Case Reports and Reviews: Open Access

Background: Penetrating traumatic brain injury (pTBI) is an uncommon but potentially devastating form of traumatic brain injury characterized by violation of the skull and intracranial structures by a foreign object. Although most penetrating brain injuries described in the literature are caused by firearms or other missiles, non-missile penetrating injuries caused by sharp or heavy objects such as knives, axes, and other tools are rare. These injuries may produce extensive skull disruption, cerebral laceration, vascular injury, contamination, and secondary brain damage. Prompt resuscitation, appropriate neuroimaging, controlled removal of the penetrating object, surgical debridement, hemostasis, and dural reconstruction are central components of management.
Case Presentation: An 18-year-old male presented to the Emergency Department approximately 10 hours after sustaining a severe penetrating craniocerebral injury caused by an axe. On arrival, his Glasgow Coma Scale (GCS) score was 7/15. Both pupils were 3 mm, equal, and reactive to light. He was immediately endotracheally intubated for airway protection and ventilatory support. Cranial computed tomography demonstrated a retained metallic axe blade traversing the cranial vault from the left temporal region toward the right parieto-temporal region, with extensive comminuted and displaced calvarial fractures and a large underlying cerebral parenchymal defect and traumatic laceration. Metallic streak artifact from the retained blade substantially limited evaluation of the remaining intracranial structures. The patient underwent emergency neurosurgical intervention, including controlled removal of the axe blade, debridement of devitalized cerebral tissue, hemostasis, dural reconstruction, and management of the extensive cranial defect. Postoperatively, he remained critically ill and mechanically ventilated. On the second postoperative day, his GCS was 6/15 and both pupils were 4 mm with sluggish bilateral light responses. Despite intensive postoperative management, his neurological condition remained poor. He subsequently deteriorated and died on postoperative day 11.
Conclusion: This case demonstrates the catastrophic nature of severe non-missile penetrating craniocerebral trauma caused by an axe. Extensive calvarial destruction, major cerebral laceration, retained intracranial foreign material, and profound neurological impairment at presentation were associated with an unfavorable outcome despite urgent surgical management. Early recognition, airway stabilization, careful imaging, controlled extraction of the penetrating object, appropriate debridement, hemostatic control, and dural reconstruction remain important principles in the management of these rare injuries.

Keywords: Penetrating brain injury; Axe injury; Non-missile trauma; Retained foreign body; Cerebral laceration; Neurosurgery; Case report.