History
Intracranial foreign bodies such as metallic objects, wood and bone are usually due to penetrating injuries through the cranial bones, orbit, and ear [1, 2]. Sewing needles are among the more unusual foreign bodies that may be found in the brain. Such incidents often happen in infancy or early childhood (before the closure of fontanelles) and may not present until much later in life with symptoms like headache, seizures or altered behavior [11]. The reported cases in the literature are from different countries including Germany, the United States, Turkey, Poland, Hungary, Yugoslavia, and Iran (Table 1).
Our patient’s skull X-ray reveals that intracranial metal foreign body could be a sewing needle. This female patient was raised by her grandmother when she was young. She did not recall any history of trauma. There are no signs of bending extrusions on the metal foreign body. It is quite impossible that sewing needle penetrated into the brain through the cranium as a result of trauma or any accident.
Cranial X-ray shows that the metal foreign body is in front of the coronal suture and near the sagittal sinus. This is the position of the bregma in infants. Therefore the intracranial metal foreign body of this patient should have been inserted into the brain before the closure of anterior fontanelle.
The cause of this intracranial metal needle is not clear. There have been reports of voluntary infanticide earlier in literature. The offending person is usually the stepmother, but psychopathic mother, aunt, stepsister, and baby sitter have also been mentioned as offenders [12, 13]. If the first homicide attempt were not successful, a second, third, or even more attempts might be performed to harm the victim [14]. There are reports of insertion of needles to the other parts of victims’ body such as chest and abdomen [12–16]. But the patient presented here is from the Zhuang ethnicity. Girls usually wear colorful traditional dress with many metal pins attached to hold the decorations in place. This could be the underlying reason in our case as the patient’s history did not reveal any incidence of child abuse.
The clinical symptoms
There are many reports of foreign objects retained in the brain for long periods of time without any symptoms [8, 16]. Tuncer et al. [16] reported a man who first experienced a Generalized Tonic-Clonic (GTC) seizure at the age 32 years old. Ameli et al. [14] reported a 32-year-old man who had developed epilepsy 8 years earlier. Sewing needles were visible in both cases on skull radiography. Late-onset epilepsy due to an intracranial needle have been reported previously [8, 15].
Headache and epilepsy are the main symptoms and they often appear when the patient reaches adulthood [12]. Other rare clinical features of intracranial needles are hemiparesis and gait disturbance, brain abscess, hemi-chorea and cranial nerve palsy [9, 17, 18]. However, to date, no case presenting with absence seizure has been described.
The intracranial metal foreign body has toxic effect on brain tissue. This leads to the secondary infection and the intractable epilepsy. It also leads to focal neurologic symptoms. The movement of the foreign body also can cause secondary damage.
In our case, apart from being susceptible to colds and fevers during childhood, the patient has unremarkable medical history. Mental development of the patient was normal. Appearance of clinical symptom of absence seizure only until the age of 25 years old makes this case is rare.
Management
In our case, the intracranial metal foreign body passed through the sagittal sinus. Tuncer et al. [16] suggests that surgical removal is not indicated in asymptomatic patients. Similarly, Ilbay et al. [19] recommends conservative approach if the patient is symptom-free and diagnosis is purely incidental and there is no risk of infection. Also, Abbassioun et al. [12] point out that metallic foreign bodies are much better tolerated in the brain than fragments of bone.
According to the majority of authors, the therapy of choice should consist of follow-up alone when no clinical signs or symptoms are present. Antiepileptic drugs should be reserved only for patients with seizures [9]. Amirjamshidi et al. [7] described that there was no absolute indication for removing intracranial sewing needles detected in the later decades of life. Vedat Ali [20] points out that patient with intracranial needles may present late in life with epilepsy or status epilepticus. They suggest that surgical intervention is unnecessary if seizures are under control with antiepileptic drug therapy.
However, in this case, the patient was young and new onset of absent epilepsy was observed. With the use of intraoperative navigation and positioning, intraoperative fluorescein angiography to avoid sagittal sinus rupture and use of microscope to attain minimally invasive approach, the treatment of intracranial metal foreign body tends to be more attainable with minimum damage to the brain tissues and thus postoperative complications.
