Intracranial pencil injuries

Spontaneous resolution of a wooden foreign-body granuloma in the conjunctiva of a child

A conjunctival foreign-body (FB) granuloma may result following trauma with synthetic and non-synthetic materials including organic and non-organic objects. Children usually manifest with FB granulomas that develop due to inoculation of FBs from soft toys, blankets or woollen clothes. Encapsu- lation of these FBs following a granulomatous inflammatory response results in a nodular swelling in the conjunctiva. Reports of a wooden FB granuloma in the conjunctiva in children are anecdotal. A 5-year-old boy suffered an un- witnessed direct ocular trauma to his left eye (OS) with a wooden arrow while playing. He developed redness and nodular swelling at the inferotemporal aspect of the OS without any visual complaints. The diagnosis of a wooden FB granuloma is a challenge to ophthalmologists and may go undetected in children who neglect their symptoms. It characteristically presents as a unilateral conjunctival nodule. Surgical excision is the definitive management. However, spontaneous extrusion of the FB might be observed due to protective blinking and tearing mechanisms in the eye.

Transbasal penetrating traumatic brain injury caused by a rifle rod: A case report

Background

Penetrating traumatic brain injury (TBI) caused by a low-velocity object is a rare entity with a potential range of critical complications.

Case Description

We report a unique case of a 30-year-old male presenting with penetrating TBI caused by a rifle's cleaning rod. The rod passes through the left nostril to reach the frontal lobe after transgressing the sella turcica. A cranial computed tomography scan shows the extension of brain damage and the trajectory of the rod with no evidence of an associated vascular injury. Surgical removal of the rifle rod was performed using a transnasal approach by a multidisciplinary with the postoperative course went uneventfully.

Conclusion

Transbasal penetrating TBI through the nose is an extremely rare entity. This type of head injury carries its own peculiarities that deviate from the classic treatment algorithms.

Traumatic prolapse of the globe into the anterior cranial fossa: a case report

Background

Orbital fracture associated with traumatic intracranial prolapse of the eyeball is rare. In all previously reported cases, vision was severely impaired with no light perception. Herein, we report a case of traumatic prolapse of the globe into the anterior cranial fossa, in which the patient’s vision was preserved by early repositioning.

Case presentation

The present case report focused on a man hit by a steel pipe, leading to prolapse of the globe of the right eye into the anterior cranial fossa through fractures in the superior orbit roof, accompanied by cerebral contusion. The eyeball was immediately repositioned into the orbital cavity, along which the wound tract was debrided and the skull base was repaired. The patient underwent a follow-up period of 12 months, during which the visual acuity increased to 12/20 without any intracranial infections. However, the patient’s ptosis persisted and was associated with complete loss of supraduction.

Conclusions

In this case, early diagnosis and proper globe repositioning with reconstruction of the orbital roof could allow recovery of vision, as well as prevention of intracranial infection.

Epilepsy caused by an unrecognized pencil lead misdiagnosed as intracerebral cavernous malformation

Transorbital penetrating injury is relatively uncommon following head trauma, and delayed onset of neurological complications due to retained intracerebral foreign bodies has rarely been reported. We describe the first child case of late-onset epilepsy caused by an accidental transorbital penetrating injury, resulting in a retained pencil lead fragment that was mistaken for cavernous malformation. A 14-year-old girl presented with abrupt onset of nocturnal bilateral tonic seizures. The patient was previously healthy and denied any head trauma. The seizures were not well controlled by antiepileptic drugs. Right frontal lobe epilepsy due to a cavernous malformation was suspected on the basis of brain magnetic resonance imaging and electroencephalography findings. A planned operation unexpectedly revealed the intracerebral pencil lead. This foreign body had gone undetected for 11 years following a minor transorbital penetrating injury. The patient remained seizure-free during the 1-year post-operative follow-up period. Head trauma by a pencil can cause transorbital penetrating injury in children. It is difficult to detect retained small foreign body fragments and the clinical presentation can be delayed. It may be mistakenly diagnosed as other pathologies, especially when patients deny any history of head trauma.

Penetrating Injury of the Eye Causing Bilateral Visual Loss: An Eye Opener!

Penetrating orbitocranial injuries are often serious and life-threatening trauma. A thorough knowledge of the mechanism of injury, direction of the projectile object, low index of suspicion, appropriate radiological investigations, medical management, and timely surgical intervention are necessary for the prevention of any serious complication. The penetrating objects are usually lodged at the site of entry with very less chances of intracranial migration. Authors here describe their experience in the management of such an injury with a discussion of pitfalls in surgical treatment.

