TRAUMA

Case Report
Trauma
14(3) 263–269

Phineas Gage revisited: Modern ! The Author(s) 2012

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management of large-calibre DOI: 10.1177/1460408612442462
tra.sagepub.com
penetrating brain injury

BD Mitchell1, BD Fox1, WE Humphries III1, A Jalali1

and S Gopinath1,2

Abstract
We present the case of a 19-year-old man who suffered a penetrating injury to the brain with a large-
calibre steel industrial prybar approximately 1 m long and 2.5 cm wide that was retained in his cranium.
The management of this type of injury is discussed, based on our experience with penetrating brain
injuries with large-calibre retained objects, from initial presentation to surgical removal of the object to
post-operative care. Additionally, given the similarities of the injuries suffered by our patient with those of
Phineas Gage, we discuss the extensive lessons learned in treating this type of large-calibre injury.

Keywords
Low energy transfer, penetrating brain injury, trauma, foreign object

an associated shock wave, as occurs in high-

Introduction
Low-energy transfer (LET) penetrating brain
injuries (PBIs) represent an uncommon subset
of traumatic brain injuries, which usually have
their own unique set of circumstances that
necessitates a flexible approach to management.
Whether intentional or accidental, these injuries
commonly have retained foreign objects in the
brain that are almost never sterile and may or
may not be radio-opaque. Many of the penetrat-
ing objects enter the brain through the orbit
(Balasubramanian et al., 2009; Dunn et al.,
2009; Gutierrez et al., 2008; Jacob et al., 2005;
Mackerle et al., 2009; Orszagh et al., 2009;
Satyarthee et al., 2009). The damage to the
brain from low-energy transfer penetrating
injuries can be substantial, even though these
injuries frequently do not have damage from
energy transfer penetrating brain injury, and
careful planning is critical to maximising the
possibility of a good outcome. In our case,
there was sufficient force of impact for the indus-
trial prybar to enter the cranium above the orbit,
through the frontal bone, exiting from the
contralateral superior frontoparietal region.
1
Department of Neurosurgery, Baylor College of Medicine,
Houston, TX, USA
2
Department of Neurosurgery, Ben Taub General Hospital,
Houston, TX, USA
Corresponding author:
BD Mitchell, Baylor College of Medicine, Department of
Neurosurgery, 1709 Dryden, Suite 750, Houston, TX 77030,
USA.
Email: bartleym@bcm.edu
264
Case presentation
A 19-year-old man fell from a 24-foot ladder at
work while holding a large-calibre steel indus-
trial prybar that measured 1 m in length and
2.5 cm in diameter, with a flared beveled tip. In
an attempt to brace himself from a head-first
fall, he threw the prybar out in front of himself.
As he landed face-down with his arms out-
stretched, the prybar, which had had landed
upright, penetrated through the frontal bone
and entered superior to the left orbit at the
medial eyebrow (Figure 1). It traversed the left
frontal brain, crossed the midline, and exited at
the contralateral superior right parietal area.
The patient was fully awake, alert, and oriented
upon arrival to the emergency room, with min-
imal blood loss from his wound. He had full
strength in all extremities and his cranial
nerves were intact, with the exception of left eye-
brow movement. Vital signs were stable, with no
evidence of hypotension. The prybar protruded
approximately 25 cm out of the exit site and
70 cm out of the entry site, with approximately
15 cm traversing the cranium (Figure 1).
Pre-operative preparation
Due to the large size of the protruding parts of
the prybar, CT scanning was not possible.
Instead, anteroposterior and lateral skull
X-rays were obtained, confirming that the
course of the shaft penetrated the calvaria and
crossed the midline (Figure 2). At this point, the
patient was taken to the operating room for
immediate controlled removal of the prybar.
The patient was awake and alert throughout
the initial triage and evaluation process, with a
particular concern directed towards securing an
airway in this patient. Because of the extensive
protruding ends of the prybar and the patient’s
inability to recline flat, it was necessary to per-
form an awake, upright endo-nasal intubation.
Given the trajectory of the prybar crossing the
midline and exiting just lateral to the midline
opposite the side of entry, sagittal sinus injury
was assumed from the initial presentation, and
Trauma 14(3)
our institution’s mass transfusion protocol was
enacted, which called for a rapid transfuser, vas-
cular clips, surgical microscope, intra-operative
ultrasound, haemostatic agents, and rapid
mobilisation of equipment and personnel.
Surgery
Once the airway was secured, general anaes-
thesia was induced. The patient was placed
in a semi-recumbent position, with the posterior
head resting on a horseshoe support (Figure 1).
The entire frontoparietal scalp was shaved and
prepped, along with the majority of the exposed
prybar shaft. At this point the head was draped,
with the entry point for the prybar over the left
orbit being just outside the draping. The prybar
handle and shaft were supported at all times by a
non-scrubbed neurosurgical resident using
hand-held support to prevent traction. With
the prybar in place, a bifrontal craniotomy was
then performed, with extension to the fracture
lines of the superior exit point of the cranium.
Care was taken to preserve and dissect out the
pericranium, given the penetration of the frontal
sinus and the need for a bifrontal craniotomy.
Transfusion of blood products was initiated
prior to removal of the metal prybar, in antici-
pation of massive, rapid blood loss. Once the
bone flap was elevated, with blood transfusion
ongoing, an intraoperative ultrasound was per-
formed to examine for intraparenchymal haem-
orrhage or other internal injuries not readily
apparent, based on the exposed portion of the
anatomy. The prybar was then carefully
extracted by pulling the handle at the entrance
side in the reverse direction of the original entry
vector. At this point, attention was given to
repairing the sagittal sinus, which had been
injured and was bleeding copiously. The sagittal
sinus injury was quickly covered with large
pieces of gelfoam and cottonoids, in an attempt
to achieve haemostasis. Preparations were in
place to ligate the sagittal sinus, however this
ultimately proved unnecessary. Once haemosta-
sis was achieved with direct pressure, gelfoam,
and cottonoids, the tract of the prybar was
Mitchell et al. 265

