Bolt gun injury to central forehead, sagittal sinus and frontal lobes: A case report

TL;DR

A 24-year-old man survived a rare self-inflicted bolt gun injury to the head through timely medical interventions including surgery and antibiotics.

Contribution

This case report provides insights into the successful management of a rare bolt gun injury to the head.

Findings

CT imaging and angiography are essential for assessing the extent of brain and vascular injury.

Craniectomy and cautious debridement helped prevent complications like infection and iatrogenic injury.

Prophylactic antibiotics were effective in preventing intracranial infections.

Abstract

Bolt gun injuries to the head are rare and are usually in the context of suicide. Bolt guns are used in the meat processing industry to induce unconsciousness prior to slaughter. A bolt penetrates 7–10 cm through the skull into the brain and then is retracted by a spring. Mortality has been reported to be up to 80–90 %, with survivors left with severe neurological and functional deficits.

A 24-year-old man presented with a self-inflicted bolt gun injury to the central forehead. He presented confused and agitated to a rural emergency department and was subsequently intubated and transferred to a tertiary trauma centre. CT demonstrated a midline frontal bony defect with an underlying 8.5 cm wound tract into both frontal lobes. There was associated intracranial haemorrhage and impacted skin and bone fragments within the wound tract. CTA/V showed an injury to the superior sagittal sinus but intact arterial vessels. He underwent a bifrontal craniectomy, débridement and evacuation of haematoma with ICP monitor placement. The patient demonstrated a remarkable recovery at 3 months with only mild cognitive impairment.

CT imaging including angiography assesses extent of parenchymal and vascular injury. Decompression of the brain and careful debridement off the brain reduced the risk of infection but prevented iatrogenic injury. Prophylactic treatment with broad-spectrum antibiotics prevented intracranial infection.

This case report highlights multiple lessons which contributed to successful management of a bolt gun injury to the head: preoperative CT angiography, craniectomy if indicated, cautious debridement and prophylactic antibiotics.

•CT/A assesses parenchymal and vascular injury•Craniectomy prevents cerebral perfusion compromise from brain swelling.•Meticulous but cautious débridement prevents infection and iatrogenic injury•Prophylactic antibiotics prevent meningitis/cerebritis

CT/A assesses parenchymal and vascular injury

Craniectomy prevents cerebral perfusion compromise from brain swelling.

Meticulous but cautious débridement prevents infection and iatrogenic injury

Prophylactic antibiotics prevent meningitis/cerebritis

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