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

Transorbital penetrating intracranial injury involving bilateral frontal lobes with evisceration of right eye: A case report

Key Clinical Message

Timely diagnosis, multidisciplinary surgical intervention, and appropriate imaging are crucial in managing transorbital-penetrating intracranial injuries (TOPIs), minimizing morbidity, and optimizing patient outcomes.

Abstract

Transorbital-penetrating intracranial injuries (TOPIs) are rare occurrences with potential for severe neurological complications and high mortality rates. Prompt diagnosis and management are essential to mitigate adverse outcomes. Understanding injury patterns and employing appropriate imaging modalities are crucial for effective surgical planning and patient care. We present a case of a 22-year-old male mechanic who sustained a TOPI involving bilateral frontal lobes with evisceration of the right eye following a workplace accident with a metal cutter. Upon arrival at the emergency department, the patient exhibited vision loss in the right eye, proptosis, and a dilated pupil. Imaging studies revealed the trajectory of a metal arrow through the right orbital roof, necessitating surgical intervention. A multidisciplinary team performed bifrontal craniectomy with duroplasty to remove the foreign body and address associated injuries. Postoperatively, the patient received broad-spectrum antibiotics and anticonvulsants, leading to full recovery and discharge on postoperative day 10. TOPIs present unique challenges due to their rarity and potential for devastating consequences. Our case highlights the importance of timely diagnosis, meticulous surgical planning, and multidisciplinary collaboration in achieving favorable outcomes. Radiological imaging plays a crucial role in guiding treatment decisions and optimizing patient care. This report underscores the significance of early surgical intervention, antimicrobial therapy, and prophylactic measures in reducing morbidity and mortality associated with TOPIs.

Penetrating Orbital Trauma by Large Foreign Body: Case Series Study with Treatment Guidelines and Literature Review

Purpose

The present study aims to describe a case study of large penetrating orbital trauma and treatment guidelines associated with a review of English-language literature of large foreign bodies impacting the orbit from 1997 to 2020.

Patients and Methods

Five patients suffered large penetrating orbital trauma and required emergency surgical procedures.

Results

Together with this present study, a total of 33 cases were selected. The present work has data similar to the literature, and emergency surgical treatment was required in the majority of the cases.

Conclusion

Penetrating orbital trauma by large objects is a challenge. The initial assessment and treatment are fundamental to determine the case severity. The large foreign body should be surgically removed by a trained and experienced team in an advanced hospital unit as soon as possible to minimize visual, functional and aesthetic sequelae.

Retrograde cranio-orbital penetrating injury: A case report

Background

Transorbital (Orbito-cranial) injuries are uncommon, but they are among the most debilitating types of traumatic brain injury (TBI), mainly caused by high-velocity gunshot wounds. In addition, the management of transorbital TBI is well documented in the literature. In contrast, the cranio-orbital migration of a bullet following TBI is rarely reported. In this article, we report a reverse cranio-orbital penetration of a bullet after a TBI from the occiput with a discussion about its management.

Case Description

A 34-year-old male presented with a loss of consciousness to the emergency department. His Glasgow Coma Scale was 10 (E3, V3, M4), with a left-sided weakness grade of 3 on the Medical Research Council of Canada scale. A head computed tomography (CT) scan was performed, which revealed a bullet embedded in the right orbit with an entrance point from the right occipital bone. Moreover, the CT scan showed an intraventricular hemorrhage in the lateral ventricle. The surgery was performed where the hematoma was evacuated, the scalp was debrided, and the bullet was removed successfully. However, the patient died on the 7^th postoperatively.

Conclusion

Cranio-orbital penetrating brain injury is a severe yet rare type of penetrating brain injury. The direction of cranio-orbital injury is usually from the orbital region to the cerebrum. In our case, the retrograde fashion of the bullet migration renders it unique and calls for further studies to highlight the differences in injury and management of such cases.

