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Kessely YC, Ndortolnan A, Toudjingar FG, Ndolembai N, Li-Iyané Ouambi O, Aggad M, Berete I, Aouami A, Dobian SR, Kader N, Berret M, Traore S, Abbassi A, Assi C, Code M. Craniocerebral Gunshot Injuries in Chad: A Study of 44 Cases. World Neurosurg 2022; 163:e458-e463. [PMID: 35398577 DOI: 10.1016/j.wneu.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Firearm head injuries cause great public health concern because of their severity. They are life-threatening due to intracranial lesions and sepsis risks. This prospective study evaluates the management of craniocerebral wounds in Chad. METHODS This is an observational study conducted over a period of 65 months with 44 patients with a ballistic craniocerebral wound (BCW), of which only 7.18% were assessed by neurosurgeons with gunshot wound. RESULTS The mean age was 30.57 ± 13 years (range:2-60 years). The 21-30 age group was the most affected (31.8%). The sex ratio was 21. A total of 63.6% of cases involved military personnel. The average admission time was 24.95 ± 12 hours (range: 1-72 hours). Explosive device attacks represented 29.5% of cases, of which 53.3% occurred in civilian practice. Point-blank shooting was reported in 70.5% of cases. The entry hole of the projectile was frontal in 40.9%. Intracranial sequestration of the projectile was found in 56.8%. Association of upper limb trauma was found in 9.1% of cases. Brain scans were performed in 95.5% of cases. Surgical treatment was undertaken in 68.18% of cases. The recovery process was marked by brain abscess in 6.8% of cases. Seven deaths were recorded. CONCLUSIONS This study shows that BCW is frequent and mainly affects young male individuals in Chad. Many of the cases were related to improvised explosive device attacks, especially in civilian practice (70.5%). The delay in diagnostic and therapeutic management favors the high rate of sequelae.
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Affiliation(s)
| | - Aser Ndortolnan
- Department of Neurosurgery, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | | | - Njesada Ndolembai
- Department of Neurosurgery, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | | | - Mourad Aggad
- Department of Neurosurgery, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Ibrahima Berete
- Department of Neurosurgery, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Aboubacar Aouami
- Division of Radiology, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Succés R Dobian
- Division of Radiology, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Ndiaye Kader
- Division of Anesthesiology, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Martine Berret
- Division of Anesthesiology, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Sorry Traore
- Division of Anesthesiology, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Adamou Abbassi
- Division of Anesthesiology, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Constant Assi
- Division of Medicine, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Momar Code
- Department of Neurosurgery, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
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Hamit AYTAR M, Şakir EKŞİ M, AYATA A, AYDIN A, DÜZ B. Transconjunctival Approach: A Safe and Effective Access to Mass Lesions in the Anterior Orbit. World Neurosurg 2022; 162:e534-e541. [DOI: 10.1016/j.wneu.2022.03.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/12/2022] [Accepted: 03/14/2022] [Indexed: 11/30/2022]
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Ares WJ, Jankowitz BT, Tonetti DA, Gross BA, Grandhi R. A comparison of digital subtraction angiography and computed tomography angiography for the diagnosis of penetrating cerebrovascular injury. Neurosurg Focus 2020; 47:E16. [PMID: 31675711 DOI: 10.3171/2019.8.focus19495] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Penetrating cerebrovascular injury (PCVI) is a subset of traumatic brain injury (TBI) comprising a broad spectrum of cerebrovascular pathology, including traumatic pseudoaneurysms, direct arterial injury, venous sinus stenosis or occlusion, and traumatic dural arteriovenous fistulas. These can result in immediate or delayed vascular injury and consequent neurological morbidity. Current TBI guidelines recommend cerebrovascular imaging for detection, but there is no consensus on the optimum modality. The aim of this retrospective cohort study was to compare CT angiography (CTA) and digital subtraction angiography (DSA) for the diagnosis of PCVI. METHODS The records of all patients presenting to two level I trauma centers in the United States between January 2010 and July 2016 with penetrating head or neck trauma were reviewed. Only those who had undergone both CTA and DSA were included. Clinical and neuroimaging data were collected, and PCVIs were stratified using a modified Biffl grading scheme. DSA and CTA results were then compared. RESULTS Of 312 patients with penetrating trauma over the study period, 56 patients (91% male, mean age 32 years) with PCVI met inclusion criteria and constituted the study cohort. The mechanism of injury was a gunshot wound in 86% (48/56) of patients. Twenty-four (43%) patients had sustained an angiographically confirmed arterial or venous injury. Compared with DSA as the gold standard, CTA had a sensitivity and specificity of 72% and 63%, respectively, for identifying PCVI. CTA had a positive predictive value of 61% and negative predictive value of 70%. Seven patients (13%) required immediate endovascular treatment of PCVI; in 3 (43%) of these patients, the injury was not identified on CTA. Twenty-two patients (39%) underwent delayed DSA an average of 25 days after injury; 2 (9%) of these patients were found to harbor new pathological conditions requiring treatment. CONCLUSIONS In this retrospective analysis of PCVI at two large trauma centers, CTA demonstrated low sensitivity, specificity, and positive and negative predictive values for the diagnosis of PCVI. These findings suggest that DSA provides better accuracy than CTA in the diagnosis of both immediate and delayed PCVI and should be considered for patients experiencing penetrating head or neck trauma.
