Combined Therapeutic Treatment for Traumatic Skull Defect With Brain Abscess in a Schizophrenic Patient

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.

Case Description

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.

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).

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.

Discussion

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.