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

Multidisciplinary Approach for the Management of a Case With Craniofacial Penetrating Injury Compressing the Internal Carotid Artery

A craniofacial penetrating injury can be severe when a foreign object reaches the skull base, causing an intracranial hemorrhage or a pseudoaneurysm. We report a case of sharp craniofacial injury in which a thin wooden rod moved from the orbit to the internal carotid artery. With a multidisciplinary team consisting of neurosurgeons, plastic surgeons, and otolaryngologists, the foreign body was safely removed, and the patient healed without complications or sequelae. Careful risk management is necessary when treating a case of craniofacial penetrating injury because the depth of the foreign body cannot be determined from the external appearance, making it challenging to decide on the severity of the damage from the injury.

Transorbital penetrating head injury with a favorable outcome: illustrative case

BACKGROUND

Transorbital penetrating head injuries (PHIs) are uncommon but can lead to substantial deficits, depending on intracranial involvement and the neuroanatomical structures affected. Complete recovery after such injuries is rare.

OBSERVATIONS

A 7-year-old boy sustained a PHI when he fell onto a garden spike while climbing a fence. Initial imaging showed an orbital roof fracture, focal subarachnoid hemorrhage, and an intraparenchymal hemorrhage in the right frontal lobe with associated linear tract extending to the contralateral superior temporal gyrus. Relevant neuroanatomical structures, including the anterior cerebral arteries (ACAs) and the basal ganglia, were spared. This is in keeping with superior transorbital PHI caused by a garden spike, which had transgressed the skull entering from the right superior orbit. Clinically, he experienced some transient right-sided weakness and mild speech disturbance. Some questionable vasospasm of the ACAs observed on interim magnetic resonance imaging was absent in a repeat imaging study, followed by an unremarkable radiographic follow-up at 6 months after injury. At 18 months after injury, he is neurologically intact without deficit.

LESSONS

Most PHIs bear serious lifelong consequences, but here was a case of a deep, penetrating object that managed to avoid all significant neuroanatomical pathways, leading to complete recovery in follow-up.

A Rare Case of Orbitocranial Penetrating Injury with Intracranial Wooden Foreign Body Residue

Orbitocranial penetrating injuries (OPIs) caused by wooden foreign bodies (WFBs) are very rare and life threatening. Their diagnosis and treatment could be challenging for an ophthalmologist, requiring us to remain alert for possible intracranial extension. We present a case of a 52-year-old man with a residual wooden foreign body in the left frontal lobe. He had a notable history of trauma from a fall on a tree stump and surgical removal of a wooden foreign body from his left orbit 6 years ago. He was referred to us due to recurrent discharge from the eyelid wound. Wooden foreign body residue was successfully removed with a carefully planned craniotomy without complications. This case describes the clinical manifestation, radiographic features, and treatment of this rare trauma, with an emphasis on imaging diagnosis and multi-disciplinary management.

Development of posttraumatic frontal brain abscess in association with an orbital roof fracture and odontogenic abscess: A case report

Background:

Brain abscess is a potentially fatal condition. Orbital fractures caused by penetrating injury may be associated with intracranial infection. Such complication associated with blunt trauma, orbital roof fractures, and odontogenic abscesses is exceedingly rare.

Case Description:

We report the case of a 40-year-old transgender female with a frontal abscess presenting several weeks following a motor vehicle crash from which she suffered multiple facial fractures and an odontogenic abscess. On computed tomography scan, the patient had multiple right-sided facial fractures, including a medial orbital wall fracture and a right sphenoid fracture extending into the superior orbital roof. There was hemorrhage notable in the right frontal lobe. Communication with the ethmoid sinuses likely provided a conduit for bacterial spread through the orbit and into the intracranial and subdural spaces.

Conclusion:

Skull base fractures that communicate with a sinus, whether it be frontal, ethmoid, or sphenoid may increase the risk of brain abscess, especially in patients who develop an odontogenic abscess. Surgical repair of the defect is essential, and treating patients prophylactically with antibiotics may be beneficial.

