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11/59. Penetrating injury of the brain by the burr of a high-speed air drill during craniotomy: case report.

    The most critical complications of craniotomy are caused by the plunging of a skull drill, and there have been no reports of penetrating brain injury caused by the broken burr of a high-speed air drill during craniotomy. Left orbitofrontal craniotomy was performed to clip two aneurysms in a 44 year old man. While cutting the lateral orbital rim with the burr of an Ultra Power surgical drill system, the burr broke off and penetrated the frontal lobe down to the falx cerebri. There were no discernible contusion or haemorrhage in the brain. The accident occurred because a long burr for the angled attachment of a Surgairtome was erroneously attached to the angled attachment of an UltraPower surgical drill. The mismatch between the steel strength and torque of the two burrs designed for different drill systems seemed responsible for breakage of the burr. We learned a valuable lesson from this failure: that all new instruments, including high-speed air drills, must be studied carefully so that staff become thoroughly familiar with their handling.
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12/59. Saddam's revenge: a post-gulf war casualty.

    Artillery weapons are designed to inflict death and destruction by way of fragmentary and blast injuries. As pieces of modern machinery, they are also capable of causing serious injury by their very complex nature. The authors present a case analysis of an artillery piece that caused a projectile death without a shell.
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13/59. Long-term effects of bilateral frontal brain lesion: 60 years after injury with an iron bar.

    BACKGROUND: Harlow's report of the case of Phineas P. Gage in 1848 was one of the earliest description of the personality and behavioral changes following frontal lobe damage. Since Harlow's articles, a few more case reports of frontal lobe damage have been published. As standard neuropsychological and neurologic evaluations may reveal subtle defects, case reports have been particularly useful in characterizing the behavioral changes that follow frontal lobe damage. OBJECTIVE: To describe the long-term outcome of an 81-year-old patient who sustained a severe frontal brain lesion 60 years ago caused by the passage of an iron spike through his head. RESULTS: The patient has bilateral damage affecting the orbital and dorsolateral frontal regions. He displays many of the typical frontal behavioral disturbances described in the literature. His conduct is characterized by dependence on others, cheerfulness, planning difficulties, problems establishing realistic goals, lack of drive, and difficulties in initiating, continuing, and finishing activities. Although gross cognitive functioning is intact, neuropsychological deficits are present in the executive functioning, memory, and visuoconstructive domains. CONCLUSIONS: In contrast with the antisocial conduct pattern usually associated with frontal damage in the literature, this case suggests that large frontal lesions can produce behavioral and personality changes that are compatible with stable functioning in family, professional, and social settings. In addition to the localization of the lesion, many other factors should be considered in the long-term prognosis of frontal brain injured patients.
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14/59. Usefulness of gradient-echo T2*-weighted MR imaging in evaluation of transorbital penetrating cerebral injury.

    Transorbital penetrating cerebral injury can cause severe morbidity if not identified and treated. After the removal of the object and without the clinical information, even the chance of suspicion of penetrating cerebral injury might be missed in the first investigation. We report a case of transorbital penetrating cerebral injury caused by a metal rod and diagnosed by MRI including gradient-echo T2*-weighted imaging.
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15/59. Intracranial penetrating injury associated with an intraoperative epidural haematoma caused by a spring-laden pin of a multipoise headrest.

    Lack of an intermediary piece that should have been placed between the pin and spring resulted in skull penetration due to a rapid waste in the spring's compensatory capacity. Checking integrity of internal pieces should be performed regularly. Designing intermediary piece and spring as a single piece might increase safety.
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16/59. air-gun pellet injuries to the head and neck in children.

    air-gun pellet injuries to the head and neck are seldom reported in pediatric practice, although they typically occur in children. The adult skeleton stops these projectiles, but they can easily transverse the thin bones of children. If unnoticed, these apparently trivial injuries may have catastrophic consequences. We report three children who sustained a central nervous system injury resulting from a shot by a compressed-air gun. The true nature and extent of the lesion in two infants was established only by neuroradiological investigations. We also briefly review the management and prevention of this type of injury.
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17/59. Difficult endotracheal intubation as a result of penetrating cranio-facial injury by an arrow.

    Penetrating injury of the face and airway may make endotracheal intubation difficult or impossible. We report the case of a patient who attempted to commit suicide with a crossbow. Surgery under general anesthesia was required to remove the arrow. The oral intubation route was impossible, and a fiberoptic nasal intubation under local anesthesia was performed. IMPLICATIONS:We report a case of a 42-yr-old patient who underwent surgery for a penetrating craniofacial injury caused by an arrow. Because of the median vertical trajectory of the arrow (from the chin to the frontal skull), only the right nasal approach was accessible for endotracheal intubation. Fiberoptic nasal intubation and securing the airway under local anesthesia are described.
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18/59. Ossification of autologous pericranium used in duraplasty. Case report.

    Pericranium is frequently used in duraplasty and is considered superior to the many other alternatives because of its easy availability and because it offers a watertight dural closure while minimizing the problems of adhesion, infection, and rejection. Although the osteogenic potential of all periosteal tissues is recognized, a review of the literature did not reveal a reported case of osseous formation following use of pericranium for duraplasty. The authors report the case of a 17-year-old man who presented with a self-inflicted gunshot wound to the head. He was obtunded, but moving all extremities purposefully. Computerized tomography scanning demonstrated bifrontal injury. A bicoronal craniotomy with debridement was performed on an emergency basis, with vascularized pericranium used for a duraplasty. Follow-up cranioplasty demonstrated significant ossification of the pericranium 5 months after the original surgery. Pericranium is an attractive material for duraplasty; however, its osteogenic potential may interfere with future cranioplasty and cosmesis. This may be especially relevant in young persons.
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19/59. Perseveration of traumatic re-experiencing in PTSD; a cautionary note regarding exposure based psychological treatments for PTSD when head injury and dysexecutive impairment are also present.

    This case study describes the psychological treatment of a man with co-existing PTSD, head injury and mild dysexecutive impairment. It describes the detrimental consequences when the re-experiencing of a traumatic event appears to have become a perseverated response. In this case, the perseveration meant that the most distressing part of the traumatic event became unavoidable and lead to it being continuously re-experienced without remittance over a very prolonged period (7-10 days). This type of re-experiencing has not been reported before. It potentially has significant implications for the treatment of PTSD in such circumstances. It may also have implications for behavioural models of PTSD in general.
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20/59. Cranial penetration injury caused by a reinforcing steel bar.

    One case of cranial penetration injury was reported caused by a reinforcing steel bar. The patient was well cured and discharged. After six years of follow-up, the patient had good functional recovery.
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