neurosurgical trauma: a prospective series of 30 patients.  J Trauma. 1997;  43 97-99
• 27 Loew F, Pertuiset B, Chaumier EE, Jaksche H. Traumatic, spontaneous and postoperative CSF rhinorrhea.  Adv Tech Stand Neurosurg. 1984;  11 169-207
• 28 Manipady S, Menezes RG, Bastia BK. Death by attack from a wild boar.  J Clin Forensic Med. 2006;  13 89-91
• 29 Mason AC, Zabel DD, Manders EK. Occult craniocerebral injuries from dog bites in young children.  Ann Plast Surg. 2000;  45 531-534
• 30 Mendez Gallart R, Gomez Tellado M, Somoza Argibay I, Liras Munoz J, Pais Pineiro E, Vela Nieto D. Dog bite-related injuries treated in a pediatric surgery department: analysis of 654 cases in 10 years.  An Esp Pediatr. 2002;  56 425-429
• 31 Metz M, Kross M, Abt P, Bankey P, Koniaris LG. Tree stand falls: a persistent cause of sports injury.  South Med J. 2004;  97 715-719
• 32 Miller SJ, Copass M, Johansen K, Winn HR. Stroke following Rottweiler attack.  Ann Emerg Med. 1993;  22 262-264
• 33 Miyazaki Y, Hashimoto T, Kanki T, Abe S, Nakamura N. A case of traumatic cerebrospinal fluid rhinorrhea manifested ten years after head injury.  No Shinkei Geka. 1991;  19 375-378
• 34 Norwood S, MacAuley C, Vallina VL, Fernandez LG, MacLarty JW, Goodfried G. Mechanisms and patterns of injuries related to large animals.  J Trauma. 2000;  48 740-744
• 35 Ologe FE, Odebode TO. Cerebrospinal fluid (CSF) rhinorrhoea and/or otorrhoea in patients with head injury.  Afr J Med Med Sci. 2005;  34 173-175
• 36 Park SH, Cho KH, Shin YS, Kim SH, Ahn YH, Cho KG, Yoon SH. Penetrating craniofacial injuries in children with wooden and metal chopsticks.  Pediatr Neurosurg. 2006;  42 138-146
• 37 Piek J. Surgical treatment of complex traumatic frontobasal lesions: personal experience in 74 patients.  Neurosurg Focus. 2000;  9 e2
• 38 Russell T, Cummins BH. Cerebrospinal fluid rhinorrhea 34 years after trauma: a case report and review of the literature.  Neurosurgery. 1984;  15 705-706
• 39 Samii M, Draf W. Surgery of the Skull Base. Berlin: Springer-Verlag 1989: 159-232
• 40 Schiffer J, Sarfaty S, Milo R, Shikar S. CSF fistula and tension pneumatocele 22 years after head injury.  Neurochirurgia (Stuttg). 1988;  31 228-231
• 41 Senior BA, Jafri K, Benninger M. Safety and efficacy of endoscopic repair of CSF leaks and encephaloceles: a survey of the members of the American Rhinologic Society.  Am J Rhinol. 2001;  15 21-25
• 42 Sheard RM, Smith GT. Penetrating eye injury following a snake attack.  Eye. 2003;  17 279-280
• 43 Smith GA, Scherzer DJ, Buckley JW, Haley KJ, Shields BJ. Pediatric farm-related injuries: a series of 96 hospitalized patients.  Clin Pediatr (Phila). 2004;  43 335-342
• 44 Temes RT, White JH, Ketai LH, Deis JL, Pett Jr SB, Osler TM, Wernly JA. Head, face, and neck trauma from large animal injury in New Mexico.  J Trauma. 1997;  43 492-495
• 45 Tiago RS, Salgado DC, Correa JP, Pio MR, Lambert EE. Foreign body in ear, nose and oropharynx: experience from a tertiary hospital.  Rev Bras Otorrinolaringol (Engl Ed). 2006;  72 177-181
• 46 Wright JC. Severe attacks by dogs: characteristics of the dogs, the victims, and the attack settings.  Public Health Rep. 1985;  100 55-61
• 47 Wullstein HL. Has the terminology for the definition of otorhinolaryngology a practical significance?.  Arch Klin Exp Ohren Nasen Kehlkopfheilkd. 1972;  202 549-553

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