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The Spectrum of Penetrating Craniocerebral Injuries in Pakistan: A Narrative Review

Submitted:

10 October 2026

Posted:

13 October 2026

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Abstract
Background: Although penetrating craniocerebral injuries (PCIs) are rare, they can be extremely serious and are linked with a high level of neurological morbidity and mortality. In Pakistan, published work mainly consists of individual case reports and small case series, with wide variation in mechanisms, anatomical paths, radiological findings, surgical methods, and outcomes. This narrative review aims to bring together the existing literature on various types of penetrating brain and craniocerebral injuries in Pakistan and describe their clinical, radiological, and management characteristics. Methods: Studies were screened against predefined eligibility criteria, with an emphasis on injuries caused by penetrating objects, including unusual low-velocity foreign bodies. Relevant information was extracted on the mechanism and circumstances of injury; clinical and neurological presentation; anatomical entry site and trajectory; depth and location of the foreign body; radiological characteristics; surgical management; and postoperative outcomes and complications. Results: Six Pakistani publications met the eligibility criteria and were included in the narrative synthesis. The reported injuries demonstrated considerable heterogeneity in the type of penetrating object, anatomical entry site, trajectory, and intracranial location. Penetration occurred through different cranial and facial regions, with foreign bodies traversing cortical and deeper intracranial structures in some cases. Clinical presentation ranged from relatively preserved neurological status to severe neurological impairment, depending on the trajectory and structures involved. Computed tomography was central to defining the entry site, trajectory, depth, retained foreign body, and associated intracranial injuries. Despite the severity of some injuries, selected patients had favorable neurological outcomes, while complications included infection, neurological deficits, and other procedure- or injury-related sequelae. Conclusion: Pakistani literature demonstrates that PCIs are clinically diverse and require individualized assessment based on the entry site, trajectory, depth, and anatomical relationship of the foreign body to critical intracranial structures. However, evidence remains limited to a small number of case-based publications, highlighting the need for systematic reporting and larger multicenter studies to define better injury patterns, management strategies, complications, and long-term outcomes of PCIs in Pakistan.
Keywords: 
penetrating brain injury
;  
penetrating craniocerebral injury
;  
traumatic brain injury
;  
neurosurgery
;  
Pakistan
Subject: 
Public Health and Healthcare  -   Primary Health Care

Introduction

Penetrating craniocerebral injuries (PCIs) take place when an object goes through both the skull and the protective membranes, referred to as meninges, surrounding the brain [1]. Although these injuries can lead to neurological deficits, rare instances occur in which patients do not exhibit any neurological impairments [2]. Various factors influence this, including the object’s trajectory, the specific brain regions affected, and individual neural compensation. Notable anatomical and physiological differences between adult and pediatric brains help explain the differing responses to injury. While children’s scalps and soft tissues provide less effective cushioning, their nerve fibers are more flexible and less prone to rupture from trauma [3].
Management of PBI depends on severity, anatomical location, and presenting symptoms. Antiepileptic drugs and antibiotic prophylaxis are commonly used to control symptoms and prevent complications. Surgical intervention is frequently required to remove foreign bodies, evacuate hematomas, and mitigate post-injury edema. PBI often leads to cerebrospinal fluid (CSF) leaks resulting from dural tears, which are difficult to seal effectively through standard tissue healing at entry or exit sites [4].
PBI is less common than closed head trauma but has a more adverse prognosis [5, 6]. In civilian populations, the majority of these injuries are due to high-velocity objects, and this results in more complicated injuries with a high rate of death [7]. Injuries caused by non-missile, low-velocity objects are rare among civilians and have better outcomes because the primary injury is more localized [5, 8]. These injuries are generally the result of violence, accidents, or even suicide attempts [8-17]. The burden of deliberate self-harm and suicide in South Asia, including Pakistan, is largely unknown and under-reported [18]. Self-inflicted low-velocity penetrating head trauma is extremely rare [19]. Globally, only a few such cases have been reported, with presentations ranging from asymptomatic to life-threatening brain injury. Reported tools include metallic rods, nails, screws, intraocular chopsticks, and pencils [20-25]. Repeated hammering of nails into the head is particularly uncommon [26]. The current review focused on the spectrum of PCIs that were reported in Pakistan. The focus was on injuries by non-ballistic objects such as knives, daggers, and everyday non-conventional objects like nails, axes, keys, hammer and even T-shape metallic spanner.

Methodology

The review deliberately classified the mechanism of injury as object-based instead of velocity-based. The inclusion criteria for the articles were human studies that were conducted or reported patients from Pakistan who sustained a penetrating craniocerebral injury.

