Intentional Self-Inflicted Transcranial Screwdriver Injury: A Case Report

Transcranial screwdriver injuries are rare forms of low-velocity penetrating cranial trauma that are most often described after interpersonal violence and may result in neurologic impairment or death. These injuries can be difficult to recognize when external wounds are small and may be incompletely characterized on initial imaging, particularly when retained metal produces artifact. Plain radiography and computed tomography (CT) are useful for defining foreign-body trajectory and guiding operative planning, but the full severity of injury may only become apparent through serial imaging and surgical exploration. A 61-year-old male patient with schizophrenia, methamphetamine use, and prior self-inflicted injuries sustained a self-inflicted penetrating right-sided cranial injury after using a rock to drive a screwdriver into his skull. He presented with the screwdriver in place and dense left hemiplegia. Initial skull radiography demonstrated a retained transcalvarial metallic foreign body and an additional metallic density raising concern for a detached screwdriver tip. Admission noncontrast CT clarified that the second density represented a retained bullet fragment from prior injury and demonstrated a penetrating right frontoparietal foreign body with small foci of subarachnoid hemorrhage and marked streak artifact. Emergent right craniotomy with foreign-body removal revealed additional epidural and subdural hematomas not fully appreciated on initial CT and confirmed a tract extending through the right frontal motor region, across the falx, and into the left parietal region. Serial postoperative CT and MRI demonstrated the expected evolution of the injury without a discrete abscess. His hemiplegia improved during a prolonged hospital stay, with left-sided strength improving to 3/5 at discharge. Although screwdriver-related cranial penetration has been described previously, this case is notable for its intentional self-inflicted mechanism, artifact-limited imaging, operative clarification of injury severity, multidisciplinary management, and neurologic recovery despite severe initial deficits. This case highlights the value of staged imaging, controlled operative exploration, and postoperative surveillance in low-velocity penetrating cranial trauma, particularly when retained metallic artifact limits complete radiographic characterization.