Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 54, Num. 4, 2006, pp. 447-447

Neurology India, Vol. 54, No. 4, October-December, 2006, pp. 447

Letter To Editor

Incidentally detected intracranial sewing needles: An enigma

Teegala Ramesh, Menon SK, Panikar Dilip

Department of Neurosurgery, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala
Correspondence Address:Department of Neurosurgery, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, panikar@aims.amrita.edu

Code Number: ni06157

Sir,

Intracranial foreign bodies are a rare entity. These may be secondary to traumatic brain injuries, mainly warfare or civilian injuries,[1] surgical procedures or rarely as a child abuse.[2] We report an incidental detection of two sewing needles found in the cranium of a four-year-old child. This entity represents a special class of intracranial foreign bodies. To the best of the authors' knowledge, it is the first reported case in Indian literature.

We report a four-year-old child with the history of a fall on the ground while playing. There was no history of loss of consciousness, headache, vomiting or seizures. On examination child had stable vital signs and a normal neurological examination. There was small scalp abrasion over the right posterior parietal area. There was no previous history of operative intervention or trauma. The child was evaluated with plain X-ray of skull and subsequently noncontrast computed tomography of the brain [Figure - 1]. The radiological images revealed one sharp sewing needle in the left parafalcine area pointing down and laterally. There was another blunt needle below that in the left frontal area posterior to the coronal suture. There was no evidence of scalp swelling or fracture of the skull. The child was discharged with an advice to be in regular follow-up after counseling the parents.

Sewing needles are among the more unusual foreign bodies that may be found in the brain. May occur as homicidal attempts or accidental injuries. Though the incidents often occur in infancy or early childhood before the closure of Fontanelles, they can present later in life with features of headache, seizures or altered neurological behavior.[2] Abbassioun[2] reported a series of three cases and reviewed another ten cases of intracranial sewing needles and found attempted homicide or infanticide to be the main cause (62%). Delayed presentation at the age of 20 years has also been reported.[3]

In our case, the parents did not have any clue regarding this. They didn't have any idea whether it was a failed infanticidal attempt or accidental. Whatever may be the possible cause inferred from radiological findings [Figure - 1], it is possible that the needles would have entered through the anterior fontanel before its closure. The needles probably entered on the left side of the midline crossing through the falx to their current location in the right parafalcine area. The child is presently asymptomatic.
Intracranial foreign bodies sometimes can show migration as reported by Ramesh et al[1] in case of shotgun pellets. Though the exact mechanism is unknown, it may be because of the greater specific gravity of these foreign bodies when compared to brain matter, which enables them to sink down. Cerebral pulsations may also contribute to the movement of these foreign bodies.

There are no clear-cut guidelines regarding the management of these foreign bodies. Symptoms like seizures and focal deficits if present may improve after removal of these foreign bodies.[2] When they are situated in the periphery and in noneloquent areas they can be safely removed. Foreign bodies located in the deep brain matter and in eloquent areas remain a problem. In an asymptomatic patient with deeply situated foreign bodies one can wait till the patient becomes symptomatic or till they reach a safe location by migration with the regular follow-up X-rays.

References

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