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

Penetrating brain injury through the cavernous sinus by chopsticks in Vienamese: a case report

Introduction and importance

Penetrating brain injuries from chopsticks are exceedingly rare, often documented through case reports. Management strategies are tailored to individual cases, with a focus on mitigating postoperative complications.

Case presentation

A 33-year-old male presented with a chopstick lodged in his right eye. Computed tomography (CT) imaging revealed two foreign bodies, prompting collaborative surgical removal by neurosurgery and ophthalmology teams. The procedure involved intricate bone drilling to access critical structures, ensuring a successful outcome with stability at 1-month follow-up.

Clinical discussion

Common trajectories involve orbital roof penetration, posing risks of frontal lobe injury and intracerebral hematoma. Challenges arise with wooden foreign bodies, necessitating advanced imaging like CT angiography to assess vascular involvement. Surgical intervention offers benefits such as foreign body extraction, neurovascular protection, tissue debridement, hematoma evacuation, and dural repair.

Conclusion

Although rare, chopstick-related penetrating brain injuries warrant vigilance in neurosurgical practice. Surgical intervention remains the cornerstone of treatment, ensuring optimal patient outcomes.

Low-velocity penetrating brain injury: a review of the literature and illustrative case

INTRODUCTION

Low-velocity penetrating brain injury (LVPBI) is a class of brain injury where a foreign object violates the skull and damages the brain. Such injuries are rare and consequently understudied.

CASE

As such, we report an illustrative case of a 29-year-old female with a dense, plastic spike penetrating her right orbit and into her midbrain. After assessment with a CT scan and angiography, the object was removed with careful attention to possible vascular injury. The patient had an uncomplicated post-operative course and received antibiotic and antiepileptic prophylaxis. She was discharged on post-operative day 5, experiencing only mild left-sided weakness.

DISCUSSION

Common concerns regarding LVPBI include infection, post-traumatic epilepsy, and vascular injury. A review of published LVPBI cases over the past 20 years demonstrated that most cases (55.2%) are due to accidents. Of patients undergoing surgery, 43.4% underwent a craniotomy, and 22.8% underwent a craniectomy. Despite the grave nature of LVPBI, only 13.5% of the patients died. Additionally, 6.5% of patients developed an infection over their clinical course.

CONCLUSION

In all, more reported cases further paint a picture of the current state of management and outcomes regarding LVPBI, paving the way for more cohesive guidelines to ensure the best possible patient outcomes.

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.

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.

Combined transcranial and transnasal endoscopic approach in transnasal-penetrating intracranial injury: A rare case report

INTRODUCTION

Transnasal-penetrating intracranial injuries are rare traumatic brain injuries that can cause serious and fatal brain damage and a high mortality rate and necessitate immediate multidisciplinary surgical management. We describe an uncommon case whereby a patient who presented with an accidental penetrating injury of the brain was found to have a wooden transnasal-penetrating intracranial object.

CASE PRESENTATION

A 28-year-old man consulted an ear, nose, and throat (ENT) surgeon after complaints of headache for two days, a history of epistaxis, and vomitus. The right side of the nose had been punctured by wood as a result of falling from a motorcycle. A computed tomography (CT) scan led to diagnosis of a transnasal penetrating intracranial injury. Removal of the transcranial foreign body was carried out jointly by a neurosurgeon and ENT surgeon. Postoperatively, antibiotics were given for 14 days, and the patient was discharged without neurological deficit.

CLINICAL DISCUSSION

Early diagnostic procedures, such as CT scan of the skull to assess trajectory and extent of vascular and brain tissue injury, are required for appropriate surgical planning and post-operative treatment of such patients. Surgery was performed by combined transcranial and transnasal endoscopy to identify the skull base, dura mater defect, and brain tissue damage. Removal of the corpus alienum by transnasal endoscopy yielded a good outcome.

CONCLUSION

Combined transcranial and transnasal endoscopic approach showed better result than transcranial approach only. The wooden foreign body can be completely eliminated transnasally without active bleeding using this approach. The patient was discharged with good outcome.