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Affiliation(s)
- William J Ares
- 1Department of Neurological Surgery, NorthShore University Health System, Evanston, Illinois
| | - Brian T Jankowitz
- 2Department of Neurological Surgery, Cooper University Hospital, Camden, New Jersey
| | - Daniel A Tonetti
- 3Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Bradley A Gross
- 3Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Ramesh Grandhi
- 4Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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4
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Erickson BP, Feng PW, Ko MJ, Modi YS, Johnson TE. Gun-related eye injuries: A primer. Surv Ophthalmol 2019; 65:67-78. [PMID: 31229522 DOI: 10.1016/j.survophthal.2019.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 06/01/2019] [Accepted: 06/07/2019] [Indexed: 02/03/2023]
Abstract
Gun-related eye injuries are relatively common in the context of gunshot wounds to the head and neck. Many of the fundamental principles of gunshot wound management apply to the care of these patients, but the complex anatomy and functional relationships of the periocular region do pose special challenges. We provide a focused primer for physicians seeking a more in-depth understanding of gun-related eye injuries and present 3 representative cases outlining the spectrum of pathology, provide a focused review of the relevant ballistics concepts, and discuss the management of injuries to the periocular soft tissues, orbital structures, and globe. We found that good cosmetic and functional results can often be achieved with appropriate early intervention, but visual prognosis may remain guarded despite optimal treatment.
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Affiliation(s)
- Benjamin P Erickson
- Stanford Health Care, Byers Eye Institute at Stanford, Palo Alto, California, USA.
| | - Paula W Feng
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Marcus J Ko
- Nevada Centre for Eye Plastic Surgery, Reno, Nevada, USA
| | - Yasha S Modi
- Department of Ophthalmology, New York University School of Medicine, New York, New York, USA
| | - Thomas E Johnson
- Oculofacial Plastic Surgery, Bascom Palmer Eye Institute, Miami, Florida, USA
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5
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Pham T, VanWoudenberg C, Chandrasekar I. Fetal gunshot brain injury leading to late postnatal hydrocephalus. J Neonatal Perinatal Med 2019; 11:427-431. [PMID: 30149472 DOI: 10.3233/npm-17138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A male fetus was delivered by emergent caesarean section after a term pregnant mother was caught in crossfire and sustained gunshot injury to her abdomen. Examination of the infant was unremarkable except for a small laceration of the scalp at the anterior fontanelle. Skull radiography showed a dense bullet shaped opacity in the brain. He was managed conservatively and was discharged home on full feeds with normal neurological examination. He developed seizures and progressive hydrocephalus, and underwent a ventriculoperitoneal (VP) shunt placement at 5 weeks of age. At 13 months of age the bullet was removed. To our knowledge this is the first report of fetal brain injury with intact bullet in the brain with survival. This case provides the context for a discussion about factors that contribute to survival and favorable prognosis of infants with fetal penetrating gunshot brain injury.
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Affiliation(s)
- T Pham
- Valley Children's Healthcare, Madera, CA, USA
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6
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Promsopa C, Prapaisit U. Removal of intraconal bullet through endoscopic transnasal surgery with image-guided navigation system 8 months after injury: a case report. J Med Case Rep 2019; 13:65. [PMID: 30878036 PMCID: PMC6420961 DOI: 10.1186/s13256-019-2007-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 02/04/2019] [Indexed: 11/22/2022] Open
Abstract
Background Lodgment of a bullet within the orbit is uncommon. The decision to remove these objects poses a challenge to surgeons due to a high risk of complications. Currently, endoscopic transnasal surgery with navigator assistance facilitates the localization of foreign bodies allowing their safe removal with minimal surrounding tissue damage or optic nerve injury. Case presentation We describe a case of a 26-year-old Thai woman with a chronic intraorbital foreign body located within her medial intraconal space. The chronic intraorbital foreign body was successfully removed by endoscopic transnasal surgery, combined with assistance from a navigation system, 8 months after injury without any damage to her eye or disturbance in vision. Conclusion Intraconal foreign bodies, such as bullets, are a chronic problem and should be observed in the long term; prompt surgical removal should be performed if indicated.
