Pediatric Traumatic Brain Injury: Surgical And Medical Management Following A Delayed Presentation Of A Penetrating Tree Branch Injury.

Abstract

Background: A pediatric patient presents several days following a traumatic fall from a tree resulting in a penetrating brain injury. Pediatric injury after falling from a tree is not uncommon in rural Africa but typically presents with extremity or pelvis fracture. This case emphasizes the value of neurosurgical expertise in providing adequate surgical and medical management of this complex and unusual injury. Case Description: A 9-year-old boy presented with a mild neck stiffness, headaches, mild photophobia and fever for one week. Patient reports falling from a tree and landing on a sharp piece of wood one week previously. He also presented with CSF rhinorrhea. He underwent CT of the brain with and without contrast which showed a foreign body containing air in the anterior cranial fossa extending into the left frontal lobe with fracture of the left cribriform plate. He was started on intravenous broad-spectrum antibiotics and taken to the operating room for transnasal endoscopic extraction of the foreign body with autologous duroplasty. Patient had an improving post-operative course for the first few days, but headaches returned. A repeat head CT with contrast revealed a large left frontal abscess. He was subsequently taken in for a left supraorbital craniotomy with drainage of the abscess and repeat duroplasty. He completed a six-week course of intravenous broad-spectrum antibiotics. A repeat scan revealed benign post inflammatory changes without recurrent abscess. Discussion: Pediatric injury as a result from falling from a tree is not uncommon in rural Africa. However, the injury is usually an extremity or pelvic fracture. Penetrating traumatic brain injury with a wood fragment is uncommon and unexpected, and as a result was not detected by the family until several days after the injury, resulting in a delayed presentation. In this case, direct inoculation of a contaminated foreign body (wood and debris) lead to the delayed formation of an abscess despite prophylactic antibiotic therapy and removal of the wood fragment. Wood is known to harbor a myriad of microorganisms due to its porosity. Conclusion: Penetrating traumatic brain injury from wood is an uncommon complication from a fall from tree, with a challenging management in this case due to delayed presentation and abscess after surgical intervention. There is value in exploring appropriate antibiotic regimes in penetrating traumatic brain injury especially in rare cases such as wood penetration.