Transorbital Craniocerebral Penetration by a Sharp Object with an Intact Globe

Traumatic eye injuries are common in children and are mostly superficial. Vigilance must always be practiced when examining these children to avoid missing any hidden serious injuries that may result in devastating complications. We describe the acute and definitive management of a child treated 17 h after transorbital craniocerebral penetration by a sharp object. Despite the rarity of these types of injury, a good outcome can be achieved if they are promptly recognized and managed.

Bidirectional Management of a Transnasal Intracranial Chopstick Transecting Optic Nerve

Herein, the authors report a rare patient with a transnasal intracranial penetration injury caused by a chopstick that resulted in optic nerve transection as well as the removal of the chopstick using a bidirectional approach. A 25-year-old male presented to our emergency department with right blindness and bilateral epistaxis. Preoperative computed tomographic angiography demonstrated a transnasal stick-like foreign body causing a skull base fracture and suspected vascular injury. Due to the shape of the chopstick and the high risk of massive bleeding, an exclusively endoscopic or open craniotomy approach is not suitable for removal. A bidirectional method, including both an open craniotomy and transnasal endoscopy, was used to remove the chopstick. After the operation, there were no further neurologic deficits or complications during the treatment course and follow-up. The bidirectional approach may provide an alternative method to address a foreign body when the patient is not a candidate for an exclusively endoscopic or open craniotomy approach management.

Unusual cranial trauma caused by pencil in teenager: case report

Introduction: Penetrating lesions by pencil in the temporal lobe in children and adolescents are uncommon. We present the case of a teenager with penetrating injury by strange object in the temporal lobe. Case: Twelve years old male patient, with history of trauma while he was playing with his friends, presents alteration of the consciousness state, weakness in right hemibody and dysphasia. Urgent surgery is practiced employing an incision in “C” form with improvement of the consciousness state during post-operative. Discussion: Penetrating lesions in the skull and brain are classified as missiles and non-missiles depending of their impact velocity. The wood is a porous organic material that provide a natural deposit of microbian agents, making it potentially lethal. Pre-operative radiological evaluation allows check the trajectory of the penetrating object and secondary lesions present guiding de neurosurgical approach. The prognostic depends on penetration site, timely handling and complications associated. Conclusion: Penetrating lesions by pencil are uncommon, an appropriate imaging evaluation is fundamental to determine the neurosurgical approach that allows prevent and/or decrease secondary damage.

Penetrating Orbital Injuries: A Review

Penetrating injuries to the orbit represent a small but very complicated portion of head injuries. Because of the close proximity to many vital structures, any penetrating orbital injury requires a multidisciplinary follow-up. Cases of penetrating injuries have flooded the literature, but no one has presented a systematic approach to the complications associated with these types of injuries. Herein, we present the complications associated with each orbital entry mode: superior, inferior, medial, lateral rims of the orbit, and extraorbital entry.

Orbital and Orbitocranial Trauma From Pencil Fragments: Role of Timely Diagnosis and Management

PURPOSE

To emphasize the importance of early detection and radiologic evaluation of retained organic foreign bodies (FBs) in orbital or orbitocranial penetrating injuries by pencil.

DESIGN

Retrospective case series.

METHODS

A retrospective chart review of patients who had penetrating orbital or orbitocranial trauma at 2 tertiary hospitals was conducted. Patients whose mechanism of injury was penetrating trauma by pencil were included. The patients' demographics, time between initial trauma and detection of foreign body, radiologic images, and resulting sequelae were reviewed.

RESULTS

Four patients were included in this study. All patients were male; 3 were less than 2 years of age and 1 was 34 years old. Accidents were witnessed in 2 cases, and initial detections of FBs were delayed in 3 cases, from 2 days to 7 weeks. Three cases involved the right orbit. Computed tomography (CT) imaging of the head demonstrated penetration of the orbital walls in 3 cases. Three-dimensional CT scans were used to differentiate the penetrating graphite pencil fragments from the orbital wall, and catheter angiography was used in 1 case of suspected orbital apex penetration. Vision was lost in 1 patient while other severe neurologic deficits were fully recovered after removal of FB.