Screening

Exclusion criteria included high-velocity injury, closed head injury, superficial scalp injury, or non-penetrating skull fracture. Blast-dominant and firearm-related injuries were excluded from the broad literature search because the review was designed based on non-ballistic penetrating injuries.
We conducted a broad literature search using PubMed/MEDLINE, PubMed Central, and Google Scholar as primary databases. The search covered literature from databases from 2022 till 30th September 2026. No restrictions were applied based on study design.

Search Strategy

The search included the injury terms, Object terms, and Geography terms as follows:
[“Penetrating brain injury” OR “penetrating cerebral injury” OR “penetrating craniocerebral injury” OR penetrating head injury”] AND [“Axe” OR “Ax” OR “hatchet” OR “knife” OR “dagger” OR “nail” OR “needle” OR “hammer” OR spanner” OR “screwdriver” OR “tap” OR “faucet” OR “metallic object” OR “keys”] AND [Pakistan]
The search strategy was intentionally expanded with individual object terms because unusual non-ballistic injuries may not be indexed under the generic term “penetrating brain injury”.

PECO Framework

We incorporated the PECO framework, replacing Intervention with Exposure because of the injury’s broad spectrum.
Table 1. PECO Framework.
Table 1. PECO Framework.
Component Details
(P)opulation Patients of any age or sex with penetrating craniocerebral/brain injuries reported in Pakistan
(E)xposure Non-ballistic penetrating objects/instruments, including axes, knives/daggers, Axe/hatchet, nail, needle, hammer, tap, faucet, metallic object, and keys
(C)omparison Not applicable
(O)utcomes Injury characteristics, anatomical site/trajectory, neurological presentation, associated injuries, imaging findings, complications, surgical/medical management, mortality, neurological outcome and functional outcome
Context: Pakistan

Results

Literature Search and Study Selection

We found at least 10 Pakistan-related records on PubMed/MEDLINE, and 7 full-text articles on PubMed Central (PMC). We used Google Scholar for cross-checking. After removing duplicates, we reviewed 6 distinct Pakistan-related publications (see Table 2).

Spectrum of Penetrating Objects

A 2025 case report from Peshawar narrated retained intracranial needles, including a prolonged retained-foreign-body presentation [31]. The 2023 Karachi case series reported two self-inflicted penetrating brain injuries caused by nails driven into the head, with deep intracerebral penetration but preserved neurological function [19]. The 2025 study from Sindh is particularly important here because it contains 61 surgically managed axe injuries, providing considerably more evidence than a single case report [30]. The 2023 Rawalpindi report provides the dagger example: an 18-year-old male sustained a penetrating injury involving both parietal cortices through a midline trajectory [28]. The 2024 pediatric publication describes two accidental penetrating injuries involving a pencil and a toy wheel [29]. The 2014 Lahore case involved a bicycle wheel spoke, which penetrated through the orbit into the frontal lobe [27].

Mechanism and Circumstances of Injury

The largest Pakistani series consisted of 61 surgically managed axe injuries at Liaquat University of Medical and Health Sciences (LUMHS), Jamshoro. The mechanism was a direct axe/hatchet strike to the head, producing penetrating craniocerebral trauma [30]. The Rawalpindi case involved an 18-year-old male who sustained penetrating trauma from a hand-held dagger [28]. The dagger traversed the midline and involved both parietal cortices. In a case series, two patients with psychotic depression attempted suicide by hammering nails into their own heads [19]. In one case, a patient used a brick to hammer four 10-cm nails into his head and presented two days later. The nails had penetrated deeply into the brain parenchyma. In the 2024 pediatric case, a 3-year-old boy was running while holding a wooden pencil and fell forward [29]. The fall drove the pencil through the superomedial aspect of the orbit, through the ethmoid bone, and into the frontal lobe. The second case in the same 2024 publication involved a 19-month-old child who was playing with toys [29]. A toy car wheel became lodged in the occipital region, producing intracranial penetration. The injury had occurred approximately two hours before presentation. The 2025 Peshawar case represents a very different circumstance [31]. A 14-year-old girl was found to have two metallic needles embedded intracranially, which had apparently been inserted when she was an infant. The 2014 Lahore case involved a 3.5-year-old girl with a bicycle wheel spoke penetrating through the orbit into the frontal lobe [27].
Table 3. Mechanism of injuries with intent evaluation.
Table 3. Mechanism of injuries with intent evaluation.
Study Object Mechanism Circumstance/intent
Kalhoro et al., 2025 [30] Axe Direct axe strike producing cranial penetration Traumatic/assault-type injury; exact intent not clearly characterized in the abstract
Tassadaq et al., 2023 [28] Hand-held dagger Direct penetration by dagger through the skull Traumatic assault
Shaukat et al., 2023 [19] Nails Nails deliberately hammered into the skull using a brick Self-inflicted/suicidal, associated with psychotic depression and alcohol use
Shaukat et al., 2024 [29] Pencil Child fell forward while running while holding a pencil Accidental pediatric injury
Shaukat et al., 2024 [29] Toy-wheel Foreign body penetrated the occipital region while the child was playing Accidental pediatric injury
Khan et al., 2025 [31] Needles Needles deliberately inserted through the infant skull Attempted infanticide/child abuse, discovered 14 years later
Ijaz et al., 2014 [27] Wheel spoke Transorbital penetration by bicycle wheel spoke Accidental childhood injury