Fatal transorbital-intracranial penetrating injury- A case report

Transorbital injuries are rare and may lead to fatal craniocerebral damage. Ocular penetrating injuries account for 24% of all penetrating head injuries in adults, while this percentage goes up to 45% in children. Any penetrating injury through the eyes may enter the intracranial cavity and might prove fatal to the victim owing to cerebral tissue damage and complex management. The dead bodies of three victims were found by the side of the river with multiple injuries to their eyes. Further examination revealed that they had sustained multiple transorbital-intracranial injuries. In such cases, identifying injury patterns is vital so that cause and manner of death can be determined precisely. A thorough postmortem examination can help identify the alleged weapon involved in the act and may clear the doubts concerned with the manner of death.

Nonmissile penetrating head injury with a wooden table leg: An illustrative case

Penetrating head injuries are relatively uncommon and require a unique approach. This report highlights a previously unreported mechanism of injury with a table leg and the steps required to evaluate and promptly treat the patient.

Transorbital-penetrating intracranial injury due to a homemade metal arrow: A case report

A transorbital-penetrating intracranial injury (TOPI) is an unusual traumatic brain injury. This rare injury has the potential to result in serious and fatal brain damage with a high mortality rate and requires prompt multidisciplinary surgical intervention. Here, we describe an interesting case in which a patient who presented with accidental penetrating injuries of the brain was found to have a transorbital-penetrating intracranial injury (TOPI). We chose an anterior approach to the foreign body above the entrance wound for removal in a retrograde manner with fluoroscopic guidance. The patient remained well with no complications and was discharged on postoperative day 10. Reasonable diagnostic imaging, surgical planning, and careful post-surgery management can increase patients successful outcomes.

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A transorbital-penetrating intracranial injury (TOPI) is an uncommon traumatic brain injury.

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TOPIs have the potential to result in serious brain damage with a high mortality rate.

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An interesting case of accidental TOPI that was treated successfully with fluoroscopic guidance is presented.

Complications, outcomes, and management strategies of non-missile penetrating head injuries

OBJECTIVE

While high-velocity missile injury (gunshot) is associated with kinetic and thermal injuries, non-missile penetrating head injury (NMPHI) results in primary damage along the tract of the piercing object that can be associated with significant secondary complications. Despite the unique physical properties of NMPHI, factors associated with complications, expected outcomes, and optimal management have not been defined. In this study, the authors attempted to define those factors.

METHODS

Consecutive adult patients with NMPHI who presented to Tygerberg Academic Hospital (Cape Town, South Africa) in the period from August 1, 2011, through July 31, 2018, were enrolled in a prospective study using a defined treatment algorithm. Clinical, imaging, and laboratory data were analyzed.

RESULTS

One hundred ninety-two patients (185 males [96%], 7 females [4%]) with 192 NMPHIs were included in this analysis. The mean age at injury was 26.2 ± 1.1 years (range 18-58 years). Thirty-four patients (18%) presented with the weapon in situ. Seventy-one patients (37%) presented with a Glasgow Coma Scale (GCS) score of 15. Weapons included a knife (156 patients [81%]), screwdriver (18 [9%]), nail gun (1 [0.5%]), garden fork (1 [0.5%]), barbeque fork (1 [0.5%]), and unknown (15 [8%]). The most common wound locations were temporal (74 [39%]), frontal (65 [34%]), and parietal (30 [16%]). The most common secondary complications were vascular injury (37 patients [19%]) and infection (27 patients [14%]). Vascular injury was significantly associated with imaging evidence of deep subarachnoid hemorrhage and an injury tract crossing vascular territory (p ≤ 0.05). Infection was associated with delayed referral (> 24 hours), lack of prophylactic antibiotic administration, and weapon in situ (p ≤ 0.05). A poorer outcome was associated with a stab depth > 50 mm, a weapon removed by the assailant, vascular injury, and eloquent brain involvement (p ≤ 0.05). Nineteen patients (10%) died from their injuries. The Glasgow Outcome Scale (GOS) score was linearly related to the admission GCS score (p < 0.001). One hundred forty patients (73%) had a GOS score of 4 or better at discharge.