Intraorbital wooden foreign bodies: case series and literature review

Intraorbital wooden foreign bodies (IOWFBs) constitute a relatively rare ocular trauma, which occupy a special type of intraorbital foreign bodies (IOFBs). Data regarding IOWFBs must be obtained from case reports or small case series due to their rarity. Here, we reported 5 cases of IOWFBs and reviewed the related literatures, which could provide comprehensive information regarding the clinical manifestations, diagnosis, and surgical treatment of IOWFBs. Combined with the published literature, a total of 51 independent cases were counted after we added 5 cases. Among them, the number of male and female patients was 35 and 16 respectively; the mean age was 27.3±18.2 (range 1-66)y. Obviously, the disorder seemed to occur mainly in young and middle-aged people. Because of the diversity in the clinical manifestations and imaging characteristics of IOWFBs, misdiagnosis and missed diagnosis often occur during the initial visit. Delayed diagnosis may lead to a high risk of orbital infection caused by IOWFBs. Surgery is the treatment of choice for most patients; however, the missed diagnosis and residue of foreign bodies after previous surgery cannot be ignored. Therefore, an accurate diagnosis is governed by the detailed trauma history, careful ocular examination, close observation of clinical manifestations, correct imaging diagnosis [e.g., magnetic resonance imaging (MRI) or computerized tomography (CT)], and timely and completely elimination of IOWFBs.

Meat Hook Injury Leading to Brain Abscess: A Rare Occurrence

Transorbital orbitofrontal penetrating injury by a nonmissile object is uncommon. The presentation of this injury varies. This injury can be easily missed during the initial clinical presentation, because the foreign body is sometimes not visible on local examination, the wound on the orbital skin is small, and very subtle signs are present. The patient can present with delayed complications of the primary injury. Our patient was a 33-year-old male who presented with an orbitofrontal injury with a meat hook. He had minor symptoms at the time of presentation, which were overlooked. Three weeks later, he developed signs and symptoms of raised intracranial pressure (ICP). Brain imaging revealed a peripheral rim of contrast-enhancing mass lesion in the right frontal lobe, extending into the right orbit with perilesional edema suggestive of posttraumatic brain abscess. Via right frontal craniotomy, pus was drained out and abscess wall was excised. The patient made good clinical recovery. A higher index of suspicion and sound knowledge of occult penetrating injury patterns is required in the cases of orbital injuries. Appropriate radiological imaging can lead to an earlier and accurate diagnosis, and can prevent its delayed sequela like brain abscess.

Minimally Invasive Subtemporal Intradural Approach for Penetrating Orbitocranial Injury by Wooden Foreign Body Into the Lateral Wall of the Cavernous Sinus

Non-missile transorbital penetrating head injuries are relatively rare, though potentially fatal injuries. Trajectory for intracranial entrance is typically via the orbital roof, the superior orbital fissure (SOF), or the optic canal. Non-metallic intracranial penetrating injuries are even scarcer and may pose unusual diagnostic and surgical challenges. Here we present and discuss a unique case of a penetrating injury by a wooden foreign body (FB) which entered and expanded the inter-dural space of the lateral cavernous sinus (CS) sinus wall without intracavernous or intradural involvement. The patient was a 71 year-old male who fell face-down and sustained a penetrating transorbital injury by a dry twig fragment, which passed through the SOF and into the interdural space of lateral wall of the ipsilateral CS. The patient was fully conscious (GCS15) at presentation but had severe ocular injury (complete ophthalmoplegia and blindness of the injured eye). The wooden FB was successfully removed via a minimally invasive subtemporal intradural approach with no apparent immediate or long-term complications. We emphasize the unusual diagnostic and surgical challenges related to this kind of rare injuries as reflected by the decision-making considerations taken in the presented case.

Fatal and Nonfatal Rip Saw Injuries

This paper deals with a fatal stab wound suffered by a 29-year-old man and nonfatal injuries of 35-year-old and 67-year-old saw operators. Rip saw is a machine that is specially designed for making a rip cut, a cut made parallel to the direction of the wood grain. Rip-saw-related injuries mostly occur when a person is struck by the cutting material, which usually involves splinters of irregular shape and diameter. When the splinter strikes the body diagonally, the injuries may include abrasions, lacerations, and cut wounds; in situations where the victim is struck directly, the most common injuries are oval- or star-shaped stab wounds with a varying width of abrasions around the wounds. Therefore, such injuries may come across as injuries produced by a knife-like instrument, which is an added difficulty in the interpretation of such injuries.

Brain Abscess with Intracranial Bone Fragment Migration

Penetrating brain injury is 1 type of traumatic brain injury. Brain abscess is a common complication after penetrating brain injury, and fragments increase the risk of occurrence of brain abscess. It is uncommon to see the migration of bone fragments in the brain in clinical cases. We report a rare case of brain abscess with migration of bone fragments after traumatic brain injury.

