Transorbital Penetrating Intracranial Injury by a Chopstick

doi:10.3340/jkns.2012.52.4.414

J Korean Neurosurg Soc. 2012 October; 52(4): 414–416.

Published online 2012 October 22. doi: 10.3340/jkns.2012.52.4.414

PMCID: PMC3488655

Transorbital Penetrating Intracranial Injury by a Chopstick

Tae-Hee Shin, M.D., Jong-Hoon Kim, M.D., Kyung-Woo Kwak, M.D., and Seong-Ho Kim, M.D., Ph.D.

Department of Neurosurgery, Yeungnam University College of Medicine, Daegu, Korea.

Corresponding author.

Address for reprints: Seong-Ho Kim, M.D., Ph.D. Department of Neurosurgery, Yeungnam University College of Medicine, 170 Hyeongchung-ro, Nam-gu, Daegu 705-717, Korea. Tel: +82-53-620-3790, Fax: +82-53-620-3770, Email: shkim/at/med.yu.ac.kr

Received June 8, 2012; Revised August 28, 2012; Accepted October 4, 2012.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

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 The clear plastic chopstick was withdrawn without difficulty.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.

Keywords: Penetrating, Foreign body, Orbit, Craniocerebral trauma

INTRODUCTION

Transorbital penetrating intracranial injury makes up only a small percentage of all head injuries. However, such injury accounts for nearly one-quarter of penetrating head injury cases in adults, and one-half of the cases in children¹⁵⁾. The diagnosis is straightforward when the absence or presence of the foreign body fragment in the wound is confirmed. Yet, diagnosis based on an incomplete history and trivial trauma is difficult and thus, the penetrating injury may be overlooked. Furthermore, patients may not exhibit immediate neurological deficits. Serious events may occur several days, months, or even years after the injury⁹^,¹⁴^,²⁰^,²⁶⁾. We treated a man with orbitocranial penetrating injury caused by a chopstick.

CASE REPORT

While heavily intoxicated, a 38-year-old man fell down from a chair with a chopstick in his hand. 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 (Fig. 1). Neurologic examination revealed a Glasgow Coma Scale of 15/15. Vision and light reflex in the left eye were lost. Examination of facial nerve revealed facial weakness on the left side. The rest of the cranial nerves were normal. There was no other motor or sensory deficit.

Fig. 1

The remarkably swollen left eyelid and a small laceration at upper medial epicanthal area of the left eye are presented.

A noncontrast 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, we were able to observe the foreign body going through the optic canal into the cranium (Fig. 2). A CT angiogram showed no vascular injury.

Fig. 2

A, B and C : A noncontrast CT study shows a linear hyperdense structure extending from the medial aspect of the left orbit to the occipital bone, suggesting a foreign body that was hyperdense relative to normal parenchyma. D and E : A CT scan with 3-dimensional (more ...)

The patient was placed on high-dose steroids for optic nerve protection as well as prophylactic antibiotics. He was taken to the operating room for removal of the chopstick via transorbital approach, conducted jointly by members of the neurosurgery and ophthalmology departments. Clear plastic chopstick was withdrawn without difficulty, and no craniotomy was performed (Fig. 3).

Fig. 3

Intraoperative photograph shows the plastic chopstick, at about 14 cm in length. Chopstick was removed surgically.

The postoperative course was uncomplicated. Antibiotics were administered for 3 weeks. The patient remained nonreactive to light and facial weakness but was otherwise neurologically intact. On postoperative Day 8, the patient was examined by magnetic resonance (MR) imaging. MR imaging revealed that left cerebellum injuries were not extended from the previous CT scan (Fig. 4A). Constructive Interference in Steady State (CISS) image also revealed no injuries to the left facial nerve (Fig. 4B). The patient was discharged home 3 weeks after his surgery.

Fig. 4

A : Axial T2-weighted MR image shows a hyperintense linear lesion injury from a chopstick. B : CISS image revealed that left facial nerve was not injured. MR : magnetic resonance, CISS : constructive Interference in Steady State.

