Delayed presentation of transorbital intracranial pen

Surviving a Self-inflicted Transorbital Pen Intrusion to the Cerebellum: Case Report

BACKGROUND

 Although intracranial traumas by penetrating foreign objects are not absolute rarities, the nature of trauma, the kind of object, and its trajectory make them a one of a kind case every time they occur. Whereas high-velocity traumas mostly result in fatalities, it is the low-velocity traumas that demand an individualized surgical strategy.

METHODS

 We present a case report of a 33-year-old patient who was admitted to our department with a self-inflicted transorbital pen injury to the brain. The authors recall the incident and the technique of the pen removal.

RESULTS

 Large surgical exposure of the pen trajectory was considered too traumatic. Therefore, we opted to remove the pen and have an immediate postoperative computed tomography (CT) scan. Due to its fragility, the pen case could only be removed with a screwdriver, inserted into the case. Post-op CT scan showed a small bleeding in the right peduncular region, which was treated conservatively. The patient was transferred back to intensive care unit and woken up the next day. She lost visual function on her right eye, but suffered from no further neurologic deficit.

CONCLUSION

 Surgical management of removal of intracranial foreign bodies is no routine procedure. Although some would favor a large surgical exposure, we could not think of an approach to do so without maximum surgical efforts. We opted for a minimal surgical procedure with immediate CT scan and achieved an optimal result. We find this case to be worth considering when deciding on a strategy in the future.

Rubber Bullet Induced Traumatic Brain Injury

ABSTRACT

Rubber bullets have long been known to cause, on rare occasions, traumatic brain injury (TBI). However, neurosurgical literature on this occurrence is limited, and no focused review of this injury pattern has been conducted. The authors present the case of a 28-year-old male struck by a rubber bullet in the left periorbital region, causing TBI in addition to complete left visual loss and complex facial fractures. After developing a cerebrospinal fluid (CSF) leak, the patient was taken to the operating room for combined neurosurgical-craniofacial intervention. Utilizing frameless intraoperative computation tomography navigation assistance, a successful repair was made of both the patient's CSF leak and complex craniofacial injuries. TBI due to a rubber bullet is a rare but severe occurrence. Unfortunately, much of the limited literature on this topic is bereft of demographic, clinical course, injury pattern, and imaging data. Presented here is the first operative case report of TBI due to a rubber bullet. Volume rendered imaging is provided to demonstrate the extent of trauma incurred. Additionally, a methodology for frameless intraoperative computation tomography navigation assistance is shared for consideration, as it served as a helpful adjunct for a combined intracranial-craniofacial surgical repair. The experience of treating the patient's traumatic CSF leak in the context of severe craniofacial and ophthalmologic injuries highlights the need for a multidisciplinary surgical approach that may arise when treating patients with TBI due to a rubber bullet.

Penetrating Midface Trauma: A Case Report, Review of the Literature, and a Diagnostic and Management Protocol

PURPOSE

Penetrating facial trauma is an uncommon injury, but patients who present with these dramatic situations require special consideration. We describe the case of a young man who had been shot with an arrow that deeply penetrated his midface as well as report the results of a literature review of penetrating midface injuries. The information gathered was used to create a diagnostic protocol for patients who sustain such injuries.

METHODS

A PubMed search up to October 2019 using several key phrases was performed, and 623 unique articles were evaluated. Excluding firearm injuries to the midface, there were 57 unique cases that involved penetrating midface injuries. Clinical and imaging data were compiled and evaluated with descriptive statistical analysis.

RESULTS

The average patient age was 27 years, with a male predilection. The most common reported etiology was accidental trauma (54%), and a knife was the most common weapon of injury (30%). The most common (32%) specific location of trauma was within the orbital region, including the canthus or the eyelid. In all cases where the patient had not died immediately, surgery was used to remove the penetrating object. We found that computed tomography was the most commonly obtained imaging study (39% of cases). Radiographs were the sole imaging in 28% of the cases, with angiography (16%) and magnetic resonance imaging (10%) used less frequently in management. In 28% of the cases, deep structures, such as the carotid artery, sphenoid sinus, or skull base, were involved in the injury. In 25% of the cases, there was injury to the central nervous system. Death occurred in 8.8% of the cases. Postoperative complications occurred in at least 21% of the cases. Statistical analysis also revealed a significant correlation between antibiotic use and full recovery. Penetration of the object posterior to the maxillary sinus was correlated with incomplete recovery or death.

CONCLUSIONS

Based on all case reports collected, a Dartmouth Penetrating Midface Protocol was developed to aid the practitioner who may happen to be responsible for these dramatic life-threatening injuries. The Dartmouth Penetrating Midface Protocol is based on the type of imaging available at the treating facility, the neurologic and hemodynamic stability of the patient, and the depth of penetration beyond the posterior wall of the maxillary sinus.

Craniofacial penetration by a wooden stick

INTRODUCTION

Penetrating craniofacial injuries caused by stick-like foreign bodies occur as a result of accidents particularly in children, and often lead to significant morbidity.

