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Letters   |    
Combined Therapeutic Treatment for Traumatic Skull Defect With Brain Abscess in a Schizophrenic Patient
Tzu-Hsuan Chen, M.D.; Dar-Yu Yang, M.D., Ph.D.; Shuo-Tsung Chen, Ph.D.; Yao-Chin Wang, M.D., M.Sc.; Chung-Hsin Yeh, M.D., M.A.; Chun-Yuan Huang, M.D.; Muh-Shi Lin, M.D., Ph.D.; Woon-Man Kung, M.D.
The Journal of Neuropsychiatry and Clinical Neurosciences 2013;25:E22-E24. doi:10.1176/appi.neuropsych.12030066
View Author and Article Information

Dept. of Physical Medicine and Rehabilitation, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (THC)
Dept. of Neurosurgery, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan (DYY, WMK)
Dept. of Mathematics, Tunghai University, Taichung, Taiwan (STC)
Dept. of Emergency, Taipei City Hospital, Chung Hsin Branch, Taipei, Taiwan (YCW)
Dept. of Emergency, Taipei Hospital, Department of Health, Taipei, Taiwan (YCW)
Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan (YCW)
Dept. of Neurology, Show Chwan Memorial Hospital, Changhua, Taiwan (CHY)
Graduate Institute of Life Sciences, National Chung Hsing University, Taichung, Taiwan (CHY)
Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (CYH)
Graduate Institute of Dental and Craniofacial Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan (CYH)
Dept. of Neurosurgery, Taipei City Hospital, Zhong Xiao Branch, Taipei, Taiwan (MSL)
Division of Neurosurgery, Department of Surgery, Taipei County Hospital, New Taipei City, Taiwan (MSL)
Dept. of Surgery, Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan (MSL)
Dept. of Surgery, School of Medicine, Taipei Medical University, Taipei, Taiwan (MSL)
Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan (WMK)
Dept. of Biotechnology, College of Medicine and Nursing, Hungkuang University, Taichung, Taiwan (WMK)

Correspondence: Dr. Woon-Man Kung; Dept. of Neurosurgery, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan; e-mail: nskungwm@yahoo.com.tw; Dr. Muh-Shi Lin, Dept. of Neurosurgery, Taipei City Hospital, Zhong Xiao Branch, Taipei, Taiwan; e-mail: neurosurgery2005@yahoo.com.tw

Copyright © 2013 American Psychiatric Association

To the Editor: We present the case of a schizophrenia patient who had a persistent foreign-body delusion and who damaged his head with a hammer. A traumatic scalp injury became a deep brain abscess. This case represents one of the most severe examples of self-mutilation found in the literature.

Schizophrenia is a lifelong disorder requiring multimodal treatment at all stages of illness. Self-mutilation is not uncommon in schizophrenia, but resultant brain lesions are rare.1

Our schizophrenia patient had been damaging his head because of delusions. One open injury on the left frontoparietal region with extended intracerebral ulceration was made.

The patient provided his written informed consent and all procedures were approved by the institutional ethics committees of Wan Fang Hospital, Taipei Medical University in accordance with Declaration of Helsinki.

A 55-year-old man had chronic schizophrenia, and a left frontoparietal cranial defect with progressive right-sided weakness was noted. He claimed that a foreign body on his head came from the underworld. He tried to remove the foreign body from his head by repetitive digging.

He had a low-grade fever and a deep purulent open scalp wound of 5×3×2 cm in size, with extension into the intracerebral space (Figure 1). Glasgow Coma Scale score was E4VAM6. There was no obvious neurological deficit except right hemiparesis.

 
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FIGURE 1.Preoperative Gross Appearance of the Patient

Laboratory data showed no evidence of leukocytosis. Mild elevation of C-reactive protein was noted. Magnetic resonance imaging showed brain abscess formation, with ring enhancement and perifocal brain edema (Figure 2, Figure 3).

   
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FIGURE 3.Preoperative MR Imaging, Coronal View, Showing Disclosed Brain Abscess Formation With Perifocal Edema Under the Scalp and Skull Defect (arrow)

Intravenous antibiotics started with ceftriaxone 2 gm every 12 hours, metronidazole 500 mg every 6 hours, and vancomycin 1 gm every 12 hours. The culture of purulent material was Staphylococcus aureus. Then vancomycin was used for a total of 90 days.