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Affiliation(s)
- Chakapan Promsopa
- Division of Allergy and Rhinology, Department of Otolaryngology Head and Neck Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkla, 90110, Thailand.
| | - Usaporn Prapaisit
- Division of Allergy and Rhinology, Department of Otolaryngology Head and Neck Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkla, 90110, Thailand
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Wen YH, Hou WJ, Lei WB, Chen FH, Zhu XL, Wang ZF, Ma RQ, Wen WP. Clinical Characteristics and Endoscopic Endonasal Removal of Foreign Bodies within Sinuses, Orbit, and Skull Base. Chin Med J (Engl) 2018; 130:1816-1823. [PMID: 28748855 PMCID: PMC5547834 DOI: 10.4103/0366-6999.211545] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Foreign bodies within the sinuses, orbit, and skull base (FBSOS) are rare; hence, diagnosis and management guidelines are lacking. Endoscopic sinus surgery (ESS) removal is preferred because of the less invasiveness and minimal morbidity. This study was designed to summarize clinical experience with ESS management of FBSOS. Methods: We retrospectively reviewed clinical manifestations, imaging findings, treatment, and outcomes in consecutive patients with ESS removal of FBSOS between 2004 and 2015 at a tertiary academic medical center. The Chi-square test was performed to compare the infection rate between wooden and nonwooden FBSOS. Results: There were 23 male and five female patients, with median age of 11 years. FBSOS were located within the sinuses (86%), orbit (75%), and skull base/intracranial region (46%). Wooden FBSOS had a significantly higher risk of infection (78%) compared with nonwooden FBSOS (5%, P < 0.05). Contrast-enhanced computed tomography (CT) plus three-dimensional reconstruction was sensitive in all cases. Twenty-seven (96%) FBSOS were removed by ESS alone, while 1 (4%) FBSOS was removed using the combined ESS and lateral cervical approach. Four of the nine intracranial penetrating FBSOS patients had intraoperative cerebrospinal fluid (CSF) leak and received endoscopic CSF leak repair. Twelve (43%) patients suffered complications (meningitis, diplopia, and vision loss). Conclusions: ESS is a minimally invasive, safe, and promising surgical approach for FBSOS removal. Contrast-enhanced CT is effective in preoperative diagnosis and intraoperative guidance. Wooden FBSOS had higher risk of infection, thus antibiotics are recommended.
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Affiliation(s)
- Yi-Hui Wen
- Department of Otolaryngology, The First Affiliated Hospital, Otolaryngology Institute, Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Wei-Jian Hou
- Department of Otolaryngology Head and Neck Surgery, Kiang Wu Hospital, Macau 999078, China
| | - Wen-Bin Lei
- Department of Otolaryngology, The First Affiliated Hospital, Otolaryngology Institute, Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Feng-Hong Chen
- Department of Otolaryngology, The First Affiliated Hospital, Otolaryngology Institute, Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Xiao-Lin Zhu
- Department of Otolaryngology, The First Affiliated Hospital, Otolaryngology Institute, Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Zhang-Feng Wang
- Department of Otolaryngology, The First Affiliated Hospital, Otolaryngology Institute, Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Ren-Qiang Ma
- Department of Otolaryngology, The First Affiliated Hospital, Otolaryngology Institute, Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Wei-Ping Wen
- Department of Otolaryngology, The First Affiliated Hospital, Otolaryngology Institute, Sun Yat-sen University, Guangzhou, Guangdong 510080, China
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Abstract
Herein, an awkward case of globe perforation with a bullet-entering from the right posterior scapular region and leaving the body from the right orbit through the eye - is reported. Route of the bullet could be devastating - as it passed through the neck and the maxillofacial region-however by chance no vital damage occurred. Its path was assessed by plain radiography and computed tomography scans. Sometimes prediction of the trajectory is very difficult without additional radiological investigations. Especially, in the case of any high velocity projectile wounding, physician must be aware of the fact that the bullet's course will not be a linear but most probably a complicated one. Prognosis of the injury depends on the path of the bullet or shrapnel fragment, close clinical observation, an open-minded approach, and the multidisciplinary care. Moreover, even the crime investigation might be needed.