CONCLUSIONS

Penetrating injury by pencils to the periorbital structures and delayed detection of retained pencil fragments can result in threat to life and vision. Radiologic examinations are essential to the detection of these retained FBs. Prompt detection and removal of the FBs within 48 hours and treatment with antibiotics can save vision and life.

Traumatic Brain Injury Due to Screwdriver Assaults: Literature Review and Case Report

Penetrating head injuries due to the use of screwdrivers as wounding agents in acts of interpersonal violence seldom occur. The aim of this article is to update and summarize the relevant literature on penetrating craniocerebral screwdriver stab wounds and to report a new case of screwdriver assault. A number of studies were reviewed to investigate the incidence, distribution, common findings, mechanism of injury, differential diagnostic criteria, complications, treatment, and prognosis of craniocerebral screwdriver stab injuries. It was observed that the degree of traumatic severity depends on the cross-sectional area of the screwdriver and the anatomical region of injury. Craniocerebral screwdriver injuries are mainly cases of interpersonal violence and the mortality rate is approximately 47.6%. In 23.8% of the incidents, the trauma is overlooked on admission because of the small entry wound and, thus, the severity of the injury is not initially appreciated.

Transorbital Orbitocranial Penetrating Injury with an Iron Rod

Transorbital orbitocranial penetrating injuries (TOPIs) are relatively rare, can be caused by high-speed projectile foreign bodies to low-energy trauma (which is rarer), and account for 24% of penetrating head injuries in adults and approximately 45% in children. We report an uncommon nonfatal case of TOPI where a 16-year-old male child sustained injury due to accidental penetration of metal bar into the forehead. A bicoronal flap was raised to remove the metal bar. The patient recovered well, had normal vision, and doing well at follow-up.

[Penetrating head and brain injuries with nonmetal foreign bodies]

Penetrating brain injuries (PBI) are common in neurosurgical practice. Most of them are civil or war-time missile and blast injuries. This type of trauma is widely presented in neurosurgical publication, textbooks and clinical evidence-based guidelines. At the same time, PBI by non-metallic foreign bodies are very rare. All the data are limited to case reports and small series of cases. Moreover, there are no clinical consideration on diagnosis, treatment, complication, outcome and prognosis of PBI by non-metallic penetrating brain injuries. In this review all the data are summarized to provide recommendations on the diagnosis and treatment of PBI by non-metallic foreign bodies.

Penetrating Orbital-Cranial Injuries Management in a Limited Resource Hospital in Latin America

Penetrating orbital-cranial injuries (POCIs) are difficult cases especially in hospitals in low-middle-income countries (LMIC) where resources are limited. We present a case series of POCI managed in a university hospital in such scenario. A retrospective case series was conducted including patients with POCI in 2011. Mechanism of injury, Glasgow Coma Scale score, imaging, medical and surgical management, complications, and Glasgow Outcome Scale (GOS) score were analyzed. A total of 30 patients with penetrating orbital injuries were admitted from March 2011 to December 2011. Of this group, only four patients were diagnosed with cranial penetration. Computed tomography (CT) angiography revealed orbital fractures and injury to frontal, temporal, or occipital lobes. Urgent craniotomy with isolation of ipsilateral carotid artery was performed. GOS score at discharge was 5 in three patients and 4 in one patient. POCIs are not uncommon in hospitals of LMIC. In such scenarios, a standard approach with CT angiography and early neurosurgical intervention results in good outcome.

Skull stab wound from a metal railroad nail perforating the right frontal lobe

STUDY DESIGN

Case report and review of literature.

OBJECTIVE

To present the rare case of a 70-year-old man with a punctured cranial lesion, who was treated with surgery and had a positive recovery.

SUMMARY OF BACKGROUND DATA

Cerebral trauma as the serious consequence of urban aggressiveness.

METHOD

Clinical and imagery review of a cranial puncture trauma caused by a metal railroad nail, which penetrated the cranium, dura mater, frontal cerebral parenchyma and deep structures, lodging itself next to the midline, without damaging the superior sagittal sinus.

RESULTS

The patient underwent a frontal craniotomy to remove the metal nail. He was hospitalized 2 weeks post-surgery and discharged. During external consultations, he manifested no neurologic deficit. A post-surgical CT ruled-out a brain abscess or other complications.

CONCLUSIONS

Skull and brain stab wound lesions are highly infrequent, but evaluating the mechanism of injury and the successful medical and surgical treatment employed is illustrative of how post-traumatic recovery of this severe head injury can be achieved. The site of the injury and the position of the object were decisive for establishing an adequate diagnosis and prognosis. The patient reported an exemplary recovery without any secondary complications.

