Fatal facial–intracranial impalement injury in an accidental fall from a height: An autopsy case report with a review of the literature

Impalement injury to the face and head is of clinical and forensic pathological significance because of its diagnostic pitfalls. This injury often penetrates the orbital, nasal or oral cavity into the skull, but impaling other sites of facial bone is rare. The present case was a rare type of facial–intracranial impalement injury with a direct cerebral arterial laceration. The victim was a 44-year-old man who fell from a height of about 2.5 m onto a broken chair and died 6 days later despite surgical treatment. The clinical diagnosis was a ‘small abrasion’ of the face and ‘traumatic intracerebral hemorrhage with intraventicular and subarachnoid hemorrhages’ on computed tomography (CT). At autopsy, a small crescent laceration was seen below the right zygomatic region. Intracranial lesions comprised a perforating skull-base fracture, a subarachnoid hemorrhage with laceration of the posterior communication artery, and a massive intraventricular hematoma that involved cerebral injury connected with the skull-base fracture, which were consistent with penetration by a steel tube from the chair. A review of the literature suggested that such severe intracranial–facial impalement injuries are caused by traffic accidents or falls, and the prognosis was poor due to an injury around the brainstem despite an appropriate clinical diagnosis. Furthermore, the present case suggested the difficulty of clinical diagnosis even using CT; thus, a forensic autopsy was necessary to determine the manner and cause of death.