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Affiliation(s)
| | - Melis Palamar Onay
- Department of Ophthalmology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Naim Ceylan
- Department of Radiology, Ege University Faculty of Medicine, Izmir, Turkey
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9
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Gaur N, Takkar B, Sharma P. Bilateral complete blindness following globe-sparing single-bullet orbital injury. Indian J Ophthalmol 2016; 64:770-771. [PMID: 27905342 PMCID: PMC5168921 DOI: 10.4103/0301-4738.195001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Nripen Gaur
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, New Delhi, India
| | - Brijesh Takkar
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, New Delhi, India
| | - Pradeep Sharma
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, New Delhi, India
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10
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Nonmissile Penetrating Injury to the Head: Experience with 17 Cases. World Neurosurg 2016; 94:529-543. [PMID: 27350299 DOI: 10.1016/j.wneu.2016.06.062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Penetrating nonmissile injuries to the head are far less common than missile penetrating injuries. Here we describe our experience in managing 17 cases of nonmissile injury to the head, likely the largest such series reported to date. We also highlight the surgical steps and techniques used to remove in situ objects (including weapons) in the penetrating wounds that have not been described previously. METHODS We conducted a retrospective study of cases of nonmissile, low-velocity penetrating injuries of the head managed in our department. The recorded data of patients with penetrating head injuries were studied for the cause of the injury, type of object, type and extent of penetration, Glasgow Coma Scale score on admission, other clinical issues, evaluation and assessment, interval from penetration to operation, surgical steps and notes, difficulty during the operation, major and minor complications, follow-up, and ultimate outcome. RESULTS Our 17 cases included 6 cases of accidental penetration and 11 cases of penetration as the result of violence. Weapons and other foreign objects causing injury included a teta (a pointed metal weapon with a wooden handle and a barb near the tip, used for hunting and fishing) in 4 cases, a dao (a sharp metal cutting instrument with a wooden handle used for cutting vegetables, fish, meat, bamboo, wood, etc.) in 3 cases, a bamboo stick in 3 cases, a metal rod in 2 cases, a knife in 2 cases, a sharp stone in 1 case, a metal steam chamber cover in 1 case, and a long peg in 1 case. GCS on admission was between 13 and 15 in 15 cases. Only 1 patient exhibited limb weakness. Four patients with an orbitocranial penetrating injury had 1-sided vision loss; 2 of these patients had orbital evisceration, and 1 of these patients died. In 14 patients, the foreign object was in situ at presentation and was removed surgically. Computed tomography scan and plain X-ray of the head were obtained in all patients. Postoperatively, 2 patients (11.7%) needed support in the intensive care unit but died early after surgery. One patient developed late osteomyelitis. The remaining patients were doing well at the most recent follow-up. CONCLUSIONS The presenting picture of nonmissile penetrating injury to head may be daunting, but these cases can be managed with very good results with proper (clinical and radiologic) evaluation and simple neurosurgical techniques.
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11
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Andrews BT, Jackson AS, Nazir N, Hromas A, Sokol JA, Thurston TE. Orbit fractures: Identifying patient factors indicating high risk for ocular and periocular injury. Laryngoscope 2015; 126 Suppl 4:S5-11. [PMID: 26690301 DOI: 10.1002/lary.25805] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Maxillofacial trauma frequently involves the bony orbit that surrounds the ocular globe. Concomitant globe injury is a concern whenever orbit trauma occurs and in severe cases can occasionally result in vision loss. The mechanism of injury, physical exam findings, and radiographic imaging can provide useful information concerning the severity of the injury and concerns for vision loss. Using these three tools, it is hypothesized that the patient's history, physical exam, and radiographic findings can identify high-risk maxillofacial trauma patients with concomitant ocular injury. Identification of high risk patients who require comprehensive ophthalmologic evaluation may alter management and possibly preserve or restore vision. STUDY DESIGN A retrospective clinical chart review was performed at a tertiary academic medical center. METHODS Subjects were identified using the institutional trauma registry. Data collected included subject demographics, patient medical records and notes, ophthalmologic testing, and radiographic imaging. The incidence of orbit fracture and concomitant ocular injury associated with the mechanism of injury, physical exam findings, and radiographic imaging was determined. Statistical analysis was performed using a chi-square and Fisher exact test. RESULTS In this study, 279 subjects with orbit fractures were identified and the incidence of concomitant ocular injury was 27.6% (77 of 279). Mechanism of injury was statistically associated with an increased risk of ocular injury (P = 0.0340), with penetrating trauma being the most likely etiology. The physical exam findings of visual acuity and an afferent pupillary defect were statistically associated with ocular injury (P = 0.0029 and 0.0001, respectively). Depth of orbit fracture on radiographic imaging was statistically associated with ocular injury (P = 0.0024), with fractures extending to the posterior third of the orbit being most likely to have associated ocular injury. CONCLUSION Maxillofacial trauma patients with orbit fractures and concomitant ocular injury occur in more than one in four patients. Comprehensive ophthalmologic evaluation is recommended for all patients who sustain an orbit fracture. Subjects with a penetrating trauma mechanism of injury, physical exam findings of visual acuity deficits and an afferent pupillary defect, and radiographic imaging demonstrating fracture depth involvement of the posterior orbit are at highest risk for vision loss and warrant specific concern for ocular injury assessment. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Brian T Andrews