Anatomical Entry Site and Injury Trajectory

Anatomical entry sites and injury trajectories were heterogeneous across the reported cases—penetrating objects entered through transorbital, transethmoidal, parietal, occipital, and other transcalvarial routes. The wheel-spoke injury demonstrated a transorbital trajectory extending into the frontal lobe, while the pencil injury followed a transethmoidal route to the frontal region [27, 29]. The dagger injury involved bilateral parietal cortices, indicating a trajectory extending across the intracranial compartment [28]. Hammer-driven nails produced deep intracranial penetration, including involvement of the region of the superior sagittal sinus [19], whereas the toy-wheel injury entered through the occipital region and penetrated approximately 1.5 cm intracranially [29]. The retained-needle case represented a focal anterior intracranial penetrating injury with retained foreign bodies [31]. Overall, the cases demonstrate that PCIs may follow diverse anterior, posterior, orbital, skull-base, and transcalvarial trajectories, with injury extending from localized cortical penetration to bilateral or deep intracranial involvement.

Clinical Presentation and Neurological Status

The clinical presentation of PCIs varied considerably across the six identified Pakistani publications, ranging from complete preservation of neurological function to severe focal neurological deficits. In the 61-patient axe-injury series, the severity of neurological injury varied among patients, with Glasgow Coma Scale (GCS) scores assessed at admission and discharge [30]. The dagger case showed that preserved consciousness did not necessarily indicate preserved neurological function [28]. The 18-year-old patient had a GCS of 15/15 on presentation but had marked motor deficits in the form of triplegia, consisting of paraplegia and contralateral upper-limb monoplegia. No neurological recovery was observed following surgical removal of the dagger.
In contrast, the two patients with self-inflicted nail injuries had deep penetration into the brain parenchyma without neurological deficits or symptoms attributable to the brain injury [19]. One patient continued to function normally for two days before presentation despite having multiple nails penetrating the skull and brain. Similarly, the patient with long-retained intracranial needles presented mainly with intermittent frontal headache and had an unremarkable neurological examination [19]. Neurological function was also preserved in the pediatric cases. The child with the transorbital wheel-spoke injury had a GCS of 15/15 and no focal neurological deficit despite approximately 10 cm of intracranial penetration into the frontal lobe [27]. Likewise, both children in the pencil and toy-wheel case reports remained neurologically intact despite intracranial extension of the foreign bodies [29]. The pencil-injured child was alert with no neurological or ocular deficits, while the child with the occipital toy-wheel injury was well oriented and had intact neurological function without evidence of increased intracranial pressure.
Table 4. Clinical Presentation and Neurological Status.
Table 4. Clinical Presentation and Neurological Status.
Study Penetrating object Patient(s) Clinical presentation Neurological status
Axe injuries, LUMHS Jamshoro [30] Axe 61 Presented with penetrating craniocerebral trauma of varying severity; patients underwent surgical management. Neurological severity varied across the series; GCS was assessed at admission and discharge.
Dagger injury, Rawalpindi [28] Hand-held dagger 18-year-old male Presented with severe motor impairment involving all four limbs asymmetrically GCS 15/15, but severe focal deficit with triplegia; no neurological recovery reported after surgery
Self-inflicted nail injuries, Karachi [19] Nails 2 patients Self-inflicted penetrating injuries; one patient remained functional for 2 days before presentation Neurologically intact despite deep intracerebral penetration; no major neurological deficit reported
Intracranial needles, Peshawar [31] Metallic needles 14-year-old female Delayed presentation approximately 14 years after injury; intermittent frontal headache Neurological examination unremarkable
Wheel-spoke injury, Lahore [27] Bicycle wheel spoke 3.5-year-old female Accidental transorbital penetration into frontal lobe GCS 15/15; no focal neurological deficit; favorable neurological recovery
Pencil and toy-wheel injuries, Pakistan [29] Pencil; toy-wheel 2 children Pediatric accidental penetrating injuries involving orbital/frontal and occipital regions Both were neurologically intact; no significant neurological sequelae reported