explored both manually and with ultrasound,
and then irrigated thoroughly. Following tract
exploration and washout, the pericranium was
reflected on top of the internal portion of the
entry site. The craniotomy bone flap was then
replaced and secured with titanium craniofacial
plates.
Post-operatively, the patient recovered well,
with near immediate return to his baseline
status. His affect was notably flattened, most

Figure 1. Pre-operative position of the prybar. There is clear crossing of the midline. The left globe was intact with
no visual deficit.
266
Figure 2. Pre-operative anteroposterior and lateral skull X-rays, showing intracranial penetration of the prybar rod.
likely due to his left frontal injury. Post-surgical
CT scan of the head revealed good evacuation of
the area traversed by the prybar shaft, with no
new haemorrhage, stroke, or venous congestion
(Figure 3). After 2 days, he was transferred out
of the Intensive Care Unit, and then was able to
go home in good condition with his vision
completely intact in both eyes. Prophylaxis to
prevent venous thromboembolism was enacted.
At 3- and 6-month follow up, the patient was
doing well, his wounds had healed uneventfully,
with no reported cognitive problems or deficien-
cies by his own report as well as his father’s
report. He was interviewed extensively, and
although formal neuropsychiatric evaluation is
not available at the county system hospital in
which he received his operative and follow-up
care, his family members independently verified
his excellent cognitive recovery without notice-
able psychiatric or behavioral manifestations of
his injury.
Discussion
A penetrating brain injury with a large-calibre
industrial metal rod through the frontal lobe,
such as this one, has obvious similarities to
perhaps the most famous case of a survived
Trauma 14(3)
penetrating brain injury, that of Phineas Gage.
Originally reported in 1848, Dr John Harlow
described the explosive trajectory of a metal
tamping rod similar in size to the one in this
case, that shot into Gage’s head just underneath
the left zygomatic process, behind and through
the left orbit, traversing the left frontal brain,
and finally exiting in its entirety through the
midline top of the head, at the junction of the
coronal and sagittal sutures (Harlow, 1848).
Harlow also noted that the superior sagittal
sinus had been lacerated (likewise in the current
case), and although Gage remained awake, alert
and conversant throughout his initial presenta-
tion, he was noted to appear exhausted from the
profuse bleeding, and according to Harlow’s
description of his initial assessment, ‘‘I passed
in the index finger its whole length, without the
least resistance, in the direction of the sound in the
cheek, which received the other finger in like
manner.’’ Although Gage went on to achieve
quite a remarkable, albeit clinically fascinating
recovery, his initial recovery was wrought with
problems, including abscess formation, a fungat-
ing lesion thought to originate from the brain
spreading from the orbit, intermittent lethargy
and decreased consciousness, as well as non-
healing bone fragments, including one expelled
Mitchell et al. 267

Figure 3. Post-operative CT head showing complete removal of the prybar shaft, with reconstruction of the cranial
vault. CT Reconstructions of the cranium demonstrate the extent of the craniotomy performed, as well as its relation
to the penetrating entry and exit points on the skull.