- Department of Otolaryngology and Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas, U.S.A
| | - Anee Sophia Jackson
- Department of Otolaryngology and Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas, U.S.A
| | - Niaman Nazir
- Department of Preventative Medicine and Public Health, University of Kansas Medical Center, Kansas City, Kansas, U.S.A
| | - Alan Hromas
- Department of Ophthalmology, University of Kansas Medical Center, Kansas City, Kansas, U.S.A
| | - Jason A Sokol
- Department of Ophthalmology, University of Kansas Medical Center, Kansas City, Kansas, U.S.A
| | - Todd E Thurston
- Department of Otolaryngology and Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas, U.S.A
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12
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Bizhan A, Mossop C, Aarabi JA. Surgical management of civilian gunshot wounds to the head. HANDBOOK OF CLINICAL NEUROLOGY 2015; 127:181-93. [PMID: 25702217 DOI: 10.1016/b978-0-444-52892-6.00012-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Each year close to 20000 Americans are involved in gunshot wounds to the head (GSWH). Over 90% of the victims of GSWH eventually fail to survive and only a meager 5% of the patients have a chance to continue with a useful life. One of the fundamental jobs of providers is to realize who the best candidate for the best possible management is. Recent evidence indicates that a good Glasgow Coma Scale (GCS) score at the time of admission puts such patients at high priority for management. Lack of abnormal pupillary response to light, trajectory of slug away for central gray, and visibility of basal cisterns upgrade the need for utmost care for such a victim. Surgical management is careful attention to involvement of air sinuses and repair of base dura. Patients with diffuse injury should have intraventricular intracranial pressure (ICP) monitoring and if needed a timely decompressive craniectomy. Since close to 2% of patients with penetrating brain injury may harbor a vascular injury, subjects with injuries close to the Sylvian fissure and those with the fragment crossing two dural compartments should have computed tomography angiography and if needed digital subtraction angiography to rule out traumatic intracranial aneurysms. In case of a positive study, these patients should have endovascular management of their vascular injuries in order to prevent catastrophic intracerebral hematomas and permanent deficit. Although supported by class III data, subjects of GSWH need to be on broad spectrum antibiotics for a period of 3-5 days. If cerebrospinal fluid (CSF) fistulas are observed at any time during the patient's hospital course, they should be taken very seriously and appropriate management is needed to prevent deep intracranial infections.
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Affiliation(s)
- Aarabi Bizhan
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
| | - Corey Mossop
- Walter Reed National Military Medical Center, Bethesda, MD, USA
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Gilhooly J, Siu A, Beare M, Ecklund JM. Acute management of military-related injury. HANDBOOK OF CLINICAL NEUROLOGY 2015; 127:379-93. [PMID: 25702229 DOI: 10.1016/b978-0-444-52892-6.00024-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Since the dawn of armed conflict head trauma has remained one of the most challenging afflictions for surgeons and medical personnel to treat. Interventions for head trauma from antiquity through the American Civil War were met with dismal outcomes. In the 20th century, despite greater lethality of weapons, progressive advances in management led to improved outcomes for head injured patients. A triage system consisting of appropriate levels of care from the front lines, through combat support hospitals to reconstructive and rehabilitative hospitals, has also contributed to the improved outcomes of head injured patients. This chapter examines the progressive improvement in management strategies during major conflicts, the mechanisms causing head trauma during conflict, and the current medical and surgical therapies recommended in the care of head-injured patients during armed conflict.
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Affiliation(s)
- Jonathan Gilhooly
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Alan Siu
- Department of Neurosurgery, George Washington University, Washington, DC, USA
| | - Marianne Beare
- Department of Neurosciences, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - James M Ecklund
- Department of Neurosciences, Inova Fairfax Medical Campus, Falls Church, VA, USA.
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14
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Seçer M, Ulutaş M, Alagöz F, Çınar K, Yayla E. Penetrating shrapnel injuries of the posterior fossa. Eur J Trauma Emerg Surg 2014; 41:157-60. [PMID: 26038259 DOI: 10.1007/s00068-014-0481-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Accepted: 11/18/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Gunshot injuries of the posterior fossa are rare and may follow a fatal course. In posterior fossa gunshot injuries, cerebellar hematoma, contusion, obstruction of cerebrospinal fluid (CSF) circulation by the shrapnel, and intracranial hypertension caused by autoregulation loss lead to mortality in the early stage. METHODS In this study, four cases of patients who underwent surgical intervention after penetrating shrapnel injuries of the pure posterior fossa were evaluated. RESULTS All of the patients were male; their mean age was 26.5 ± 5 years. The lowest and highest Glasgow Coma Scale scores were 4 and 12, respectively. Neural injury was detected by computed tomography performed after systemic and neurological examination following admission to the emergency service. The shrapnel was found in the cerebellar tissue in three cases and in the fourth ventricle in one case. Following preoperative procedures, surgery was performed with the patient in the prone position. Postoperative monitoring revealed no CSF fistula, meningitis, or hydrocephalus. None of the patients required revision surgery. There were no postoperative mortalities. CONCLUSION Due to the small volume of the posterior fossa, acute pathologies may lead to rapid neurological deterioration and death. Early surgical intervention and close postoperative follow-up after penetrating shrapnel injuries of the posterior fossa play a significant role in reducing mortality and morbidity.