Occult orbitocranial penetrating pencil injury in a child

Transorbital slow-penetrating injury is an uncommon type of head injury that is seen more often in the pediatric age group. This type of injury can be occult, which is often associated with serious complications. We report on a 4-year-old female who presented with orbital swelling after an unwitnessed right orbital injury following a fall on her face at her school. Three days after injury, the presence of a foreign body was discovered on imaging study when she presented with orbital swelling and purulent discharges. She recovered well after surgical and medical management. This paper sheds light on the importance of high suspicion for the presence and early surgical management of a penetrating foreign body.

Transorbital craniocerebral occult penetrating injury with cerebral abscess complication

Transorbital intracranial penetrating injury is an uncommon mechanism of head injury. These injuries can be occult during the initial clinical presentation. Certain patients develop an intracranial cerebral infection. Herein, we report a 5-year-old child with an occult transorbital intracranial penetrating injury caused by a pen. A retained pen tip was found at the superior orbital roof and was not noticed at initial presentation. This was complicated by a right frontal lobe cerebral abscess. This paper emphasizes the importance of orbitocranial imaging in any penetrating orbital injury. A review of the literature on intracranial infection locations in relation to the route and mechanism of injury is included to complement this report.

Oro-cranial penetrating pencil injury

Oro-cranial penetrating injuries are often seen in ear, nose and throat practices. Cases of penetrated pencil injuries are rarely reported despite being common in the developing world. A 7-year-old boy referred from a neighboring hospital was playing at school with the sharp end of a pencil in his mouth when he was pushed from behind by another child. He fell on his face and the sharp end of the pencil penetrated his throat with the distal end hanging out. There was no bleeding at presentation, as the pencil completely sealed the entrance point. The entrance point was at the posterior wall of the oropharynx corresponding to the uvulo-palatine junction. It penetrated posterosuperiorly through the soft tissue to reach the anterior part of the posterior cranial fossa. Since sharp and pointed objects in the upper aerodigestive tract can result in potentially fatal complications, prompt diagnosis, a systematic treatment protocol, and an experienced trauma team are necessary to prevent a potential catastrophe.

Occult orbito-cranial penetrating injury by pencil: role of beta tracer protein as a marker for cerebrospinal fluid leakage

Orbito-cranial foreign bodies present a treacherous situation that can escape detection. The only evidence of these foreign bodies may be the entry wound in the form of a small lid laceration. A two-year-old boy presented with right upper lid laceration following a fall two hours back. Analysis of the fluid around the wound revealed a beta-tracer protein (beta-TP) value of 33.5 mg/l suggestive of cerebrospinal fluid (CSF). Three-dimensional computed tomography (CT) scan revealed a foreign body measuring 4.2 cm x 0.8 cm passing from the orbital roof to the frontal lobe. The foreign body tract was explored through the eyelid laceration and a broken pencil was removed followed by dural patch graft. The patient developed no ocular or intracranial complications. Beta-TP, a highly specific marker of CSF is routinely used in screening patients of neurosurgery and otolaryngology with CSF leaks, however, its use has never been reported in ophthalmic literature based on an online PubMed search.

Endoscopic treatment of transnasal intracranial penetrating foreign body

Transnasal intracranial penetrating injury is rare. We report a case of transnasal intracranial penetrating metallic chopstick, which was removed successfully by endoscopic approach, and management of transnasal intracranial penetrating injuries.

Management of a long-standing organic intracranial foreign body

Organic foreign bodies of the skull base are an uncommon problem with the potential for serious morbidity that present complicated treatment dilemmas best managed by a multidisciplinary approach. A 58-year-old male presented to the emergency department with fevers and mental status changes and was found to have bacterial meningitis. Computed tomography of the sinuses revealed two adjacent defects of the ethmoid roof with associated soft tissue density concerning for an encephalocele. He had a remote history of a penetrating left maxilla injury with a stick 13 years earlier. An attempted endoscopic repair of the defects revealed a pulsating splinter of wood emanating from the ethmoid roof defect. Neurosurgery and infectious disease were consulted and several wood fragments were removed endoscopically from the intracranial space. The skull base defects were closed using a septal cartilage underlay and free mucosal overlay graft. The patient has done well in follow-up with no evidence of cerebrospinal fluid leak. Organic foreign bodies from skull base trauma can have a delayed presentation and require a multidisciplinary team approach. In the appropriate setting endoscopic removal is a minimally morbid option.

