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A Unique Presentation of an Intracranial Abscess Secondary to Retained Projectile after Debridement with Dural
1Neurosurgery, Ohio Health.
Abstract:
Patients with penetrating head trauma with retained projectiles develop intracranial abscesses as a common complication. The most common presentation is a suddenly worsening headache. The most common pathogen identified is staphylococcus. Outcomes are related to adherence of Matson's tenets. This case study details the presentation of a 19-year-old patient that presented to the neurological surgery clinic without neurologic deficits. Further questioning revealed complaints of intermittent diffuse headaches with bilateral upper extremity shock-like sensation for two weeks. Eight weeks prior he had undergone right craniotomy, after a gunshot wound, for debridement and watertight dural closure. The patient denied symptoms of fever, chills, nausea, vomiting, diarrhea, or seizure. The patient presented with a noncontrast head computed tomography (CT) which revealed retained projectile fragments without clear evidence of abscess. On physical exam, the patient was without any neurological deficit. Laboratory investigation revealed normal white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and negative blood cultures. Head CT with contrast revealed a large intracerebral abscess adjacent to the thalamus. The patient was taken to the operating room for repeat craniotomy with resection of the abscess and removal of the intracranial projectile fragments. Post-operatively, the patient remained neurology intact. Intraoperative cultures were not significant for the growth of any bacteria. In eight weeks time, the patient returned to his employment and his baseline level of activity. This case underscores the importance of thorough assessment in patients with retained intracranial projectiles as well as the need to routine follow-up. The unique presentation of this patient prompted further investigation which elucidated a lesion which correlated to his symptoms although laboratory assessment was without abnormality.
Insights
A penetrating head trauma patient with retained projectile fragments developed an intracranial abscess. Early detection and surgical intervention led to a full recovery, highlighting the importance of thorough assessment.
Area of Science:
- Neurosurgery
- Infectious Disease
Background:
- Penetrating head trauma with retained projectiles is a risk factor for intracranial abscesses.
- Staphylococcus is the most common pathogen identified in these cases.
- Sudden worsening headache is the typical presentation.
Observation:
- A 19-year-old patient with a history of gunshot wound and craniotomy presented with intermittent headaches and shock-like sensations.
- Initial noncontrast head CT showed retained fragments but no clear abscess; physical and laboratory exams were normal.
- Contrast-enhanced head CT revealed a large intracerebral abscess adjacent to the thalamus.
Findings:
- Surgical resection of the abscess and removal of projectile fragments were performed.
- Postoperative cultures were negative, and the patient experienced no neurological deficits.
- The patient returned to his baseline activity level within eight weeks.
Implications:
- This case highlights the necessity of comprehensive evaluation and routine follow-up for patients with retained intracranial projectiles.
- Subtle or atypical presentations of intracranial abscesses can occur despite normal initial investigations.
- Prompt surgical management is crucial for favorable outcomes in brain abscesses secondary to penetrating trauma.