CASE SUMMARY

We describe a 5-year-old boy who sustained facial trauma after falling on a wooden stick which penetrated his left cheek. At the initial visit, his vital and neurological signs were normal. However, the stick had penetrated the frontal lobe to a depth of 3cm via the orbital cavity and the anterior skull base. The stick was successfully removed while visualizing the anterior skull base in an endoscopic transethmoidal approach. A follow-up examination one year after the accident demonstrated normal visual acuity and ocular motility, with no diplopia, tearing or pain.

DISCUSSION

Penetrating facial injuries caused by stick-like objects carry a significantly higher risk of serious neurological involvement. Even if penetrating facial injuries sometimes appear trivial, the external injury site is often insufficient to determine the position of the object within the head. Although the cheek is a rare entry site for intracranial injuries, the extent of damage should be assessed fully before attempting removal.

Intracranial Migration of a Broken Rod After Orbitocranial Injury in an Adult

BACKGROUND

Craniocerebral injuries due to the induction of sharp objects are relatively rare and are nearly always observed in the pediatric rather than the adult population. Orbitocranial injuries involving a piece of smooth steel rod are extremely rare and to our knowledge have yet to be reported in previous publications. When this particular category of injury does occur, the invading intracranial foreign body usually remains lodged within its entry position. This is most often near the entry point and within the frontal lobe after penetrating the orbit. Migration of the penetrating object far from the initial entry point is quite rare and has been historically confined to low-velocity bullet wounds.

CASE DESCRIPTION

An adult man was injured on the right eyelid by a section of steel rod. The rod had entered the cranium through the right orbital roof and was lodged within the corresponding right frontal lobe. An initial plain radiograph showed that the rod was within the right frontal lobe. However, computed tomographic angiography of the brain performed during the second day of admission demonstrated displacement of the rod to the left hemisphere. This finding was clearly demonstrated through subsequent imaging. As a result of the migration, the rod could be distracted fairly easily through a left parasagittal and interhemispheric approach. Postoperatively, the patient made a full recovery.

CONCLUSIONS

Migration of traumatically introduced intracranial foreign bodies far from their initial entry places should be suspected in objects possessing sufficient weight and a smooth surface. This means that a correct assessment of the final position of such objects is necessary before surgery, even while the patient is on the operating table.

Presentation, workup, and management of penetrating transorbital and transnasal injuries: A case report and systematic review

BACKGROUND

A foreign body (FB) penetrating intracranially after passing transorbitally or transnasally is a rare occurrence. However, otolaryngologists are increasingly being asked to participate in the care of these patients for both endoscopic removal of the object and repair of any skull base defects.

OBJECTIVE

To assess the presentation, workup, and management of transnasal or transorbital penetrating FB injury.

METHODS

Systematic review of the presentation, workup, and management of transnasal or transorbital penetrating FB injury; plus, a case report of a 53-year-old woman with a transorbital penetrating rose bush branch. We searched medical literature data bases, which resulted in 215 total titles, which were then narrowed based on inclusion and exclusion criteria.

RESULTS

Thirty-five cases of transorbital or transnasal low-velocity trauma that involved the paranasal sinuses were reviewed from 33 articles. The average age was 30 years, 40% of the objects were made of wood. Fifty-seven percent of the cases were transorbital, whereas 43% were transnasal. Forty-six percent of the surgical interventions were completed endoscopically or with endoscopic assistance. Complications of injury were common, with 66% of patients experiencing cerebrospinal fluid leaks; 23%, permanent blindness; 17%, meningitis; 14%, ophthalmoplegia; 9%, decreased visual acuity; and 3%, brain abscess. Our patient presented with a traumatic cerebrospinal fluid leak, and recovered well after transorbital and endoscopic removal of the branch, skull base repair, and a prolonged course of antibiotics and antifungal medications.

CONCLUSIONS

Transnasal and transorbital penetrating FB injuries are a relatively uncommon occurrence but when they do occur require rapid workup and interdisciplinary management to prevent acute and delayed complications.

Transorbital penetrating brain injury by a wooden stick: A neuro-ophthalmologic emergency

Accidental penetrating brain injury through transorbital route is an unusual occurrence in emergency practice of civilian cases. At time, it could be potentially life threatening. We report an interesting case of transorbital penetrating brain injury with a wooden stick in a 44-year-old male epileptic patient. The stick was removed successfully through transorbital exploration, without any neurovascular complications. The pertinent literature is reviewed and emergent management of such cases is discussed.

Neurosurgical Management of Nonmissile Penetrating Cranial Lesions

OBJECTIVE

The objective of this study is to present a case series of nonmissile penetrating (NMP) injuries and to establish a workflow for an uncommon mechanism of traumatic head injury through the analysis of each case, classification of the type of lesion, management, and outcome score at follow-up.

METHODS

From January 1991 to December 2008, 36,000 patients presenting with traumatic brain injury (TBI) were admitted in the Department of Neurosurgery, Hospital Antônio Targino, Campina Grande-PB, Brazil. From these patients, 11 presenting with lesions caused by NMP objects were selected.