Pencils and Pens: An Under-Recognized Source of Penetrating Injuries in Children

Unlike other sharp objects, pens and pencils are readily available to children both at home and school. Although case reports are published, no series of pen or pencil injuries have been reported in the recent literature. We therefore reviewed the incidence and injury profiles of writing instruments as compared with other sources of penetrating trauma. The trauma registry from a large urban pediatric hospital system was queried for nonmissile, nonbite penetrating injuries from 2005 through 2009. Retrospective data was collected on demographics, injuries, operations, admissions, and mortalities. Additionally, data regarding pen and pencil injuries from 2009 to 2010 were collected prospectively, and one case from 2003 was included retrospectively. Fourteen injuries from writing instruments were seen and involved the head and neck (9), chest (1), bladder/perineum (2), and extremities (2). Eleven children were admitted and eight required surgical intervention. One child died from a transhemispheric brain injury after intraorbital penetration by a pencil. Penetrating trauma from writing instruments is not an uncommon source of injury and often requires surgical intervention to remove the object. Injuries from pens and pencils can be severe or even fatal. Appropriate parent and teacher education regarding the potential risks may help to prevent such injuries.

Pencil in the brain: a case of temporal lobe abscess following an intracranial penetrating pencil injury

The case of a 7-year-old girl with an intracranial penetrating injury due to a pencil is presented. The difficulties in diagnosis and the need for a high degree of suspicion and for prompt adequate surgical treatment are highlighted.

Rapid Development of Brain Abscess Caused by Streptococcus Pyogenes Following Penetrating Skull Injury via the Ethmoidal Sinus and Lamina Cribrosa

OBJECTIVE

Streptococcus pyogenes is a beta-hemolytic bacterium that belongs to Lancefield serogroup A, also known as group A streptococci (GAS). There have been five reported case in terms of PubMed-based search but no reported case of brain abscess caused by Streptococcus pyogenes as a result of penetrating skull injury. We present a patient who suffered from penetrating skull injury that resulted in a brain abscess caused by Streptococcus pyogenes.

METHODS

The patient was a 12-year-old boy who fell down from his bicycle while cycling and ran into a tree. A wooden stick penetrated his skin below the right lower eyelid and advanced to the cranium. He lost consciousness on the fifth day of the incident and his body temperature was measured as 40. While being admitted to our hospital, a cranial computed tomography revealed a frontal cystic mass with a perilesional hypodense zone of edema. There was no capsule formation around the lesion after intravenous contrast injection. Paranasal CT showed a bone defect located between the ethmoidal sinus and lamina cribrosa.

RESULTS

Bifrontal craniotomy was performed. The abscess located at the left frontal lobe was drained and the bone defect was repaired.

CONCLUSION

Any penetrating lesion showing a connection between the lamina cribrosa and ethmoidal sinus may result in brain abscess caused by Streptococcus pyogenes. These patients should be treated urgently to repair the defect and drain the abscess with appropriate antibiotic therapy started due to the fulminant course of the brain abscess caused by this microorganism.

Near lethal art--transorbital brain injury

Penetrative transorbital injuries put intracranial structures in peril. We present one such case where a low velocity transorbital injury resulted in traumatic temporal lobe injury, but with full recovery. Clinicians should be vigilant of intracranial complications of transorbital injuries.

Patterns of transorbital intracranial injury: a review and comparison of occult and non-occult cases

The authors present an illustrative case of occult transorbital penetrating intracranial injury in a child, and review the literature concerning patterns of low-velocity, non-projectile injury during the era of modern CT and MRI study. Review of the mechanism of injury and analysis of surface entry site of penetration in 38 cases suggests recurring patterns of injury in occult and non-occult cases. A classification system based on surface entry zone site is applied to these injuries. Knowledge of the classification system should increase clinical suspicion for this type of often occult, penetrating orbito-cranial injury and direct appropriate investigation to provide earlier detection and diagnosis of the transorbital, intracranial penetration.

Orbito-cranial injuries caused by penetrating non-missile foreign bodies. Experience with eighteen patients

BACKGROUND

Penetrating non-missile orbito-cranial injuries are uncommon civilian injuries which have some special features. Only limited case-reports are available in the international literature.

METHOD

We present a retrospective review of 18 such in presumed trivial orbital injury. Early identification and removal of retained foreign body fragments was achieved within 36 hours.