Radiological Characteristics

Radiological characteristics across the six selected Pakistani studies showed considerable variation in the anatomical extent and structural consequences of penetrating and traumatic brain injuries. In Kalhoro et al. research, CT brain was used to categorize axe injuries according to the degree of skull fracture, hemorrhage, cortical contusion, and involvement of the cranial sinus. The reported radiological spectrum ranged from a minimal cortical contusion with a linear fracture to depressed fractures penetrating the sinus with associated cortical contusions and epidural hematoma [30]. Tassadaq and colleagues reported CT evidence of a dagger entering through the left parietal region, traversing the midline, and extending into the contralateral parietal lobe and medial motor strip, demonstrating a deep trans-parietal trajectory across both cerebral hemispheres [28]. In a study conducted by Shaukat et al., CT demonstrated multiple deeply penetrating metallic nails: three entered the right frontoparietal region, one crossed the midline, and another extended toward the occipital horn of the lateral ventricle; a second patient had a nail extending from the frontal bone through the superior sagittal sinus into the brain, with an interhemispheric bleed and left frontal contusion. Three-dimensional CT reconstruction further demonstrated the precise entry sites and trajectories of the nails [19]. In another study, Shaukat et al. demonstrated two contrasting pediatric radiological patterns [29]. The pencil penetrated through the ethmoid bone into the inferomedial ipsilateral frontal lobe to a depth of approximately 5 cm without surrounding hemorrhage or edema, whereas the toy-wheel injury produced a linear hyperdense object approximately 1.5 cm deep in the left occipital region with metallic artifact and no acute intracranial hemorrhage or mass effect; 3-D CT reconstruction was used to demonstrate the foreign body’s position [29]. Khan et al. reported two retained intracranial needles identified initially on skull radiography and subsequently confirmed by CT. The needles, measuring approximately 3–4 cm, were located beneath the cranial vault within the left frontal/interhemispheric brain region and were not associated with substantial mass effect or intracerebral bleeding [31]. Lastly, Ijaz et al. reported CT findings in a larger traumatic brain injury population, with subarachnoid hemorrhage being the most frequent CT finding (24%), followed by depressed skull fracture [27]. Overall, the six studies show that radiological findings ranged from localized penetrating tracts with minimal secondary injury to extensive fractures, hemorrhage, contusion, sinus involvement, and transhemispheric trajectories, with CT serving as the primary modality for defining the anatomical extent and trajectory of injury.

Surgical Management

Across the six studies, surgical management primarily involved careful removal of the retained penetrating object and management of the associated cranial or intracranial injury (see Table 5). The operative approach varied by foreign-body type, anatomical entry site, depth of penetration, and proximity to critical brain structures. In the transorbital wheel-spoke injury, surgery was directed toward removal of the penetrating object and management of the frontal-lobe injury. The cases involving self-inflicted penetrating injuries, a hand-held dagger, and pediatric injuries caused by a pencil and toy wheel similarly required operative extraction of the foreign bodies while attempting to minimize additional neurological damage. In axe-related craniocerebral injuries, surgical treatment also addressed associated skull and intracranial damage. Intracranial needle cases presented additional challenges because of prolonged retention and potentially difficult needle locations, requiring individualized neurosurgical planning. Overall, these reports demonstrate that surgical management of penetrating brain injuries is highly individualized, with controlled foreign-body removal and prevention of secondary neurological or structural injury being central considerations.

Postoperative Outcomes and Complications

Across the six studies, postoperative outcomes varied according to the site and severity of the penetrating brain injury, neurological involvement, and characteristics of the retained foreign body. Several cases, particularly the wheel-spoke injury, self-inflicted injuries, and pediatric pencil and toy-wheel injuries, demonstrated preserved or favorable neurological function after surgical management [19, 27, 29]. In contrast, the dagger-related injury was associated with a significant neurological deficit, presenting as triplegia [28]. The axe-related injuries showed more variable outcomes because of differences in the extent of skull and intracranial damage [30]. In contrast, long-retained intracranial needles presented additional management challenges because of their prolonged retention and anatomical location [31]. Overall, the reported outcomes suggest that neurological status and the severity and anatomical characteristics of the injury were important determinants of recovery and complications. However, studies did not consistently report detailed postoperative complications.