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Affiliation(s)
- M Seçer
- Department of Neurosurgery, Deva Hospital, Osmangazi mah. 14 nolu Cadde 162/1 Şehitkamil, Gaziantep, 27560, Turkey,
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Hoffmann C, Falzone E, Dagain A, Cirodde A, Leclerc T, Lenoir B. Successful management of a severe combat penetrating brain injury. J ROY ARMY MED CORPS 2013; 160:251-4. [PMID: 24109110 DOI: 10.1136/jramc-2013-000121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We report the case of successful management of a transcranial penetrating high-energy transfer injury in a 20-year-old soldier. The bullet traversed both cerebral hemispheres and lacerated the superior sagittal sinus rendering him unconscious. We detail the care received at all stages following injury from 'Buddy Aid' on the battlefield, resuscitation by a forward medical team through to prompt neurosurgery within 2 h of injury. Subsequent aeromedical evacuation and continuing aggressive critical care has allowed the patient to survive with acceptable neurological impairment after what is generally considered an unsurvivable injury.
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Affiliation(s)
- Clément Hoffmann
- Department of Anesthesiology and Intensive Care Medicine, Percy Military Teaching Hospital, Clamart, France
| | - E Falzone
- Department of Anesthesiology and Intensive Care Medicine, Percy Military Teaching Hospital, Clamart, France
| | - A Dagain
- Department of Neurosurgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - A Cirodde
- Burns Treatment Center, Percy Military Teaching Hospital, Clamart, France
| | - T Leclerc
- Burns Treatment Center, Percy Military Teaching Hospital, Clamart, France
| | - B Lenoir
- Department of Anesthesiology and Intensive Care Medicine, Percy Military Teaching Hospital, Clamart, France
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Robiony M. Minimally Invasive Surgery: Endoscopic Removal of a Bullet from the Orbital Apex. Orbit 2013; 32:203-205. [PMID: 23663032 DOI: 10.3109/01676830.2013.777461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract I present an endoscopic approach to removal of a bullet from the orbital apex in an attempted suicide, emphasising the importance of fast, minimally invasive surgery, performing endoscopy through the bullet entrance hole, to prevent major complications and to ensure a speedy recovery.
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Affiliation(s)
- Massimo Robiony
- Department of Biological and Medical Science, University of Udine , Udine , Italy
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17
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Kazim SF, Bhatti AUA, Godil SS. Craniocerebral injury by penetration of a T-shaped metallic spanner: A rare presentation. Surg Neurol Int 2013; 4:2. [PMID: 23493510 PMCID: PMC3589838 DOI: 10.4103/2152-7806.106115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 11/30/2012] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Craniocerebral injuries caused by penetration of metallic foreign bodies present a significant challenge to neurosurgeons as an extensive surgery may be required, leading to high morbidity and mortality. CASE DESCRIPTION We describe a unique case of penetrating brain injury (PBI) caused by a T-shaped metallic spanner in an assault victim. The patient presented with profuse bleeding from the scalp and necrotic brain tissue evident at the point of entry of the retained short arm of the spanner. Skull X-ray and head computerized tomography (CT) revealed the short arm of spanner penetrating the left parieto-occipital lobe of the brain, extending up to the contralateral occipital lobe. Safe removal of the retained spanner was achieved with a craniectomy and durotomy. Postoperative CT revealed no residual metallic foreign body, and patient had a good functional and neurological outcome at six months' follow up. CONCLUSION To the best of our knowledge, the successful surgical treatment of a PBI caused by a similar metallic object has not been reported in scientific literature previously. The case is also unique considering the fact that it was managed within the medical and diagnostic constraints of an East African country.
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Affiliation(s)
- Syed Faraz Kazim
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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19
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Abstract
Orbital fractures account for a significant portion of traumatic facial injuries. Although plastic surgery literature is helpful, additional pearls and insights are provided in this article from the experience of an oculoplastic surgeon. The fundamentals remain the same, but the perceptions differ and provide a healthy perspective on a long-standing issue. The most important thing to remember is that the optimal management plan is often variable, and the proper choice regarding which plan to choose rests upon the clinical scenario and the surgeon having an honest perception of his or her level of expertise and comfort level.
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20
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Jimenez CM, Polo J, España JA. Risk factors for intracranial infection secondary to penetrating craniocerebral gunshot wounds in civilian practice. World Neurosurg 2012; 79:749-55. [PMID: 22722035 DOI: 10.1016/j.wneu.2012.06.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 04/09/2012] [Accepted: 06/14/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine risk factors for intracranial infection secondary to penetrating craniocerebral gunshot wounds (PCGWs) in civilian practice, in patients who underwent surgery with removal of bullet fragments, wound debridement, and watertight dural closure. METHODS An observational, analytical, prospective, cohort-type study was conducted with follow-up in a group of patients with PCGWs caused by a low-velocity projectile admitted between January 2000 and November 2010. There were 160 patients, 59 of whom were administered prophylactic antibiotics based on the decision of the treating neurosurgeon. Average follow-up time was 39 months (range, 3-92 months). RESULTS Infection occurred in 40 patients (25%); 20 patients received antibiotics (20 of 59 [33.9%]), and 20 patients did not receive antibiotics (20 of 101 [19.8%]). Three variables were independent risk factors for infection: (i) persistence of parenchymal osseous or metallic fragments after surgery (P < 0.0001, relative risk [RR] 7.45); (ii) projectile trajectory through a natural cavity with contaminating flora (P = 0.03, RR 2.84); and (iii) prolonged hospitalization time (P < 0.0001, RR 3.695). CONCLUSIONS Administration of prophylactic antibiotics was not associated with the incidence of intracranial infection secondary to PCGWs. Projectile trajectory through potentially contaminating cavities, persistence of intraparenchymal osseous or metallic fragments after surgery, and prolonged hospital stay were independent risk factors for intracranial infection.