FINDINGS

Patients were operated on and followed up for at least of 3 years. The final clinical outcome was excellent: 16 had a Glasgow Outcome Scale (GOS) of 5 while in the remaining 2 it was 4.

CONCLUSION

The present report indicates that good results, in managing such injuries, can be achieved by a high index of suspicion and early diagnosis of intracranial injury in presumed trivial wounds and by the removal of every possible retained foreign body.

Delayed presentation of orbito-cerebral abscess caused by pencil-tip injury

This report describes the clinical and radiologic findings of a child who was stabbed with a pencil tip in his right upper eyelid, in what initially appeared to be an innocuous injury. The child presented again 3 weeks later with a combined orbital and frontal lobe brain abscess. The mechanism of injury is discussed, the orbital and neuro-surgical interventions are detailed, and the medical treatment is presented. Ophthalmologists should have a high index of suspicion for orbital foreign bodies and possible intracranial injury in cases of penetrating eyelid trauma.

Diplegia due to transcranial knife-blade injury in a 20-month-old child

Transcranial stab wounds are uncommon among both adults and adolescents and rarely occur in children, particularly when caused by another child. A 20-month-old girl was injured by a 3-year-old cousin, who introduced a knife blade into the brain through the left parietal region. The trajectory of the wound penetrated at least 5 cm, crossed the falx cerebri, and involved both motor cortical areas. The clinical sequela was a severe symmetric spastic diplegia.

Brain abscess associated with eyelid contracture

A 4-year-old girl presented to our hospital with inability to close her left eye and headache. Seven months earlier, she had fallen and her left eye had been injured. Physical examination and radiologic investigations revealed contracture of the left eye and brain abscess. The case is interesting because we have found out that injuries of the eyelids may lead to intracranial complications in the long term, although they do not cause any symptoms of an intracranial abnormality in the short term.

[Penetrating brain injury due to a large asbestos fragment treated by decompressive craniectomy: case report]

We report the case of a 22-year-old man victim of penetrating brain injury due to a 15 x 12 asbestos fragment and a successfully treatment via decompressive craniectomy. Unlike gunshot wounds to the head, penetrating brain injury from low energy objects are unusual. Most cases reported involve cranio-orbitary injuries as well as self inflicted lesions in mentally ill patients. The reported case is noteworthy due to the large dimensions of the foreign body, the treatment via decompressive craniectomy and the good patient functional outcome.

Suicide by intracerebellar ballpoint pen

Self-inflicted eye injuries among psychiatric patients are relatively common. Transorbital penetrating traumas are more rare but if undiagnosed may cause lethal intracranial lesions. We report a fatal case of a 25-year-old schizophrenic man who introduced a plastic ballpoint pen through his right orbit up to the cerebellum. The computed tomography findings were misinterpreted as a penetrating track from a bullet. The patient died 4 days after the trauma, and the causative object was identified only at autopsy. When no precise information about an apparently trivial ocular trauma is available, clinicians and investigators must adequately consider, especially in psychiatric patients, the possibility of an intracranial penetrating lesion.

Brain abscess following transorbital penetrating injury due to bamboo fragments--case report

A 56-year-old female presented with transorbital penetrating injury caused by bamboo fragments, which resulted in brain abscess 2 weeks after the injury. Initial computed tomography (CT) of the head did not reveal the foreign bodies. However, follow-up CT demonstrated a well-defined hyperdense abnormality of 1.0 cm length in the left orbit and brain abscess in the left temporal lobe. The lesion corresponding to the hyperdense abnormality on CT appeared isointense on T1-weighted magnetic resonance (MR) imaging and hypointense on T2-weighted MR imaging. The bamboo fragments were surgically removed, and aspiration and continuous drainage were performed for the brain abscess. The postoperative course was uneventful and the patient was transferred to a local hospital with minor neurological deficits. Bamboo foreign bodies may show changes in properties on CT and MR imaging in the subacute stage. Careful radiological examination and follow-up monitoring are required for the correct diagnosis and treatment of such injuries.

