PEDIATRIC REHABILITATION, 1997, VOL. 1, NO. 3, 191-193 CASE STUDY Transorbital penetrating brain injury caused by a toy arrow: a case report Dev Neurorehabil Downloaded from informahealthcare.com by Universiteit Twente on 11/18/14 For personal use only. E. PAUCIC-KIRINCIC, I. PRPIC, M. GAZDIK, M. K R I ~ , B. VOJNIKOVIC and V. GOLUBOVIC Accepted for publication: April 1997 Keywords penetrating brain injury, arrow, children, orbital injury. Summary A case of a 9-year-old boy with a transorbital toy-arrow injury to the brain is presented. At admission he was in coma (Glasgow Coma Scale of 6) with right hemiparesis and had a completely prolapsed left eye. Computerized tomography revealed intracranial haemorrhage and frature of the orbital wall, which were treated conservatively. His left eye was enucleated due to massive injury. At the 6-month check-up the boy still show neurological signs of latent right hemiparesis. Disturbances, mostly cognitive, were noted on his psychological tests. A survey of the literature reveals no report of this nature in the paediatric age group. The necessity of continuous monitoring of new environmental risks as they occur, and the requirement for the prevention of recreational brain injuries in children, is stressed. Introduction Certain patterns and regularities in childhood injuries are well known; boys are more affected than girls, head trauma is common and brain injuries are the most common cause of trauma deaths [1,2]. On the other hand, numerous mechanisms of injuries in children are unique; e.g. child abuse, recreational or sport injuries [3,4]. Excluding perforating ocular trauma, penetrating injuries are rare in children [5,6]. Paediatric penetrating brain injuries are usually reported among adolescents. The majority of these injuries are related to gunshot wounds [7]. There are few Authors: E. PauEiC-KirinEiC (author for correspondence), I. PrpiC, M. Gazdik, M. Krii, Department of Pediatrics Children’s Hospital Kantrida, Istarska 43, 51 000 Rijeka, Croatia, B. VojnikoviC, Department of Ophthamology, University Hospital Centre, Rijeka, Croatia, V. GoluboviC, Intensive Care Unit, Istarska, 43/3, 51 000 Rijeka, Croatia. data on the incidence of non-gunshot penetrating head trauma, although sporadic, bizarre injures have been reported in adults [8,9]. Review of the literature (Medline 198C1996) revealed no report of head trauma caused by transorbital arrow penetration occurring in the paediatric age group. We describe a case of severe brain injury with consecutive hemiparesis, psychological disturbances and ocular loss secondary to transorbital toy-arrow penetration in a 9-year-old boy. Case report Two friends, 9 and 17 years old, were playing outdoors unsupervised, with a new birthday present - a bow and arrow set (Figure 1). The younger one stood a few steps aside and back from the older boy, who was propelling an arrow. The wooden arrow broke into three parts (Figure 2), and the front part, a steel-coated arrowhead, became a projectile and struck the 9-yearold boy in the left eye. The boy instinctively managed to pull out the arrow from his eye before he lost consciousness. Immediately after the accident he was transported Figure 1 A toy bow and arrow set, with broken arrow. 1363-8491/97 $12.00 0 1997 Taylor & Francis Ltd Dev Neurorehabil Downloaded from informahealthcare.com by Universiteit Twente on 11/18/14 For personal use only. E. PauC"-KirinCii et al. Figure 2 Three parts of the broken arrow. Note the Front part of the arrow (in the middle) with steel-coated arrowhead. to the Emergency Department of the University Hospital, Rijeka, Croatia. At presentation the patient had a Glasgow Coma Scale (GCS) score of 6. His blood pressure was 110/70 mmHg, pulse rate 70/min and he was breathing regularly. Ocular examination revealed left periorbital swelling with haematoma of both eyelids and completely prolapsed eye. Neurological examination revealed right hemiparesis. A computerized tomography (CT) scan demonstrated disorganized left bulbus with peribulbar and intrabulbar collection of blood, and a fracture of the top of the posterolateral orbital wall. There was haemorrhage into the brain, particularly along the left side of the suprasellar region and basal cisterns, and collection of blood in the occipital horn of the left lateral ventricle (Figure 3). The boy was admitted to the intensive-care unit and treated conservatively. Medication included corticosteroids, antibiotics, antacid with total parenteral nutrition and fluid restriction. During the next few days his mental status ameliorated, as well as his general appearance. Routine blood analyses were normal. The right hemiparesis persisted. He was under continuous ophthalmological surveillance, and on the fourth day after the accident enucleation of the left eye was performed. The postoperative course was uncomplicated, so the boy was transferred to the paediatric intensive-care unit, and after that to the neurological division of the paediatric department. The control brain CT, electroencephalogram, and right side visual evoked potentials were normal. He 192 Figure 3 Brain CT of injured boy. Note the disorganized left bulbus (top left-hand side), fracture of the orbital wall (top right-hand side) and intracranial haemorrhage. was enrolled in an intensive rehabilitation programme, due to right hemiparesis, and made considerable progress. On post-injury day 20 he walked alone, and showed almost complete use of his right hand. He became familiar with the eye prosthesis. At