Missing the point: self-inflicted traumatic brain injury in psychosis

Abstract

A 36-year-old man was brought to the emergency department by emergency medical services after being found acting unusually at a gas station with blood on his head and clothing. He presented acutely psychotic and reported that he had a pen in his head. Medical evaluation was notable for a superficial puncture wound to the right temple, and he was medically cleared for psychiatric evaluation. After he developed nausea and headache later that evening, the CT scan revealed a temporal bone fracture, pneumocephalus, intraparenchymal haemorrhage and the presence of a metal pen tip lodged in the brain parenchyma. The full nature of the injury went undiscovered in the emergency department for 16 hours due to the superficial appearance of the injury and his acute psychosis with prominent delusional thought content and disorganisation. He underwent craniotomy with removal of the pen and subsequent hospitalisation for intravenous antibiotics, followed by a prolonged psychiatric hospitalisation for psychosis.

Occult pediatric skull fracture and implications for delay in diagnosis: illustrative case

“…Other examples of similar missed skull injuries have been reported, and the parietal and temporal bones appear to be most susceptible to these types of injuries. 4,7 The development of guidelines for the utilization of head CT for the evaluation of TBI is important and has likely reduced the number of tests ordered. 8 Nonetheless, limitations of these studies should be recognized when used clinically.…”

“…Other examples of similar missed skull injuries have been reported, and the parietal and temporal bones appear to be most susceptible to these types of injuries. 4 , 7 …”

“… 3 Cranial injuries involving a thin object (e.g., pencil, rod, or nail) can present with a well-appearing patient, an unimpressive puncture site, and an underlying open, depressed skull fracture. 4 If unrecognized and not treated within 48 hours, an open, depressed skull fracture with contamination can result in infection. 5 We report on the case of a child who experienced a puncture wound with unrecognized open, depressed skull fracture with intracranial contamination.…”