CONCLUSIONS

The most common NMPHI secondary complications are vascular injury and infection, which are associated with specific NMPHI imaging and clinical features. Identifying these features and using a systematic management paradigm can effectively treat the primary injury, as well as diagnose and manage NMPHI-related complications, leading to a good outcome in the majority of patients.

Transorbital nonmissile penetrating brain injury: Report of two cases

BACKGROUND

Penetrating brain injury (PBI) is an uncommon emergency in neurosurgery, and transorbital PBI is a rare type of PBI. Reasonable surgical planning and careful postoperative management can improve the prognosis of patients

CASE SUMMARY

The first case is a 68-year-old male patient who was admitted to the hospital because a branch punctured his brain through the orbit for approximately 9 h after he unexpectedly fell while walking. After admission, the patient underwent emergency surgical treatment and postoperative anti-infection treatment. The patient was able to follow instructions at a 4-mo follow-up review. The other case is a 46-year-old male patient who was admitted to the hospital due to an intraorbital foreign body caused by a car accident, after which the patient was unconscious for approximately 6 h. After admission, the patient underwent emergency surgical treatment and postoperative anti-infection treatment. The patient could correctly answer questions at a 3-mo follow-up review.

CONCLUSION

Transorbital PBI is a rare and acute disease. Early diagnosis, surgical intervention, and application of intravenous antibiotics can improve the prognosis and quality of life of patients.

On a knife-edge: clinical uncertainty with an extensive knife blade in situ in the craniofacial region

A 25-year-old man presented to the trauma department following a penetrating stab wound to his left infraorbital margin with retained knife blade causing superoposterior displacement of the globe. Plain skull X-ray revealed an extensive retained blade with subsequent CT imaging revealing the tip of the blade had reached the right styloid process with no neurovascular compromise. Initial concern was primarily for the left eye leading to ophthalmology being the first specialty requested to review the patient. However, once the extent of the injury was established, ophthalmology requested further review from maxillofacial, ENT and neurosurgery. This resulted in an 84 hours wait between the initial injury and the removal of the knife blade. Incredibly, the patient had no initial sequelae from such an extensive injury and had an unremarkable recovery with no further complications aside from a laceration to the left inferior rectus muscle that was conservatively managed.

Nonmissile Penetrating Head Injuries: Surgical Management and Review of the Literature

BACKGROUND

Nonmissile penetrating head injuries (NPHIs) in the civilian population are rare but potentially fatal. Although numerous cases have been reported in the literature, the surgical management of such injuries is still ambiguous, especially with development of surgical techniques. Here, we report 5 cases of NPHIs managed with different surgical techniques and review the literature on surgical treatment of these injuries to outline the appropriate management for these patients from a neurosurgical perspective.

METHODS

We retrospectively reviewed 5 cases of NPHIs managed surgically in our department. The clinical data were collected, including cause, type of objects, way of penetration, initial clinical evaluation, imaging, surgical intervention, postoperative care, complication, follow-up, and outcome. In addition, a systematic review of the literature was performed in the PubMed database to search for articles on surgical treatment of these injuries.

RESULTS

These 5 cases were caused by twisted steel bar, electric welding rod, and sewing needle, respectively. Preoperative imaging, including computed tomography, magnetic resonance imaging, and digital subtraction angiography, was selectively performed to assist the operative plan. Foreign objects were removed surgically in all cases. Postoperative prophylactic administration of antibiotics and anticonvulsants was used to prevent infectious and epileptic complications. Most of the patients achieved a better outcome except for one.

CONCLUSIONS

NPHIs can be fatal but they can be managed with satisfactory results by proper preoperative imaging evaluation, rapid appropriate surgical management, and accurate postoperative care. Personalized surgical intervention should be undertaken depending on the mechanism and extent of the NPHI.

Penetrating cranial injury with giant intraorbital foreign body

The article describes clinical and radiological picture as well as early results of surgical treatment of a rare kind of open craniocerebral trauma - cranio-orbital injury with giant intraorbital foreign body