the last check-up, 6 months after the accident, neurological examination revealed signs of latent right hemiparesis (dysmetria, right-sided hyper-reflexia, clonus of the right feet, positive Babinski's sign). Impaired cognitive functions were noted at psychological testing. His mother claimed there were school problems which he did not usually have. Discussion Stab or penetrating slow-energy missile brain injuries are exceptional in the paediatric age group. Most of these injuries are incidental. Neal and Downing reported a case of a 6-year-old girl who had been struck with an arrowhead in the left temple [lo]. The boy in our study suffered transorbital penetrating brain injury with a toy arrow. To our knowledge this is the first description of the brain injury caused by a hazardous toy in childhood. O'Neil et al. described a similar situation in a 25-yearold man, caused by a hunting arrow [1 11. Upon admission the patient was in coma (GCS 6) with noted right hemiparesis. Hemiparesis withdrew Dev Neurorehabil Downloaded from informahealthcare.com by Universiteit Twente on 11/18/14 For personal use only. Brain injury with a toy arrow considerably after the vigorous rehabilitation programme. At &month check up the detailed neurological examination showed persisting latent right hemiparesis. Children with the same GCS score may have different outcomes, so injury severity and type of lesion are very important factors in determining outcome [12,131. Binocular visual loss remains the main handicap in this boy. Observing the incidence of child abuse, violence, sport and recreational injuries, a continued increase is noted, particularly in some geographical areas [14]. Brain injuries, despite various reports, account for up to 94% of all trauma deaths in children [14]. Effective rapidity of response in dealing with new types of childhood accidents as they arise has not been sufficiently developed to date. New environmental risks occur as the results of changed lifestyle, of the rich consumer society, and cultural changes superimposed on children living in societies hitherto in danger safety equilibrium. Unfortunately, during recent years we have gained experience with penetrating brain injuries [ 151. Furthermore, we witnessed many disturbed children, with long-lasting consequences [16,171. Children injured during recreation should be a subject of topical concern. The majority of such injuries can be prevented, and this should always be borne in mind. Clinical paediatricians are in a particular position to acknowledge the cost of preventable childhood head trauma, which remains unchecked, and can monitor accident trends and implement preventive strategies. Because of the extent of the problem and, more importantly, the long-term psychomotor consequences on development, everyone who works with children has an inevitable role in the prevention of such accidents in the future. References 1. RIVARA,F. P. and BROWNSTEIN, D.: Injury control. In R. E. Behrman, R. M. Kliegman and A. M. Arvin (editors) Nelson Textbook of Pediatrics (W. B. Saunders, Philadelphia), pp. 226231, 1996. M. S.: Update on pediatric trauma care. Current Opinion 2. WRIGHT, in Pediatrics, 7: 292-296, 1995. A., HAREL, Y. et at.: Sports and recreation 3. BUUR,P. E., TRUMBLE, injuries in US children and adolescents. Archives of Pediatrics & Adolescent Medicine, 149 1009-1016, 1995. 4. BAKER, S. P., FOWLER, C., LI, G. et al.: Head injuries incurred by children and young adults during informal recreation. American Journal of Public Health, 84: 649452, 1994. 5. ALFARO,D. V., CHAUDHRY, N. A., WALONKER, A. F. et al.: Penetrating eye injuries in young children. Retina, 14 201-205, 1994. 6. LUFF,A. J., HODGKINS,P. R., BAXTER, R. J. et al.: Aetiology of perforating eye injury. Archives of Disease in Childhood, 68: 682683, 1993. L., THOMPSON, N. M., MINER,M. E. et al.: Gunshot I . EWING-CQBBS, wounds to the brain in children and adolescents: age and neurobehavioral development. Neurosurgery, 35:225-233, 1994. 8. SMRKOW,V., BALAZIC, J. and PRINCIC, J.: Intracranial injuries by a screwdriver. Forensic Science International, 76: 21 1-216, 1995. H., BOYAR,B. et al.: The nonsurgical 9. ILDAN,F., BAGDATOGLU, management of a penetrating orbitocranial injury reaching the brain stem: case report. Journal of Trauma, 36: 116118, 1994. 10. NEAL,G. and DOWNING, E. F.: Clostridial meningitis as a result of craniocerebral arrow injury. Journal of Trauma, 40:47&480,1996. 11. O’NEILL, 0. R., GILLILAND, G., DELASHAW, J. B. et al.: Transorbital penetrating head injury with a hunting arrow: case report. Surgical Neurology, 42: 494497, 1994. 12. PRPIC,I., GAZDIK,M. and ZEIDLER, F.: Early outcome predictors in children with head trauma. Lije6nic’ki vesnik, 115: 224-229, 1993. 13. GREENSPAN, A. I.: Functional recovery following head injury among children. Current Problems in Pediatrics, 2 6 17G177, 1996. 14. BERNEY, J., FAVIER,J. and FROIDEVAOX, A. C.: Pediatric head trauma: influence of age and sex. I: Epidemiology. Children’s Nervous System, 10: 509-516, 1994. 15. ESKINJA, F. M., NEGOVETIC, L. et al.: Penetrating N., STANCIC, ballistic head injuries in the current Croatian war. Abstract, 7th international symposium of weapons traumatology and wound ballistics. Russia, St Petersburg, September 1994. 16. DOROTKA, V.: Psychological problems in children at war. Pediatria Croatica, 37 (Suppl. 1): 11, 1993. 17. PALLE-ROTAR, D.: Posttraumatic syndrome disorder in children and adolescents. Pediatria Croatica, 37 (Suppl. 1): 19, 1993. 193