RESULTS

Among the 11 patients, 9 were men and 2 were women. Their ages ranged from 7 to 74 years old (mean age ± SD, 29.1 ± 22.99 years). All patients underwent neuroradiologic evaluation. The entry point was classified as natural (orbit) or artificial (skull transfixation), and we also divided the patients presenting with secondary parenchymal or vascular damage from those presenting with only lesions caused by the primary penetration into the cranium and meninges. All patients were neurosurgically treated with removal of the foreign body through craniotomy, except the patient whose object (pen) was removed without craniotomy with local anesthesia. Glasgow Coma Scale (GCS) score on admission was a statistically significant factor on prognosis, and any patient who presented with a GCS score of 15 evolved satisfactorily, and there were no deaths in this group of patients (P = 0.04).

CONCLUSIONS

TBIs caused by NMP objects are unusual and caused by aggression, self-inflicted harm (in the case of psychiatric patients), and accident. The foreign body may enter into the skull through a natural hole (orbit, nose, mouth, or ear) or crosses the skull, causing a fracture and creating an artificial hole. Preoperative neuroradiologic assessment is paramount for the correct neurosurgical approach. The main prognostic factor for these patients is the GCS score at admission.

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.

Unusual intraorbital foreign body

A case of a 41-year-old patient presenting late post-trauma with out any major signs or symptoms is presented herewith. On radiological investigation, a peculiar foreign body was identified in the orbital floor. To our surprise the point of entry of the foreign body was not proportionate with the size of it. Moreover, the trajectory and final location of foreign body did not concur with the symptom less presentation of patient. After what was thought to be adequate investigation, the patient was taken under general anaesthesia to reveal an additional foreign body that put most of the preoperative queries to rest. This case in retrospect emphasises the need for ruling out foreign body in the case of any penetrating injury of orbit with the help of not just radiographs and CT scans but also ultrasonography and MRI.

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.

Orbitocerebral injury by a knife: case report

Orbital penetrating injuries may cause significant harm to the optic nerves and eyeball as well as to the brain and cerebral vessels. Management of orbital foreign bodies should include prompt recognition of the extent of the injury, broad-spectrum parenteral antibiotics, tetanus prophylaxis, anticonvulsant medication and early surgical intervention under direct vision to remove the foreign body and to avoid immediate and long-term complications. We report a penetrating orbital injury caused by a bread knife that extended from the orbit to the tegmental dura mater of the temporal bone. The knife's main trajectory coursed through the temporal lobe. Adjacent cerebral structures were explored before removal of the knife.

Transorbital penetrating brain injury by branchlet: a rare case

Penetrating injury of the brain and skull is uncommon, representing about 0.4% of head injuries. With advances in radiological techniques such as high-resolution and reconstruction computed tomography (CT), assessment of injuries is more accurate and easier. In this article, we report the case of a 46-year-old man presenting with head injury after a branchlet had penetrated through the right orbit into the brain. CT scan of the brain revealed diffuse subarachnoid hemorrhage, intraventricular hemorrhage, and mild obstructive hydrocephalus. CT scan of the brain with reconstruction revealed that the branchlet tip penetrated through the medial aspect of the right orbit to the parasellar region. CT scan of the brain with contrast showed gradual tapering of the right proximal internal carotid artery with total occlusion after the carotid bulb. Advance radiological examinations, such as three-dimensional CT, are required to obtain the correct emergent diagnosis and treatment of such injuries.

Management of transorbital brain injury

Transorbital brain injuries caused by metal bar penetration are uncommon and often cause serious damage without prompt treatment. Artifacts caused by the penetrating metal bar on computed tomography (CT) often obscure the actual brain damage along the path of penetration, and delayed treatment for the brain insult may result. We present 2 cases of transorbital brain injury following penetration by a metal bar. CT scans were initially performed on both patients. However, image resolution was poor and the extent of brain damage could not be ascertained due to severe artifacts associated with the metal bars. Both patients deteriorated in the emergency room and subsequently received surgical intervention. One patient recovered uneventfully. Unfortunately, the other patient died following surgery due to an unrecognized intracranial hemorrhage with brain herniation. Based on this experience, we recommend prompt surgical decompression with early CT follow-up to determine the true extent of brain damage and assess for possible delayed events inpatients with extended transorbital brain injuries caused by metal bars.

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.

Souvenir knife: a retained transcranial knife blade

Upon necroscopic examination of a homeless male found comatose in the street and pronounced dead at a medical center 12 hours later, a sharp tip of a knife lodged in the right parietal region of his skull was incidentally discovered. The blade transected the diploe and penetrated the cerebral cortex. Subsequent police investigation revealed that this was the remnant of a stabbing attempt on his life several months prior to his death. The cause of death was determined to be unrelated to the metallic blade fragment, thus making it a truly incidental and rare finding of a "souvenir knife." Nevertheless, since the injury sustained in the stabbing was potentially life threatening, the investigation into that assault was reopened.A case report is presented, along with a brief review of the literature on "souvenir objects."