Neuroradiology 15, 137-139 (1978)
Neuroradiologv
ORIGINALS
A Fatal Brain Injury Caused by a Needlefish
M. J. McCabe I, W. M. Hammon 2, B. W. Halstead 3, and T. H. Newton 4
Departments of RadiologyI and Neurosurgery2, The Straub Hospital,Honolulu,Hawaii,WorldLife Research Institute3, Colton, CA,
and Department of Radiology4, Universityof California,Schoolof Medicine,San Francisco,CA, USA
Summary. A traumatic internal carotid-cavernous
sinus fistula due to a penetrating injury caused by a
needlefish is described.
Key words: Carotid-cavernous sinus fistula - Nee-
dlefish - Penetrating carotid injury.
Introduction
Numerous species of fishes are known to inflict pain-
ful and sometimes fatal wounds to human beings.
One of the more uncommon traumogenous fishes
the marine needlefish, a member of the family
Belonidae. Needlefishes resemble the freshwater
garpike in form and are sometimes referred to as
garfish, but are phylogenetically unrelated to their
freshwater counterpart. Needlefishes are inhabitants
of tropical seas, and are found in bays, inshore areas
and at times in deeper water. They are largely surface
swimmers. They have a long slender body and pos-
sess two pointed elongate jaws that are filled with
sharp unequal teeth (Fig. 1). Some of the larger
species may attain a length of two meters. When
undisturbed, needlefishes move along with an
undulating motion of the body, but when excited they
are capable of moving with surprising speed. When
excited or chased by larger fishes they scull rapidly
over the surface of the sea with the major part of
their body out of the water. Needlefishes are fre-
quently attracted by light at night and may leap out of
the water in the direction of the light. They have been
frequently observed leap-frogging over objects in the
water [1]. It is during these periods of excitation that
they may inflict their wounds by plunging their sharp
beaks into anyone in their flight path.
© by Springer-Verlag1978
Needlefishes have inflicted serious injuries and
even fatalities to humans. These injuries have con-
sisted of puncture wounds to the chest, abdomen,
arms, legs and neck [2, 3, 4].
This report documents the first known instance of
penetration of the brain and the creation of a carotid-
cavernous fistula by a needlefish. The exact species of
needlefish was not identified, but is believed to be
Strongylura gigantea (Temminck and Schlegel).
Case Report
A ten-year-old Hawaiian boy was fishing with his
father at Hanamulu Bay, Kauai on September 5,
1977. As the boy was pulling in a fishing net, a start-
led 3 to 4 foot long needlefish jumped from the
water, striking the boy in the region of the fight eye.
The fish then landed in the boat. The father, who did
not witness the incident, turned to see his son slump
to the floor of the boat, holding the right side of his
face. His father asked him what happened. The boy
did not speak, but took his hands away and showed
the father the area of injury. The father took the boy
by truck to the hospital on Kauai. During the truck
ride the boy lost consciousness. On admission to the
hospital he was found to be comatose, with a flaccid
paralysis involving the right side of the body. He was
intubated and flown to Straub Hospital in Honolulu.
Physical examination at Straub Hospital revealed
a comatose boy with endotracheal tube in place. The
right eye was swollen with ecchymotic lids. There was
a small (approximately 8 mm. long) wound at the
external canthus of the right eye. The fight pupil was
dilated and fixed. There were periarteriolar hemor-
rhages in the right eye but intraocular pressure was
normal. The patient carried out no verbal commands.
Occasionally he had purposeful movements, other
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 138 M.J. McCabe et al.: A Fatal Brain Injury Caused by a Needlefish

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Fig. 1. a Strongylura gigantea (Temminck and Schlegel). Giant needlefish (Auacu or Aha'aha in Hawaiian). Length up to one meter or
more (Drawing by R. H. Knabenbauer). b Close-up of head, showing needle like beak and teeth, c Roentgenogram of head (Courtesy of
Dr. Richard Haedrich, Woods Hole Oceanographic Institute)

Fig. 2 a and b. Left internal carotid arteriogram, lateral projection, a Mid-arterial phase, b Late arterial phase. Immediate opacification of
the cavernous sinus with drainage into the petrosal sinuses is noted. Peri-arterial luxury perfusion and early venous opacification of parietal
veins indicate the presence of infarction, probably on an embolic basis

times he thrashed about, using only the left side. ment of the left carotid-cavernous sinus fistula with
Bilateral carotid angiograms revealed a left internal drainage into left pterygoid plexus, both cavernous
carotid-cavernous sinus fistula, evidence of cerebral sinuses, and both superior ophthalmic veins, right
infarction, and a small left subdural hematoma greater than left (Fig. 3). The midline structures were
(Fig. 2), shifted to the right compatible with increased left
The patient was maintained on steroids, Man- hemisphere edema. The patient continued to do
nitol, and endotracheal tube. On September 7, he poorly, and gradually worsened until his temperature
began to show signs of decerebrate posturing. Bruit suddenly dropped to 34 degrees on September 10,
was then noted over the left eye. On September 8, a 1977. He became unresponsive to all stimuli, had no
repeat carotid angiogram revealed interim enlarge- corneal reflexes and apnea began, which required
M. J. McCabe et al.: AFatal Brain Injury Caused by a Needlefish 139

Fig. 3 a and b. Left internal carotid arteriogram three days later, a Lateral and b frontal projection. The internal carotid-cavernous sinus
fistula now is larger with drainage into the superior ophthalmic vein and pterygoid plexus, Frontal views also show drainage across the
midline into the fight cavernous sinus. The horizontal portion of the middle cerebral artery is slightlyelevated and the pericallosal artery is
displaced to the right

respirator assist and then control. The patient existed
on the respirator for the next several days until car-
diac action ceased on S e p t e m b e r 16.
A u t o p s y confirmed that the needlefish had pene-
trated posterior to the lateral aspect of the globe of
the fight eye, through the sphenoid sinus and across
the midline into the left hemisphere of the brain,
creating a left internal carotid-cavernous sinus fistula
in transit.
from the water. The blunt heads of flying fish render
them less dangerous than the needlefish, built like a
spear with long thin jaws that come to a sharp, b e a k -
like point. A survey of five Kauai physicians indi-
cated needlefish attacks are not c o m m o n around the
island. All said they had never heard of such attacks
before the incident of this summer.
References

Discussion 1. Gudger, E.W.: Fishes that play "Leapfrog". Amer. Nat. 78,
451-463 (1944)
Closed head injury from automobile accidents is 2. Haneveld, G.T.: Injuries caused by garfish-like fishes in
Netherlands New Guinea. Doc. Med. Geogr. Trop. 8, 96-98
responsible for most carotid-cavernous sinus fistulae. (1956)
A basal skull fracture is usually found in these 3. Norman, J. R., Fraser, F. C.: Giant fishes, whales and dolphins.
patients. Orbitocranial perforating injuries represent Bath: Pitman Press 1948
another traumatic cause for these fistulae. Although 4. Randall, J.E.: The living javelin. Bull. Oceanogr. Found. 6,
228-233 (1960)
needlefish have b e e n k n o w n to pierce the a b d o m e n
or chest of fishermen and the gastrocnemius muscle Received: February 17, 1978
of a surfer, this report documents the first known
instance of penetration of the brain and creation of Thomas H. Newton, M. D.
carotid-cavernous fistula by a needlefish. Like its Department of Radiology
University of California
relative, the flying fish, or malolo, the needlefish will San Francisco, CA 94143
suddenly begin to swim very rapidly and then leap USA