大型刈り込み鋏による穿通性頭部外傷の1例

Frontal Base Penetrating Brain Injury by a Gardening Scissors:A Case Report

Ⅰ．はじめに

　穿通性頭部外傷は，全頭部外傷の0.4%と比較的稀な外傷であり⁶⁾，異物の性状，刺入経路などによって病態がそれぞれ異なるため，症例ごとに個別の対応が必要となる．本邦では箸・傘・ガラスなどによる外傷の報告が多いが¹⁾，われわれの渉猟し得た限り，大型の刈り込み鋏による報告はない．今回，大型の刈り込み鋏が鼻腔を貫通し前頭蓋底に到達し，さらに前頭蓋底を貫通して頭蓋内損傷を来した1例を経験した．本症例では，外科的治療により良好な治療成績が得られたので，若干の文献的考察とともにその治療方針について報告する．

　A 43-year-old woman accidentally fell from a 1.5-m height with gardening scissors, and the cutting edge of the scissors pierced into her skull base through the left nasal cavity. After she pulled the scissors out by herself, her consciousness immediately deteriorated.

　She was transferred to Juntendo University Shizuoka Hospital by an ambulance helicopter. Intracerebral hematoma in the right frontal lobe caused by the middle cerebral artery injury was detected using brain computed tomography. Emergent hematoma evacuation with decompressive craniectomy was performed. In this procedure, cerebrospinal fluid（CSF）leakage was repaired using a multi-layered flap technique, which placed both the free autologous dura mater and pedicled temporalis muscle flaps into the damaged skull base space. After the surgery, CSF drainage was managed to control both intracranial pressure and CSF leakage.

　Upon discussion, several clinical issues can be highlighted. First, the gardening scissors were pulled out by the patient herself. Second, the foreign material penetrating the intracranial space might have conferred a high infection risk. Finally, it might be difficult to repair the severe damage inflicted upon the skull base by the large gardening scissors.

　In conclusion, it was considered that favorable results were obtained by the emergent surgical intervention and by repairing the skull base through forming a multi-layered flap with a combination of free and pedicled tissues.