A case of death of purulent meningitis caused by transorbital intracranial penetrating injury due to long-term residual bamboo chopstick

This article reports a case of death caused by purulent meningitis after a long-term transorbital intracranial penetrating injury induced by a bamboo chopstick. A 53-year-old man was pierced with a bamboo chopstick into the left orbit, and the bamboo chopstick broke off. The man remained conscious after the injury but developed paroxysmal headaches. Multiple computed tomography, computed tomography angiography, and rhinoscopy detections revealed that a puncture tract had formed from the left orbit to the right edge of the brainstem through the skull base. However, there was no apparent brain injury or cerebrovascular rupture, thus excluding the possibility of a retained intracranial foreign body by the neurosurgeon. Therefore, the man only received symptomatic and conservative treatments. Unfortunately, the man was found dead one morning, 13 months later. Autopsy and histopathological examinations revealed that he died of purulent meningitis caused by a long-term residual intracranial bamboo chopstick. A review of the relevant literature regarding the diagnosis, including diagnostic values and limitations of different imaging technologies, and treatment of residual intracranial foreign bodies, revealed that this was a case of misdiagnosis, leading to delayed treatment. This case had an indirect causal relationship between the victim's death and medical treatment. This article provides clinical strategies for diagnosing and treating such cases and a forensic perspective for identifying causes of deaths attributed to medical malpractices.

Penetrating Orbital Sphenoid Sinus Trauma with a Wooden Stick: A Challenging Case Report

Transorbital and intra-sphenoidal traumas are relatively uncommon, can be challenging to manage, and are associated with a high risk of complications and potentially fatal outcome. Transorbital and intra-sphenoidal trauma pose a medical challenge due to close relationship to delicate and critical anatomical structures, such as the globe, optic nerve, the ophthalmic internal carotid arteries, and central nervous system. Rapid admission to a level 1 trauma center with a high surgical expertise level is essential to ensure the best possible treatment and outcome. We present a case of a 75-year-old man who had a severe orbital trauma, where a wooden foreign object penetrated the orbit into the sphenoid sinus without penetrating its posterior wall. This case is important because of the rare trauma presentation with a wooden foreign object, which can easily be missed on computed tomography. The case also illustrates the importance of close collaboration between ophthalmologists and rhinologists when challenged with severe orbital sphenoid sinus trauma.

Traumatic Nonmissile Penetrating Transnasal Anterior Skull Base Fracture and Brain Injury with Cerebrospinal Fluid Leak: Intraoperative Leak Detection and an Effective Reconstruction Procedure for a Localized Skull Base Defect Especially After Coronavirus Disease 2019 Outbreak

Background

Cerebrospinal fluid (CSF) leakage after penetrating skull base injury is relatively rare compared with close head injuries involving skull base fractures.

Case Description

We report the case of a 65-year-old man who had presented with epistaxis and serous rhinorrhea. When he had fallen to the ground near his bee boxes, a garden pole had poked into his right nostril. He had instantly removed the pole from his nostril himself. However, immediately after removal of the pole, he had developed nasal bleeding and serous rhinorrhea. He then drove to our emergency room. Computed tomography showed pneumocephalus with a minor cerebral contusion in the left frontal lobe and a penetrating injury in the left anterior skull base. His CSF leakage had not resolve spontaneously within 1 week after the injury with strict bed rest. We repaired the CSF leakage using a fat (adipose tissue)-on-fascia autograft plug and caulked the defect in the anterior skull base with the fat-on-fascia graft (FFG) plug through the left nostril with endoscopic guidance. The CSF rhinorrhea was successfully controlled. Intranasal local application of fluorescein aided in the detection of the direction of flow of the CSF leakage.

Conclusions

Endonasal endoscopic caulking of a skull base defect using an FFG plug can be useful to treat CSF leakage due to the localized skull base defect, especially in the coronavirus disease 2019 pandemic. It is simple, inexpensive, and timesaving. It requires no special skills nor sophisticated instruments that can cause aerosolization, reducing the risk of infection during the surgery.

Penetrating transorbital injury by a coloring pencil in a 3-year-old child: A case report

A transorbital penetrating injury by a foreign body is an extremely rare type of injury, and its severity is often difficult to estimate by examination of the superficial wound alone. Thus, such injuries are challenging for neurosurgeons to investigate and manage. We herein present a peculiar case involving a 3-year-old girl with a penetrating transorbital skull-base injury caused by a coloring pencil and discuss the anatomical location of the foreign body, radiological examination findings, diagnosis, and treatment strategy. The pencil was completely removed by manual extraction. Follow-up investigations confirmed a good outcome. Multidisciplinary cooperation, radiological examination, correct diagnosis, timely treatment, and detailed follow-up studies are necessary to manage penetrating transorbital skull-base injuries caused by foreign bodies. The orbital walls are very thin in children, and the orbital roof and superior orbital fissure are often penetrated by foreign bodies in cases such as that described herein. The anatomical location of the foreign body influences the clinical management strategy.