title: Emergency surgery in a severe penetrating skull base injury by a screwdriver: case report and literature review.
abstract: BACKGROUND
  Very few cases of severe penetrating injuries to the skull base with a seemingly innocuous object have been described in the literature. Of the cases reported, only ten involve a penetrating screwdriver. However, the choice of therapeutic management, whether it be emergency surgical or non-surgical removal of the penetrating object as well as the selected surgical approach remain quite controversial.
  
  
  METHODS
  The authors describe the case of a severe penetrating skull base injury caused by a screwdriver, following an accidental fall from a ladder. The patient was admitted in Glasgow Coma Scale (GCS) 11 with a cerebrospinal fluid (CSF) leak in the right maxillary area. The tri-dimensional computerized tomography (3-D CT) scan revealed an oblique trajectory of the screwdriver shank through the skull base. The authors opted for an emergency surgical extraction of the object. A contra-lateral pterional approach was successfully performed and a two-year follow-up showed no neurological deficits.
  
  
  CONCLUSIONS
  The reported case supports the choice of emergency surgical removal of the object in penetrating skull base injuries involving the anterior skull base with neurovascular lesions. Surgical aspects of the pterional approach, and in particular the left pterional approach as well as other cranio-facial approaches in severe penetrating skull base injuries are discussed.
authors.affiliation: Department of Neurology and Psychiatry Sciences, University of Bari, 70124 Bari, Italy. adetommasi@neurosurgery.uniba.it
authors.forename: Antonio
authors.initials: A
authors.lastname: De Tommasi
authors.forename: Pasquale
authors.initials: P
authors.lastname: Cascardi
authors.forename: Claudio
authors.initials: C
authors.lastname: De Tommasi
authors.forename: Sabino
authors.initials: S
authors.lastname: Luzzi
authors.forename: Pasqualino
authors.initials: P
authors.lastname: Ciappetta