Management of a Steel Bar Injury Penetrating the Head and Neck: A Case Report and Review of the Literature

BACKGROUND

Nonmissile penetrating injuries to the head and neck caused by a steel bar are rare, and a standard management strategy is lacking.

CASE DESCRIPTION

A 42-year-old woman sustained a steel bar injury with penetration of the head and neck. Computed tomography and three-dimensional reconstruction were performed for preoperative evaluation. Digital subtraction angiography was performed to confirm potential vascular injury. The steel bar was successfully removed through an open surgical procedure by a multidisciplinary team.

CONCLUSIONS

Relevant literature regarding nonmissile penetrating injuries involving a steel bar was reviewed to propose appropriate management strategies. Comprehensive imaging evaluation and prompt surgery by a multidisciplinary team contributed to the successful removal of the steel bar.

Fatal Transorbital Intracranial Penetrating Injury Due to a Bicycle Brake Handle

Transorbital intracranial injuries are uncommon and mostly accidental in nature. These injuries are usually associated with high mortality. The key to preventing this mortality involves an early diagnosis of intracranial injuries and immediate and appropriate management. Any delay can pose a serious risk to the patient's life. A case of a 55-year-old man who had experienced an accidental self-fall while riding a bicycle is presented. Initially, he was treated at a primary health center. He was referred to the tertiary care institute due to unavailability of ancillary investigation at the primary health center. He was declared dead on arrival at the casualty in the tertiary institute. On autopsy, it was observed that the injury above the right side of the upper eyelid was penetrating the right side roof of the orbit and the right cerebral cortex and brainstem. The highlighting feature of the case is that, despite the fatal penetrating brain injury, the eyeball did not sustain any major injury.

Management of Penetrating Skull Base Injury: A Single Institutional Experience and Review of the Literature

BACKGROUND

Penetrating skull base injury (PSBI) is uncommon among head injuries, presenting unique diagnostic and therapeutic challenges. Although many cases of PSBIs have been reported, comprehensive understanding of its initial diagnosis, management, and outcome is still unavailable.

MATERIALS AND METHODS

A retrospective review was performed for patients treated in neurosurgical department of Changzheng Hospital for PSBIs. Presurgical three-dimensional (3D) Slicer-assisted reconstructions were conducted for each patient. Then we reviewed previous literature about all the published cases of PSBIs worldwide and discussed their common features.

RESULTS

A total of 5 patients suffering PSBIs were identified. Penetrating points as well as the surrounding neurovascular structures were clearly visualized, assisting in the presurgical planning of optimal surgical approach and avoiding unexpected vascular injury. Four patients underwent craniotomy with foreign bodies removed successfully and 1 patient received conservative treatment. All of them presented good outcomes after proper management.

CONCLUSION

Careful physical examination and radiological evaluation are essential before operation, and angiography is recommended for those with suspected vascular injuries. 3D modeling with 3D Slicer is practicable and reliable, facilitating the diagnosis and presurgical planning. Treatment decision should be made upon the comprehensive evaluation of patient's clinicoradiological features and characteristics of foreign bodies.

[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.

Transorbital penetrating cerebral injury caused by a wooden stick: surgical nuances for removal of a foreign body lodged in cavernous sinus

PURPOSE

Penetrating head injury (PHI) is rare in civilian population and is mostly caused by low-velocity modes. A transorbital penetrating intracranial injury is very rare and more severe than traumatic brain injury.

METHODS

We report a rare case of transorbital penetrating cranial injury caused by a wooden stick. The surgical strategy was planned as the wooden stick was lodged in the right cavernous sinus.

RESULTS

The wooden stick was successfully removed. Patient made an uneventful recovery.

CONCLUSIONS

Transorbital penetrating injuries are uncommon form of injury and require a multidisciplinary approach. No attempt should be made to remove the foreign body without the backup of an operating room because of the possibility that the object may be tamponading an injured vessel. A careful planning and a strict adherence to basic perioperative principles can lead to a satisfactory outcome.

Bamboo in the Brain-an Unusual Mode of Injury

A 22-year-old male presented with a history of penetration of bamboo over the head which had fallen from the height of 40 ft. The position of the object was confirmed by computed tomography and patient underwent surgery immediately with removal of the object. The patient did well after surgery. Different modes of penetrating injury to the brain by bamboo and wooden objects, complications and management issues are discussed with a brief review of literature.