DISCUSSION

Transorbital penetrating brain injury by a foreign body is relatively rare. The orbit, which has the shape of a horizontal pyramid on a posteromedially directed axis, tends to deflect objects toward the apex, where the superior orbital fissure or the optic canal may provide passage intracranially¹¹⁾. However, of the two major routes by which foreign bodies penetrate intracranially²⁰^,²⁵⁾, the most frequent is via the orbital roof, due to the fragility of the superior orbital plate of the frontal bone. Such penetration often leads to frontal lobe contusion. The second most frequent site of penetration is the superior orbital fissure, through which foreign bodies occasionally reach the brain stem through the cavernous sinus, resulting in a serious injury. A third, rarer avenue of penetration is the optic canal, where the object is directed into the suprasellar cistern, close to the optic nerve and ICA¹⁹⁾.

Complete physical examination, including full neurological and ophthalmological examinations, is important in the diagnosis and appropriate treatment of any patient diagnosed with penetrating orbital trauma. All patients, regardless of age, with obvious ocular or palpebral injury should undergo full examination to rule out penetrating intracranial injury⁴^,¹⁷⁾. Intracranial trauma cannot be excluded by a benign external appearance²¹⁾ or by an intact globe¹⁶⁾.

Noncontrast CT scanning is the key imaging modality used when intracranial injury is suspected in an orbital trauma in order to determine the course of the object and the extent of bone and parenchymal injury¹^,⁸^,¹²^,²⁴⁾. MR imaging of the brain is useful in cases of wooden foreign body injury, since dry wood has a similar density to air and hydrated wood has a similar density to the soft tissue on a CT scan, making diagnosis potentially difficult⁶^,¹⁸^,²³⁾. Cerebral angiography, or other less invasive modalities including CT angiography or MR angiography, is indicated when there is evidence of possible vascular injury, either by the location and trajectory of the foreign body or by evidence of hematoma on CT scanning¹^,⁷^,²³⁾. If there is suspicion for vascular injury, angiography should also be performed to evaluate for traumatic aneurysm, which can develop soon after a perforating injury⁵⁾.

Immediate complications include intracerebral hematoma, cerebral contusion, intraventricular hemorrhage, pneumocephalus, brain stem injury, and cerebrovascular injuries³^,⁹^,¹³^,²²⁾. If the foreign body is retained in the orbit and cranium, severe infectious complications may occur later¹⁰⁾. When a patient develops a cerebral abscess postoperatively, a retained foreign body should be ruled out²⁾.

Early radical debridement and removal of the retained fragment are mandatory to prevent potentially fatal infectious complications¹¹⁾. Depending on the location of the fragment, a transorbital or transcranial approach can be selected. Postoperative intensive antibiotic treatment should be administered to prevent late infectious events.

CONCLUSION

Transorbital penetrating intracranial injuries are uncommon and therefore, the management of such injuries is often complex. However, since neuroimaging examinations, including CT and MR imaging, are widely available and early diagnosis is also possible, early surgical exploration will most likely result in success. A treatment plan for transorbital penetrating injury should be determined by a multidisciplinary team, with input from neurosurgeons, otolaryngologists, and ophthalmologists.

References

1. Carothers A. Orbitofacial wounds and cerebral artery injuries caused by umbrella tips. JAMA. 1978;239:1151–1152. [PubMed]

2. Chibbaro S, Tacconi L. Orbito-cranial injuries caused by penetrating non-missile foreign bodies. Experience with eighteen patients. Acta Neurochir (Wien) 2006;148:937–941. discussion 941-942. [PubMed]

3. De Villiers JC, Sevel D. Intracranial complications of transorbital stab wounds. Br J Ophthalmol. 1975;59:52–56. [PMC free article] [PubMed]

4. Di Roio C, Jourdan C, Mottolese C, Convert J, Artru F. Craniocerebral injury resulting from transorbital stick penetration in children. Childs Nerv Syst. 2000;16:503–506. discussion 507. [PubMed]

5. du Trevou MD, van Dellen JR. Penetrating stab wounds to the brain : the timing of angiography in patients presenting with the weapon already removed. Neurosurgery. 1992;31:905–911. discussion 911-912. [PubMed]

6. Dunn IF, Kim DH, Rubin PA, Blinder R, Gates J, Golby AJ. Orbitocranial wooden foreign body : a pre-, intra-, and postoperative chronicle : case report. Neurosurgery. 2009;65:E383–E384. discussion E384. [PubMed]