Discussion

The six studies show that, depending on the entrance site, injury trajectory, depth of penetration, and anatomical structures involved, PCIs from uncommon low-velocity objects can produce markedly different clinical presentations and outcomes. The pediatric pencil and toy wheel cases, as well as the transorbital wheel-spoke injury, show that significant brain penetration can occur despite uncommon methods and, in some cases, with preserved neurological function [27, 28]. Similarly, the series of self-inflicted penetrating brain lesions illustrates that sustained neurological state is feasible when important neuronal structures are spared [19]. In contrast, the dagger-related injury resulting in triplegia demonstrates the potential for severe neurological consequences when the penetrating trajectory involves functionally important brain structures [28]. The axe-related injuries further emphasize that greater structural disruption of the skull and underlying brain may increase the complexity of treatment and influence prognosis [30]. The cases involving long-retained intracranial needles additionally demonstrate that penetrating injuries may present delayed and create diagnostic and surgical challenges because of the foreign body’s location and prolonged retention [31]. Collectively, these reports suggest that injury anatomy may be more informative for predicting neurological outcome than the unusual nature of the penetrating object itself. However, the small number of published cases, predominantly case-report or case-series designs, and heterogeneous clinical presentations limit interpretation and make direct outcome comparisons difficult.

Conclusion

The reviewed literature demonstrates that PCIs in Pakistan are heterogeneous and can result from a wide range of unusual objects and circumstances. Across the six studies, clinical presentation and neurological outcomes varied substantially, with some patients maintaining intact neurological function despite intracranial penetration, while others developed significant neurological deficits. The entry site, trajectory, depth of penetration, anatomical structures involved, and foreign-body accessibility appeared to be important considerations in surgical management and subsequent outcomes. Early recognition, appropriate neuroimaging, careful surgical planning, and individualized removal of retained foreign bodies are therefore central to management. However, available evidence remains limited, largely to case reports and small case series, highlighting the need for larger, systematically documented studies from Pakistan to characterize better injury patterns, management approaches, complications, and long-term outcomes of PCIs.

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Table 2. Characteristics of publications reporting PCIs associated with non-ballistic objects in Pakistan.
Table 2. Characteristics of publications reporting PCIs associated with non-ballistic objects in Pakistan.
No. Publication / Study Year Penetrating object Cases Location Study type
1 Transorbital penetrating brain injury to frontal lobe by a wheel spoke [27] 2014 Bicycle wheel spoke 1 Lahore Case report
2 Self-inflicted penetrating brain injuries with preserved neurological function: a case series [19] 2023 Nails 2 Karachi Case series
3 A Rare Presentation of Triplegia Resulting from Penetrating Brain Trauma by a Hand-Held Dagger [28] 2023 Dagger 1 Rawalpindi Case report
4 Pediatric penetrating brain injuries with intact neurological function: Two case reports of a pencil and a toy wheel encounter [29] 2024 Pencil + toy wheel 2 Pakistan/
Karachi		 Two case reports
5 Traumatic Craniocerebral Injury from Axe Strikes: Presentation, Prognosis, and Complications [30] 2025 Axe/hatchet 61 Jamshoro Clinical observational study
6 Intracranial needles since 14 years: diagnostic challenges and management strategies [31] 2025 Needles 1 Peshawar Case report
Table 5. Surgical Management.
Table 5. Surgical Management.
Study Entry site Trajectory Depth Anatomical location Accessibility of foreign body
Ijaz et al [27] Transorbital/orbital entry Through the orbit into the frontal region Intracranial penetration into the frontal lobe Frontal lobe Accessible for surgical removal through the orbital entry pathway
Shaukat et al [19] Variable cranial entry sites depending on the individual case Variable; followed the path of the penetrating objects Intracranial penetration with retained foreign bodies Different intracranial regions across cases Dependent on the individual object’s location and trajectory; surgical removal was performed where feasible.
Tassadaq et al. [28] Cranial entry site produced by dagger penetration Deep intracranial trajectory along the dagger’s penetration path Deep enough to produce significant neurological injury Intracranial structures associated with the patient’s triplegia Required neurosurgical extraction because of intracranial retention
Shaukat et al [29] Cranial/orbital entry depending on the individual case Object-specific intracranial trajectories Intracranial penetration with retained objects Intracranial regions along the respective trajectories Foreign bodies were surgically accessible and removed
Kalhoro et al. [30] Scalp/skull entry produced by axe impact Penetrating trajectory through the skull into intracranial structures Variable depth, depending on severity of axe penetration Skull and underlying intracranial structures Accessibility depended on depth and extent of associated cranial injury
Khan et al [31] Previous cranial entry sites; long-retained needles Variable trajectories depending on needle position Intracranial retention for prolonged duration Intracranial locations containing retained needles Potentially difficult; accessibility depended on needle location, number, and relationship to surrounding structures
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