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.

Transorbital penetrating intracranial injury by a chopstick

A 38-year-old man fell from a chair with a chopstick in his hand. The chopstick penetrated his left eye. He noticed pain, swelling, and numbness around his left eye. On physical examination, a linear wound was noted at the medial aspect of the left eyelid. Noncontrast computed tomography (CT) study showed a linear hypodense structure extending from the medial aspect of the left orbit to the occipital bone, suggesting a foreign body. This foreign body was hyperdense relative to normal parenchyma. From a CT scan with 3-dimensional reconstruction, the foreign body was found to be passing through the optic canal into the cranium. The clear plastic chopstick was withdrawn without difficulty. The patient was discharged home 3 weeks after his surgery. A treatment plan for a transorbital penetrating injury should be determined by a multidisciplinary team, with input from neurosurgeons and ophthalmologists.

Juxtapontine abscess around a retained wooden fragment following a penetrating eye injury: surgical management via a transtentorial approach

Penetrating injury through the orbit with a retained intracranial wooden foreign body is rare. The authors report the case of a child with a juxtapontine brain abscess secondary to a retained foreign body. The pitfalls in diagnosis and the surgical management for removal of the wooden fragment and drainage of the abscess are discussed.

Transorbital penetrating injury: case series, review of the literature, and proposed management algorithm

Transorbital penetrating injury (TPI), an uncommon subset of head trauma, requires prompt multidisciplinary surgical intervention. While numerous case reports appear in the literature, there is a lack of discrete recommendations for initial evaluation, surgical intervention, and postoperative care of patients with TPI.

A retrospective review of 4 cases of TPI at the University of Michigan Health System was undertaken to assess for diagnosis, treatment, and follow-up. In addition, a PubMed search using the terms “penetrating orbital trauma,” “penetrating orbital injury,” “transorbital penetration,” and “transorbital penetrating injury” were used to search for articles discussing the presentation and management of penetrating orbital trauma.

All 4 of the patients at the University of Michigan underwent focused physical examination performed by a multidisciplinary trauma team followed by dedicated maxillofacial and head CT scanning. The patients' treatments varied, depending on the mechanism and extent of the injury. An analysis of the case series presented here as well as other published cases suggests an algorithm for diagnosis and treatment for patients with TPI, which includes focused evaluation, diagnostic imaging with maxillofacial CT scanning, and management of the injury that focuses on the path of penetration and the presence of the foreign body in situ at the time of presentation. Magnetic resonance imaging is indicated in patients who have indwelling wooden foreign bodies. Angiography should be performed in patients with suspected vascular injury. Treatment decisions should be made by a multidisciplinary team with input from neurosurgery, ophthalmology, otolaryngology, and maxillofacial surgery.

Fatal transorbital head injury by bicycle brake handle

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.

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.

Transorbital intracranial penetrating injury from impaling on an earpick

An inebriated 86-year-old man impaled himself on a wooden earpick that penetrated through the superior orbital fissure into the prepontine cistern. The patient underwent surgery immediately by a lateral suboccipital approach, and the earpick was pulled out through the wound with control of hemorrhage from the cavernous sinus. He survived this event with no neurologic deficits apart from complete ipsilateral ophthalmoplegia and ptosis. Prompt imaging and surgical intervention allowing direct visualization of the foreign body and prevention of intracranial complications are part of proper management of this problem.

Transorbital intracranial penetrating injury from impaling on an earpick

An inebriated 86-year-old man impaled himself on a wooden earpick that penetrated through the superior orbital fissure into the prepontine cistern. The patient underwent surgery immediately by a lateral suboccipital approach, and the earpick was pulled out through the wound with control of hemorrhage from the cavernous sinus. He survived this event with no neurologic deficits apart from complete ipsilateral ophthalmoplegia and ptosis. Prompt imaging and surgical intervention allowing direct visualization of the foreign body and prevention of intracranial complications are part of proper management of this problem.

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.

Self-inflicted transorbital and intracranial injury from eyeglasses

Orbital injuries are commonly seen in the emergency department, and if they are high-energy they can lead to concomitant intracranial injuries. Plain films, CT, MRI, and ultrasound are used in various combinations to evaluate the extent of these injuries. We describe a unique case of self-inflicted transorbital penetrating intracranial injury from the temporal wire rim of a pair of eyeglasses. Imaging well demonstrates the full course of the wire rim in situ, and pathoanatomic correlates are highlighted.