7. Eidsness R, Coupal DJ, Kelly ME, Hattingh S. Traumatic orbital injury. J Trauma. 2007;62:1286–1287. [PubMed]

8. Fezza J, Wesley R. The importance of CT scans in planning the removal of orbital-frontal lobe foreign bodies. Ophthal Plast Reconstr Surg. 1999;15:366–368. [PubMed]

9. Fujimoto S, Onuma T, Amagasa M, Okudaira Y. [Three cases of an intracranial wooden foreign body] No Shinkei Geka. 1987;15:751–756. [PubMed]

10. Ginsberg LE, Williams DW, 3rd, Mathews VP. CT in penetrating craniocervical injury by wooden foreign bodies : reminder of a pitfall. AJNR Am J Neuroradiol. 1993;14:892–895. [PubMed]

11. Hansen JE, Gudeman SK, Holgate RC, Saunders RA. Penetrating intracranial wood wounds : clinical limitations of computerized tomography. J Neurosurg. 1988;68:752–756. [PubMed]

12. Kahler RJ, Tomlinson FH, Eisen DP, Masel JP. Orbitocranial penetration by a fern : case report. Neurosurgery. 1998;42:1370–1373. [PubMed]

13. Kasamo S, Asakura T, Kusumoto K, Nakayama M, Kadota K, Atsuchi M, et al. [Transorbital penetrating brain injury] No Shinkei Geka. 1992;20:433–438. [PubMed]

14. Kazarian EL, Stokes NA, Flynn JT. The orbital puncture wound : intracranial complications of a retained foreign body. J Pediatr Ophthalmol Strabismus. 1980;17:247–250. [PubMed]

15. Kitakami A, Kirikae M, Kuroda K, Ogawa A. Transorbital-transpetrosal penetrating cerebellar injury--case report. Neurol Med Chir (Tokyo) 1999;39:150–152. [PubMed]

16. Knerlich F, Verheggen R. Neurological picture. Feeding cats might be dangerous : penetrating orbital and brain injury without neurological deficits. J Neurol Neurosurg Psychiatry. 2005;76:1359. [PMC free article] [PubMed]

17. Lunetta P, Ohberg A, Sajantila A. Suicide by intracerebellar ballpoint pen. Am J Forensic Med Pathol. 2002;23:334–337. [PubMed]

18. Maruya J, Yamamoto K, Wakai M, Kaneko U. Brain abscess following transorbital penetrating injury due to bamboo fragments--case report. Neurol Med Chir (Tokyo) 2002;42:143–146. [PubMed]

19. Matsumoto S, Hasuo K, Mizushima A, Mihara F, Fukui M, Shirouzu T, et al. Intracranial penetrating injuries via the optic canal. AJNR Am J Neuroradiol. 1998;19:1163–1165. [PubMed]

20. Miller CF, Brodkey JS, Colombi BJ. The danger of intracranial wood. Surg Neurol. 1977;7:95–103. [PubMed]

21. Reddy HS, Chang E. Images in clinical medicine. Penetrating orbital trauma. N Engl J Med. 2008;358:e3. [PubMed]

22. Smely C, Orszagh M. Intracranial transorbital injury by a wooden foreign body : re-evaluation of CT and MRI findings. Br J Neurosurg. 1999;13:206–211. [PubMed]

23. Turbin RE, Maxwell DN, Langer PD, Frohman LP, Hubbi B, Wolansky L, et al. Patterns of transorbital intracranial injury : a review and comparison of occult and non-occult cases. Surv Ophthalmol. 2006;51:449–460. [PubMed]

24. Walid MS, Yelverton JC, Robinson JS., Jr Penetrating orbital trauma with internal carotid injury. South Med J. 2009;102:116–117. [PubMed]

25. Wesley RE, Anderson SR, Weiss MR, Smith HP. Management of orbital-cranial trauma. Adv Ophthalmic Plast Reconstr Surg. 1987;7:3–26. [PubMed]

26. Zentner J, Hassler W, Petersen D. A wooden foreign body penetrating the superior orbital fissure. Neurochirurgia (Stuttg) 1991;34:188–190. [PubMed]

Articles from Journal of Korean Neurosurgical Society are provided here courtesy of
The Korean Neurosurgical Society