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Stabbing and Incision Wounds

Cases involving stabbing of the brain by knives or similar weapons (screwdriver, ice pick, chisel, knitting needle, pencil, etc.) are rarely encountered in civilian life (for survey see Unterharnscheidt 1993, p 641 ff). Unlike bullets, such objects strike the head at low velocity. The possibility of complete penetration of the skull depends on the thickness of the bone at the impact site and the magnitude of the locally applied force. Penetration is common in areas of relatively thin bone [e.g., orbit (Fig. 8.1), temporal bone (Fig. 8.2), transnasal drain of the frontobasal bones and, in infants, the fontanel]. A sharp object striking thick bone is more likely to break itself than to penetrate the skull (Fig. 8.3). Although it can be extremely difficult to identify the penetrating object based solely on the hole in the skin, the morphometry of a hole in the skull usually provides exact information regarding both its shape and diameter.

Objects penetrating the brain at low velocity do not create "temporary" cavitation (see below): the brain tissue injury is limited to the damage along the "permanent" cavity. The penetrating object can cause intracranial and/or intracerebral bleeding, however, if it injures a major artery or vein. The risk of this happening persists during neurosurgical re moval of foreign bodies. If blind removal of a knife blade is attempted, it must be determined in advance that the blade is not in the close vicinity of major arteries or veins. Moreover, a typical - but sterile -stab wound is the cavity resulting from such therapeutic interventions as ventricular puncture or ventricular drainage (shunt) in neurosurgical practice. As this surgical intervention occurs "blind," hemorrhage and ventricular tamponade may not always be avoided in individual cases.

Other types of open brain injury may be caused by half-sharp or blunt forces, i.e., by a chisel (Fig. 8.4), by a cut with an axe (Fig. 8.5), by a hammer (Fig. 7.4e; 8.6), by a fall from height (Fig. 8.7a, b) or by a blow caused by the fall of an iron rod wounding the head (Fig. 8.7c, d).

In cases of accidental injury, one (or several) circumscribed depressed fracture(s) are clinically-radiologically conspicuous. Any stab wound of the brain may be complicated by mechanically induced pneumoencephalos and infection (meningitis, encephalitis, abscess) and/or by intracerebral bleeding. Adult victims usually suffer additional injuries, stab wounds for example on the victim's hands or forearms incurred in an attempt to ward off the attack.

Factors significantly predictive of outcome in patients with transcranial stabbing injuries are the Glasgow Coma Scale, the occurrence of intraven-tricular hemorrhage, the type of associated lesions, i.e., intracranial bleeding, vascular abnormalities, or brain abscess, and the number of operations (Nat-hoo et al. 2000). Nathoo et al. (2000) evaluated the clinical data and outcome of 17 cases of transcranial brain stem stab injuries in a cohort of 597 patients with transcranial stab injuries (=2.9%). Knives were the most common instruments of penetration. Cere

Fig. 8.2a-c. Stabbing with a knife at the left temporal bone (a) which injured the basilar artery (b) after laceration of the left temporal lobe (c)

bral angiography identified 4 patients with vascular injury and 10 patients with obstructive hydrocephalus. Thirteen of the 17 patients died of their injuries (=76.5% mortality).

An earlier survey of stab wounds of the brain was made by de Villier (1975). He found a 17% mortality rate, most of the deaths attributable to intracere-bral bleeding. The scalp wound in many cases was small, so small in some cases, as to be overlooked. Most cases involved attempted murder or other type of physical attack. In rare cases, the injury was acci dental or - even more exceptionally -was associated with attempted suicide.

In addition to typical stab wounds, a particular type of injury is that caused by a hatchet, axe blade or sword, i.e., by any sharp-edged but not pointed weapon. Such injuries are characterized by a straight, smooth-bordered wound in the scalp, and a straight sharp perforating defect of the skull along the course of the gash, on the outer table often combined with a narrow depressed fracture on one side or both sides of the sharp defect, bursting fractures starting

Fig. 8.3a-f. Wounding of the head, especially: a the scalp; b the skull; c the dura;

and d, f the brain by incision with a knife. e The biometrically important characteristic cross section of the knife blade is seen in the skull wound

Fig. 8.3a-f. Wounding of the head, especially: a the scalp; b the skull; c the dura;

and d, f the brain by incision with a knife. e The biometrically important characteristic cross section of the knife blade is seen in the skull wound

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