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Affiliation(s)
- Carlos Mario Jimenez
- Neurosurgery Service, University of Antioquia, Hospital Universitario San Vicente de Paul, Medellin, Colombia.
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21
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Wu W, Cannon PS, Selva D, Tu Y, Wu Q. Endoscopic transorbital approach for repair of cerebrospinal fluid leakage following removal of an orbito-cranial foreign body. Clin Exp Ophthalmol 2011; 39:375-7. [DOI: 10.1111/j.1442-9071.2010.02465.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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22
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Meco C, Tezcaner CZ, Tuna H, Gokcan K, Attar A, Anadolu Y. Transfacial transsphenoidal gunshot wound: endonasal endoscopic management. THE JOURNAL OF TRAUMA 2010; 68:E94-E98. [PMID: 20386268 DOI: 10.1097/ta.0b013e3181b5da43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Cem Meco
- Department of Otorhinolaryngology-Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey.
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23
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Concomitant cranial and ocular combat injuries during Operation Iraqi Freedom. ACTA ACUST UNITED AC 2009; 67:516-20; discussion 519-20. [PMID: 19741393 DOI: 10.1097/ta.0b013e3181a5f08d] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Concomitant cranial and ocular injuries were frequently seen in combat casualties during Operation Iraqi Freedom. The incidence of these injuries is reported along with an interventional case series. METHODS A retrospective review was conducted of all surgical patients treated by U.S. Army neurosurgeons and ophthalmologists in Iraq from December 2005 to April 2006. RESULTS Out of 104 patients with cranial trauma and 158 patients with ocular trauma, 34 had both cranial and ocular injuries (32.7 and 21.5% of patients with cranial and ocular injuries, respectively). Neurosurgical procedures included exploratory craniotomy, decompressive craniectomy, and frontal sinus surgery. Ophthalmologic surgical procedures included globe exploration, open globe repair, primary enucleation, orbital fracture repair, lateral canthotomy and cantholysis, and repair of lid and periocular lacerations. Patients with cranial trauma had a higher incidence of orbital fracture, orbital compartment syndrome, and multiple ocular injuries compared with patients without cranial trauma (odds ratio 6.4, 3.9, and 3.3, respectively). CONCLUSION A strong association exists between cranial and ocular trauma in combat casualties treated during Operation Iraqi Freedom. Combat health support personnel should maintain a high level of suspicion for one of these injuries when the other is present. Co-locating neurosurgeons and ophthalmologists in support of combat operations facilitates the optimal treatment of patients with these combined injuries.
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Offiah C, Twigg S. Imaging assessment of penetrating craniocerebral and spinal trauma. Clin Radiol 2009; 64:1146-57. [PMID: 19913123 DOI: 10.1016/j.crad.2009.06.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Revised: 06/16/2009] [Accepted: 06/26/2009] [Indexed: 11/30/2022]
Abstract
Craniocerebral and spinal penetrating trauma, which may be either missile (most typically gun-related) or non-missile (most typically knife-related), is becoming an increasingly common presentation to the urban general and specialized radiology service in the UK. These injuries carry significant morbidity and mortality with a number of criteria for prognosis identifiable on cross-sectional imaging. Potential complications can also be pre-empted by awareness of certain neuroradiological features. Not all of these injuries are criminal in origin, however, a significant proportion will be, requiring, on occasion, provision of both ante-mortem and post-mortem radiological opinion to the criminal investigative procedure. This review aims to highlight certain imaging features of penetrating craniocerebral and spinal trauma including important prognostic, therapeutic, and forensic considerations.
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Affiliation(s)
- C Offiah
- Department of Neuroradiology, The Royal London Hospital, Barts and The London NHS Trust, Whitechapel, London, UK.
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25
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Chattopadhyay S, Sukul B, Das SK. Fatal transorbital head injury by bicycle brake handle. J Forensic Leg Med 2009; 16:352-3. [PMID: 19573849 DOI: 10.1016/j.jflm.2009.01.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Accepted: 01/14/2009] [Indexed: 12/12/2022]
Abstract
Accidental transorbital head injuries are quite rare. Penetrating head injuries by blunt objects are possible when the site of penetration is through the orbit or the thin temporal bone. The present case is a rare case of transorbital penetrating head injury by a blunt object - bicycle brake handle. Minor external wounds may be misleading and fatal consequences may ensue if cerebral damage is missed on diagnosis. Proper antibiotic coverage to prevent meningitis and neurosurgical intervention can reduce mortality in such cases.