through his mouth. There have been consider-
able advances in the surgical care (before, during
and after) of penetrating brain injuries, and
several ‘‘pearls’’ can be directly drawn from
this case.
In a case such as this, with minimal forewarn-
ing or radiographic support, a great deal of
the decision-making process relies heavily on
personal experience with penetrating brain inju-
ries. Although this object is the largest calibre
object we have removed from a patient (most are
half this size), the senior author (SG) has had
extensive experience with both high and low
energy transfer PBI’s. There are several factors
that should be considered in determining the
most appropriate surgical plan when presented
with a challenging penetrating intracranial case
such as this. Of foremost concern in any trau-
matic situation is the airway. In this case, supine
intubation was not possible due to the sheer size
of the prybar, so we elected to use endo-nasal
awake intubation. Alternatively, awake fiber-
optic intubation is also an excellent option.
Secondly, the question of whether it was
268
appropriate to try to remove or saw-off the ends
of the object to facilitate removal. Although this
can significantly reduce the amount of effort
needed for extraction, we felt that in this case,
a sawing strategy would have potentially caused
secondary damage to the brain by vibration,
heat, or by delaying surgical intervention.
Although the tip of the prybar was slightly
flared in this case, we felt that it could be
safely removed by pulling it out entirely without
causing significantly more injury to the vascula-
ture or brain. Additionally, the foreign object
was linear, and its shape lent itself to direct
extraction of the entire object at once. With
penetrating objects that have more irregular or
distorted shapes, direct extraction may not be
possible without significant secondary damage
to the brain and in those cases, removal of the
ends of the penetrating object may be beneficial.
Planning of the craniotomy was crucial in this
case, along with the timing of removal of the
prybar and pre-emptive transfusion of blood
products. Due to the trajectory of the object,
there was a very high probability of a sagittal
sinus injury. Furthermore, it was of utmost
importance to stabilise and continually support
the metal rod to prevent additional secondary
brain injury, with craniotomy performed prior
to removal, so that the sinus could be visualised
in the event of massive haemorrhage. Once
removed, the injury to the sinus became clear,
but with good surgical exposure and visualisa-
tion, the haemorrhaging was controlled nearly
immediately while maintaining patency of the
sinus. Planning a large exposure and craniotomy
is necessary in cases such as these, due to
the possible need for wide evacuation of the
foreign object or intraparenchymal haemor-
rhage, as well as the possible need for decom-
pressive craniectomy. Although the sinus
bleeding was controlled with gel-Foam and
cottonoids in this case and it was watched for
45–60 min while other areas of the injury
were attended to, we feel that it is critical to
be prepared to cross-clamp and ligate the sagit-
tal sinus especially with injuries in such a rostral
location.
Trauma 14(3)
Exploration of the tract is necessary to locate
any portion of non-radio-opaque objects that
may be retained and previously undetected,
and also allows detection of any portion of a
penetrating object that may have retracted fur-
ther into the tract. Due to the non-sterile con-
dition of a low-velocity penetrating object
post-operative meningitic doses of antibiotics
are essential in fighting potential infections
(Mackerle and Gal, 2009), especially in cases
where any nasal sinus has been violated by the
trajectory of the penetrating object. Our patient
was given Vancomycin, Cefepime and
Metronidazole for 1 week, and had no post-
operative infectious complications. Owing to
the lack of availability during the 1840s, the
lack of post-operative antibiotics in the case of
Phineas Gage almost certainly had a negative
impact on the course of his overall recovery.
Finally, rapid mobilisation and rehabilitation
are also key components in cases such as this,
with careful consideration for prophylaxis
against deep vein thromboembolism as well
(Talving et al., 2009).
There is limited data regarding the ultimate
outcomes of individuals having experienced
LETPBI’s. In a series from India describing
low-energy transfer PBI’s with retained objects,
the authors strongly advocated early recogni-
tion, careful surgical removal, debridement,
and antibiotics in order to avoid complications
such as further vascular or brain injury as well as
infection. Patient outcomes in that series were
largely uneventful, with no persistent neurologic
deficits in 75% of their cases (Kataria et al.,
2011). In contrast, a case series (Amirjamshidi
et al., 2003) studying the outcomes of low- or
medium-energy transfer PBI during wartime in
Iran, advocated minimal debridement and
simple wound closure as the primary treatment,
foregoing extensive surgical debridement and
exploration. In that study, the patients were fol-
lowed for more than 8 years, and 90% recovered
sufficiently to be able to return to work,
although the nature of the injuries (bullets and
penetrating fragments with depressed skull frag-
ments) was markedly dissimilar to the Kataria
Mitchell et al.
case series. Although there was no direct
comparison to those with similar injuries who
underwent surgical debridement, Amirjamshidi
et al. do offer a differing point of view on the
best treatment option for low- and medium-
energy transfer PBI’s. Our case offered a
unique set of circumstances, with a retained
non-sterile prybar, potential contamination,
bilobar injury with an orbito-frontal entry
point and sagittal sinus injury, all of which
necessitated immediate surgical intervention to
attempt to achieve the most successful func-
tional outcome for this patient.
Sterile surgical conditions, extensive transfu-
sion and anaesthesia support, peri- and post-
operative antibiotics, and radiologic imaging
are all advantages afforded to modern neurosur-
gical care that have made a huge impact on the
outcomes of such severe trauma cases, especially
when compared with the recovery noted in
Phineas Gage. In contrast to Mr Gage, despite
similar initial injuries, our patient was not noted
to have any lasting significant psychological
disturbances according to his and his close
family members’ reports. Further follow up
outpatient clinical evaluation did not reveal
any infections, hydrocephalus, or personality
changes. Although neurocognitive assessment
was not available in this case, we would recom-
mend neurocognitive evaluation in any patient
with a similar penetrating brain injury.
Conclusions
Low-energy transfer penetrating brain injuries
are an often interesting subset of penetrating
brain wounds that require their own unique
treatment strategies. Careful planning with due
regard to mechanism, operative strategy for
removal and prevention of further injury, in
addition to aggressive post-operative care are
instrumental in treating these injuries.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.
269
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