Source (Thieme>

Fig 1: Agricultural machine causing fan blade injury.
Fig 2: Resolving edema on postoperative day 8
Fig 3: Preoperative computed tomography showing B/L frontal contusion with gross edema, subarachnoid hemorrhage, and intraventricular hemorrhage.
Fig 4: Postoperative image showing primary closure of the wound
Fig 5: Follow-up and complete recovery.
Fig 6: Preoperative clinical image of patient showing extent of injury with brain herniation.


A 10-year-old male was brought to the emergency department of All India Institute of Medical Sciences (AIIMS) Patnawith the complaints of accidental fall on the fan blade of the thresher machine (►Fig. 1). On arrival, he had a Glasgow Coma Scale (GCS) of E1VTM5 status, bilateral pupil mid-dilated, and sluggish reaction to light. On secondary survey, he had a lacerated wound of size 15x4x2 cm extending from left side forehead to right temporal region exposing bone and brain parenchyma herniation through the wound (►Fig. 6). Baseline laboratory parameters showed hemoglobin of 12.1, total leucocyte count of 12,000, platelet count of 2,35,000, and serum Naþ of 136, Kþ of 4.2.

A noncontrast computed tomography (NCCT) head showed B/L frontal contusion with gross edema, subarachnoid hemorrhage, and intraventricular hemorrhage. There was fracture of bilateral frontal bone extending to right parietotemporal bone (►Fig. 3). A diagnosis of penetrating compound head injury by agricultural fan blade was made. Patient was taken to operating room (OR), where after painting and draping, the wound was irrigated with normal saline. The herniated brain was removed, securing hemostasis with surgical and Bovie cautery. Lax duraplasty was done with harvested pericranium and wound closed in layers (►Fig. 5).

Postoperatively patient was shifted to neuro intensive care unit and was kept on sedation and mechanical ventilation. He was started on cerebral decongestants, broad-spectrum antibiotic, and antiepileptic. On postoperative day 1, GCS was E1VTM5 status. A repeat NCCT head showed development of gross edema in the brain. Cerebral decongestants were continued and barbiturate coma was induced for next 48 hours. Tracheostomy was done on postoperative day 4. A repeat NCCT head on postoperative day 8 showed resolution of edema. His GCS also improved to E3VTM6 status (►Fig. 2). On postoperative day 14, he became E4VTM6. He was later shifted toward where he was decannulated. He developed left-sided hemiparesis for which he was started on physiotherapy. He underwent a prolonged neurorehabilitation and made a complete recovery after 3 months of injury (►Fig. 5).