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Affiliation(s)
- Saurabh Chattopadhyay
- Department of Forensic and State Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India.
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27
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Liu SY, Cheng WY, Lee HT, Shen CC. Endonasal transsphenoidal endoscopy-assisted removal of a shotgun pellet in the sphenoid sinus: a case report. ACTA ACUST UNITED AC 2008; 70 Suppl 1:S1:56-9. [PMID: 18789498 DOI: 10.1016/j.surneu.2008.04.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Accepted: 04/27/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Gunshot accidents are not uncommon in Taiwan, but involvement limited to the ocular region and sphenoid sinus is rare. Minimal invasive treatment by endonasal transsphenoidal endoscopy-assisted procedure should be considered if there are no additional injuries in the craniocerebral region. CASE DESCRIPTION A 39-year-old man had severe pain in the left eye with resulting blindness after being accidentally hit in the left eye by a gunshot pellet while walking in a wooded area. He was referred from another hospital with the impression of left eyeball rupture. There was no severe neurologic deficit except for blindness of the left eye when he arrived at the emergency department of our hospital. Brain and orbits CT scans showed a round metallic foreign body at the right sphenoid sinus without predominant damages of brain parenchyma. Endonasal transsphenoidal endoscopy-assisted procedure was used to remove the shotgun pellet, and the patient had good clinical outcomes. CONCLUSION Herein we present this rare case to show the possibility of a shotgun pellet injury remaining in the sphenoid sinus. The role of radiological studies such as CT scans and intraoperative C-arm fluoroscope plain films in diagnosis and management of this case is affirmed. The strategy of minimally invasive treatment by endonasal transsphenoidal endoscopy-assisted procedure for those limited injuries is a good choice for treatment.
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Affiliation(s)
- Szu-Yuan Liu
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung 40705, Taiwan, ROC
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29
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Prevention and Management of Infections Associated With Combat-Related Head and Neck Injuries. ACTA ACUST UNITED AC 2008; 64:S265-76. [DOI: 10.1097/ta.0b013e318163d2a6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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30
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Feichtinger M, Zemann W, Kärcher H. Removal of a pellet from the left orbital cavity by image-guided endoscopic navigation. Int J Oral Maxillofac Surg 2007; 36:358-61. [PMID: 17229549 DOI: 10.1016/j.ijom.2006.11.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2006] [Revised: 07/07/2006] [Accepted: 11/23/2006] [Indexed: 11/30/2022]
Abstract
In the cranio-maxillofacial field, computer-aided surgery based on computed tomography data is becoming increasingly important. Complex surgical procedures can be performed utilizing preoperative imaging to provide real-time localization of surgical instruments in the surgical field. Image-data-based navigation plays an ever-increasing role in cases of minimal invasive surgery. The case is presented here of a 58-year-old male patient referred after a hunting accident with a pellet in the left orbit. After transferring the preoperatively acquired computed tomography data to a commercially available navigation system, the bullet was removed through the original wound canal using an intraoperatively calibrated high-resolution endoscope.
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Affiliation(s)
- M Feichtinger
- Clinical Department of Oral and Maxillofacial Surgery, Medical University of Graz, Austria.
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31
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Hare SS, Goddard I, Ward P, Naraghi A, Dick EA. The radiological management of bomb blast injury. Clin Radiol 2007; 62:1-9. [PMID: 17145257 DOI: 10.1016/j.crad.2006.09.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Revised: 08/31/2006] [Accepted: 09/07/2006] [Indexed: 11/26/2022]
Abstract
A need to understand the nature and patterns of bomb blast injury, particularly in confined spaces, has come to the fore with the current worldwide threat from terrorism. The purpose of this review article is to familiarize the radiologist with the imaging they might expect to see in a mass casualty terrorist event, illustrated by examples from two of the main institutions receiving patients from the London Underground tube blasts of 7 July 2005. We present examples of injuries that are typical in blast victims, as well as highlighting some blast sequelae that might also be found in other causes of multiple trauma. This should enable the radiologist to seek out typical injuries, including those that may not be initially clinically apparent. Terror-related injuries are often more severe than those seen in other trauma cases, and multi-system trauma at distant anatomical sites should be anticipated. We highlight the value of using a standardized imaging protocol to find clinically undetected traumatic effects and include a discussion on management of multiple human and non-human flying fragments. This review also discusses the role of radiology in the management and planning for a mass casualty terrorist incident and the optimal deployment of radiographic services during such an event.
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Affiliation(s)
- S S Hare
- Department of Radiology, St Mary's Hospital, London, UK.
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