AJR 2004; 182:1551-1553
© American Roentgen Ray Society
"William Tell" Injury: MDCT of an Arrow Through the Head
Katrijn de Jongh1,
Dinska Dohmen2,
Rodrigo Salgado1,
Özkan Özsarlak1,
Johan W. M. Van Goethem1,
Luc Beaucourt2,
Philippe G. Jorens3,
Tony W. Van Havenbergh4,
Arthur M. De Schepper1 and
Paul M. Parizel1
1 Department of Radiology, University Hospital Antwerp, Wilrijkstraat 10, Edegem
2650, Belgium.
2 Department of Emergency Medicine, University Hospital Antwerp, Edegem 2650,
Belgium.
3 Department of Intensive Care Medicine, University Hospital Antwerp, Edegem
2650, Belgium.
4 Department of Neurosurgery, University Hospital Antwerp, Edegem 2650,
Belgium.
Received June 16, 2003;
accepted after revision August 18, 2003.
Address correspondence to K. de Jongh
(katrijn.de.jongh{at}uza.be).
Introduction
Crossbow injuries to the head are extremely rare
[1–8].
Most documented cases are suicide attempts, often with fatal outcomes. We
describe a 22-year-old man with a self-inflicted crossbow head injury who
survived. The position of the arrow and the associated bone and soft-tissue
abnormalities are shown using a 16-MDCT scanner and postprocessing
reformations. We also present an overview of all reported cases of crossbow
injuries to the brain.
Case Report
A 22-year-old man attempted to commit suicide by shooting an aluminum
crossbow arrow through his mouth. The arrow entered the skull through the oral
cavity and exited the skull near the vertex
(Fig. 1A). When the mobile
emergency medical team arrived, the patient was fully conscious but was blind
in his right eye and complained of a left-sided hemiparesis. The patient was
intubated and ventilated, and his head was immobilized. Initial treatment
consisted of IV administration of corticosteroids and analgetics. Sixteen-MDCT
scans were obtained when the patient arrived at the hospital (Figs.
1B and
1D).
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Fig. 1A. —22-year-old man with crossbow injury of head. Left lateral
photograph taken at patient's arrival in emergency department shows that
crossbow arrow enters through mouth and exits skull near vertex. Patient has
been intubated and ventilated, and his head has been immobilized.
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Fig. 1B. —22-year-old man with crossbow injury of head. Axial MDCT scan
obtained through sellar region shows aluminum arrow (black arrow) in
right optic canal. White arrow shows proximal part of right optic nerve near
optic chiasm.
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Axial CT scans documented the trajectory of the arrow. It penetrated the
right ethmoidal and sphenoid sinuses, passed through the right optic canal,
entered the cranial cavity immediately lateral to the anterior cerebral
arteries, continued vertically through the right periventricular area and
right frontal deep white matter, and finally exited through the frontal skull
near the vertex. The right-sided blindness was presumably caused by injury to
the optic nerve, and the leftsided hemiparesis was caused by right hemispheric
parenchymal injury. Multiplanar CT reformatting was performed in the sagittal
plane to document the entire trajectory of the hollow arrow shaft. The
relationship of the arrow to the skull base and cranial vault was documented
using a volume-rendering technique with virtual removal of the occipital
bone.
The patient immediately underwent surgery. The arrowhead was removed, and
the shaft of the missile was extracted through the mouth. An external
ventricular drain was inserted.
Postoperatively, the patient was transferred to the neurosurgical ICU. He
developed sepsis and was treated with broad-spectrum antibiotics for 3 weeks.
Intracranial hypertension was not observed. On postoperative day 15, the
patient underwent a second surgical intervention because of a cerebrospinal
fluid leak through the mouth—the arrow tract was partially filled with
autologous fat from the thigh. A follow-up CT scan showed no signs of
cerebritis. CT angiography revealed no evidence of a posttraumatic aneurysm.
The patient recovered amazingly well and was discharged from the neurosurgical
ICU tp the ward on day 20 with a right-sided hemianopsia and slight paresis of
the left leg. On day 31, the patient was discharged from the hospital in
stable condition.
Discussion
Crossbow injuries to the head are rare, with only a handful of cases
reported in the literature
[1–8]
(Table 1). Most documented
cases were self-inflicted injuries that often had fatal outcomes. Compared
with firearm projectiles, aluminum crossbow arrows have a relatively low
velocity (as fast as 58 m/sec), but their sharpness and kinetic energy are
sufficient to cause penetrating skull injuries
[2]. A study of the ballistics
of experimental arrow wounds by Karger et al.
[3] showed that the penetration
mechanism of an arrow is distinct from that of a bullet, because of the
extremely sharp cutting edge of the arrowhead. Because of the sharp force
applied by arrows, injury is limited to the tissues that are directly incised
by the blade of the arrowhead
[3]. From both a patient
treatment and a forensic point of view, the arrow should be left in situ and
stabilized to limit motion in transport until the patient reaches surgery. The
shaft of the arrow in situ appears to exert pressure on the wound, thus
functioning as an incomplete tamponade. Because the tip of the sports arrow is
the same diameter as the shaft, these lesions can be survivable. In our
patient, the trajectory of the crossbow arrow was slightly anterior to the
cavernous sinus and lateral to the anterior cerebral arteries, which prevented
fatal vascular injury. However, the right optic nerve was damaged and caused a
permanent right-sided loss of
vision.
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Fig. 1C. —22-year-old man with crossbow injury of head. Axial MDCT scan
obtained through centrum semiovale shows subarachnoid hemorrhage over right
cerebral hemisphere and parenchymal hemorrhage (arrows) around arrow
shaft.
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MDCT is the technology of choice for acquiring CT data in a complex
neurotrauma case. The increased spatial resolution allows for high-quality 3D
postprocessing [9]. In this
case, volume-rendered and multiplanar reformatted images provided clinically
relevant information for the management of this complex neurotrauma. The
reformatted images clearly depict the anatomic relationships and are much
easier to interpret than hundreds of thin axial images, especially for
nonradiologists. Postprocessing techniques also allow the radiologist and
treating neurosurgeon to explore the findings together interactively on a
workstation and improve their preoperative evaluation of the patient.
In conclusion, crossbow injuries to the head are rare and pose a medical
and surgical challenge. This case illustrates the potential of 3D images as
aids in treating complex penetrating neurotrauma. With postprocessing, the
total acquired scanning volume is represented on a few significant views with
a high degree of accuracy, thereby accentuating the diagnostically relevant
details and facilitating the planning of further therapy.
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Introduction
Case Report