Delayed presentation of transorbital intracranial pen

A 13 year old Fijian boy sustained a stab wound to the left orbit 3 years ago. It was not appreciated by the treating physicians in Fiji that the plastic pen had crossed from the left orbit, through the nose, right orbit and right optic nerve, into the right middle cranial fossa and lodged in the right temporal lobe and that the pen remained in situ for the past 3 years. The boy presented to Australia with a discharge from the entry wound in his left lower eyelid. The retained foreign body was not detected on computed tomography imaging, but was detected on subsequent magnetic resonance image. A combined neurosurgery/plastic surgery craniofacial approach was undertaken with successful complete removal of the retained pen, and preservation of vision in his only seeing eye.

Use of antibiotics in penetrating craniocerebral injuries. "Infection in Neurosurgery" Working Party of British Society for Antimicrobial Chemotherapy

The Working Party was instituted to investigate the rationale of prophylactic and therapeutic antibiotic use in penetrating craniocerebral injuries (PCCI), and to make recommendations for current practice. A systematic review of papers on civilian and military PCCI over the past 25 and 50 years, respectively, was done via electronic databases and secondary sources, and data were evaluated. Guidelines on the removal of indriven bone or metal fragments only if further neural damage can be avoided were supported. However, no publications were identified where the data on infection or its treatment and prevention were complete or satisfactorily derived, and no controlled trials have been published. All studies were retrospective or anecdotal. Working Party recommendations are based on the data available and the professional experience and knowledge of the members. Broad-spectrum antibiotic prophylaxis is recommended for both military and civilian PCCI, Including those due to sports or recreational injuries.

Orbital "shanking": a unique prison injury

The purpose of this paper is to describe orbitocranial penetration due to "shanking", a common mode of assault in prison facilities. We report the case of a prisoner who presented with orbital apex syndrome 5 days after an assault. He died 9 days after surgical removal of the "shank" due to a presumed ruptured traumatic aneurysm. Physicians who evaluate prisoners must maintain a high index of suspicion for penetrating injuries. The entrance site is often inconspicuous and the history may be limited in this unique population.

Penetrating pencil injury: an unusual case of child abuse

OBJECTIVE

We report an unusual case of penetrating pencil injury in a young child that turned out to be a case of physical abuse.

METHOD

This is a case report with review of the literature.

RESULTS

A 4-year-old boy was brought by his mother to the accident and emergency department for a penetrating wound of the right hand. He was said to have injured himself during a fall at home while holding a sharpened lead pencil. The pencil broke after penetrating the hypothenar eminence, leaving the graphite tip embedded in the palm. On surgical exploration, a piece of graphite measuring 1.3 cm was removed. The injury was actually inflicted by his mother because he failed to complete his homework properly. Deep penetrating injuries associated with the lead pencil are uncommon events in the medical literature. They are often reported as accidental and usually involve the oropharynx and the orbit.

CONCLUSION

Deep penetrating injury with a pencil is unusual in childhood and the public should be made aware of the possibility of nonaccidental injury.

Household objects as a cause of self-inflicted orbital apex syndrome

This report describes two cases of self-inflicted penetrating nonprojectile orbitointracranial injury. Suicide attempts caused by these types of injuries are very rare. An understanding of the orbital and intracranial anatomy and the avoidance head turn help to predict potential injury sites. Computed tomography and cerebral angiography were helpful in the treatment of these two cases.

Penetrating trauma of the posterior fossa resulting in Vernet's syndrome and internuclear ophthalmoplegia

We report the case of a young male assaulted with a screwdriver, which was embedded in the posterior fossa, causing Vernet's syndrome and internuclear ophthalmoplegia. His hospital course and the cranial nerve deficits sustained as a result of the injury with the relevant neuroanatomy are discussed.

Intracranial injuries by a screwdriver

Two patients with unusual intracranial foreign bodies are presented. Intracranial injuries produced by a piece of screwdriver as a wounding agent have not yet been reported in the literature. In one of our two cases we had to deal with homicide and in another with accidental self-inflicted injury. Both patients died, 5 and 14 days, respectively, after successful removal of the foreign body. In both cases death was due to brain ischaemia and the resulting oedema secondary to arterial injury.

Retained pieces of wood in the retromaxillary space: a case report

Detection and operative removal of wood as a foreign body in the cranio-maxillary area has received frequent attention in the literature. However, as a rule, most of the cases described are related to the orbit or the orbito-neurocranial space. Almost no literature exists on the detection and treatment of wooden foreign bodies in the retromaxillary space. The authors present an unusual case of long-term retained wood in this area in a child. The case inspires discussion of the general problem of detecting retained retromaxillary wood, even using modern diagnostic tools in this area and the question of the operative therapy, especially the most favourable surgical access.