Surgical treatment included thorough debridement of the infected area and immediate reconstruction of the scalp defect with a rotational flap. Craniectomy was done to remove the infected bone adequately. After sequestration of the exposed necrotic and infected calvarium, a full-thickness scalp rotational flap was made to cover brain tissue.

Cranial defects are rarely created by patients in the process of chronic psychotic illnesses. Penetration of foreign objects into the brain with resultant infection may follow even after minor head-penetrating wounds.2

Our patient had an infected lesion affecting scalp, cranium, and brain tissue caused by continuous digging. Treatment of brain abscess involves removing the source of infection, draining the brain abscess, and administering culture-directed intravenous antibiotics therapy.3Staphylococcus aureus is the most common isolated pathogen, and antibiotics therapy for a total of 6–12 weeks should be applied. Debridement of devitalized tissue may be necessary to control infection, to improve healing, or to prepare the base for reconstruction.4 Repair of cranial defects, especially when infected, presents generally with apparent difficulty. After this goal is achieved, reconstruction and repair of cranial and scalp defect can be performed in a stepwise fashion.5

Our surgical treatment had two sessions including early debridement of necrotic tissues and fasciocutaneous rotational flap to cover the area. Another advantage of this flap is that they are highly vascularized, providing delivery of adequate amount of antibiotics to the infected area.

In conclusion, surgical treatment should be performed in two separate sessions.

Schebesch  KM;  Herbst  A;  Schoedel  P  et al:  Extended extra- and intracerebral ulceration and brain abscess following self-mutilation in an auto-aggressive 51-year-old woman: case report.  Cent Eur Neurosurg 2010; 71:43–45
[CrossRef] | [PubMed]
 
Noterman  J;  Rétif  J;  Klastersky  J:  Staphylococcal meningitis and abscess associated with intracranial foreign body, as a late complication of cranial trauma.  Acta Neurochir (Wien) 1973; 29:131–136
[CrossRef] | [PubMed]
 
Arts  H;  Neely  J:  Intratemporal and intracranial complications of otitis media, in Head Neck Surgery–Otolaryngology. Edited by Bailey  B;  Calhoun  K;  Healy  G  et al.  Philadelphia, PA,  Lippincott Williams & Wilkins, 2001, pp 1078–1079
 
Delashaw  JB;  Percing  JA:  Cranial defects and their repair, in Youmans Neurological Surgery: A Comprehensive Reference Guide to Diagnosis and Management of Neurosurgical Problems, 3rd Edition, vol 4. Edited by Youmans  JR.  Philadelphia, PA,  WB Saunders Company, 1990, pp 2290–2304
 
Murray  CJL;  Lopez  AD:  The Global Burden of Disease .  Cambridge, MA,  Harvard University Press, 1996, p 21
 
References Container

FIGURE 1. Preoperative Gross Appearance of the Patient

FIGURE 2. Preoperative MR Imaging, Sagittal View

FIGURE 3. Preoperative MR Imaging, Coronal View, Showing Disclosed Brain Abscess Formation With Perifocal Edema Under the Scalp and Skull Defect (arrow)
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References

Schebesch  KM;  Herbst  A;  Schoedel  P  et al:  Extended extra- and intracerebral ulceration and brain abscess following self-mutilation in an auto-aggressive 51-year-old woman: case report.  Cent Eur Neurosurg 2010; 71:43–45
[CrossRef] | [PubMed]
 
Noterman  J;  Rétif  J;  Klastersky  J:  Staphylococcal meningitis and abscess associated with intracranial foreign body, as a late complication of cranial trauma.  Acta Neurochir (Wien) 1973; 29:131–136
[CrossRef] | [PubMed]
 
Arts  H;  Neely  J:  Intratemporal and intracranial complications of otitis media, in Head Neck Surgery–Otolaryngology. Edited by Bailey  B;  Calhoun  K;  Healy  G  et al.  Philadelphia, PA,  Lippincott Williams & Wilkins, 2001, pp 1078–1079
 
Delashaw  JB;  Percing  JA:  Cranial defects and their repair, in Youmans Neurological Surgery: A Comprehensive Reference Guide to Diagnosis and Management of Neurosurgical Problems, 3rd Edition, vol 4. Edited by Youmans  JR.  Philadelphia, PA,  WB Saunders Company, 1990, pp 2290–2304
 
Murray  CJL;  Lopez  AD:  The Global Burden of Disease .  Cambridge, MA,  Harvard University Press, 1996, p 21
 
References Container
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