Transorbital intracranial injury is uncommon, representing 0.04% of penetrating head trauma with a high mortality rate. Orbital penetrating injuries may cause severe brain injury if the cranium is entered, typically via the orbital roof, the superior orbital fissure, or the optic canal. A 13-year-old male sustained a severe brain injury due to penetration of the right orbit with an iron bar. The bar entered the inferiomedial aspect of the orbit and emerged from the left occipital bone. Neurological examination revealed deep coma (GCS: E1M2V1) with fixed, dilated, and non-reactive pupils. The bar followed an intracranial trajectory, through the third ventricle and suprasellar cistern. The patient underwent an immediate exploration with removal of the bar. Unfortunately, he died 10 days postoperatively due to severe diencephalic injury with brainstem herniation. In this case report, we discuss the radiologic diagnosis and surgical management of transorbital orbitocranial injury by foreign body penetration.
Metal bar; orbit; orbitocranial injury; penetrating trauma
Penetrating brain injuries caused by explosions are survived in extremely rare cases only. However, potential casualties of such cases may be encountered by regular physicians even outside a war zone, e.g., due to an assault or terror blast. There is very limited literature to this end; therefore, we report the successful neurosurgical management of a penetrating head injury due to a pipe bomb explosion.
A 19-year-old man was brought to the ER with a swollen, bleeding right orbit, and a severely injured left hand after having sustained an unwitnessed explosion from a self-made pipe bomb. He presented with a GCS (Glasgow Coma Scale) of 15 at time of admission, work-up revealed an intracranial retained metal fragment measuring 5 × 1 × 0.2 cm lodged retro-orbitally and in the skull base. The patient underwent emergent right temporal craniotomy and temporal lobectomy and simultaneous right enucleation before the petrous bone and sphenoid wing lodged metal fragment was successfully removed.
This case underscores the importance of having a high suspicion for the presence of an intracranial injury and a retained foreign body in the setting of a penetrating head injury. Aggressive and timely workup as well as expeditious surgical management are crucial in these settings and can generate exceptionally good outcomes despite a major trauma.
Brain injury; explosion; intracranial foreign body; pipe bomb; transorbital
Objectives Intracranial penetration by foreign bodies entering via the orbit represent an unusual form of traumatic brain injury. Nevertheless, much is at stake with high risk for cranial nerve and neurovascular injury. We present a case where the bristled end of a toothbrush entered the brain as a projectile via the superior orbital fissure and discuss considerations for surgical management.
Setting A 35-year-old woman suffered a periorbital injury after her husband threw an electric toothbrush at a wall and the head of the toothbrush became a missile that projected through her superior orbital fissure and into her right temporal lobe. She complained of headache and incomplete vision loss in the affected eye.
Intervention After obtaining a cerebrovascular angiogram, we proceeded with emergent orbital decompression and anterograde extraction of the foreign body via a modified frontotemporal orbitozygomatic approach with drilling of the skull base allowing for en bloc removal of the toothbrush.
Conclusions The patient recovered well with improvement in her vision and partial third and sixth nerve palsies. This report illustrates a unique mechanism of injury with a novel intracranial foreign body. We review the neurosurgeon's need for prompt management with an approach customized to the structure of the offending object, the damaged elements, and the surrounding cranial nerves and vascular anatomy.
foreign body; penetrating; superior orbital fissure; superior orbital fissure syndrome; toothbrush; traumatic brain injury
Transorbital penetrating injuries are unusual but may cause severe brain damage if cranium is entered. These kinds of injuries are dangerous as the walls of orbit are very thin, hence easily broken by the otherwise innocent objects. Because of the very critical anatomical area involved, these injuries pose a serious challenge to the physicians who first receive them as well as the treating team. These may present as trivial trauma or may be occult and are often associated with serious complications and delayed sequel. Prompt evaluation by utilizing best diagnostic modality available and timely interference to remove them are the key aspects to avoid damage to vital organs surrounding the injury and to minimize the late complications. We report a case of transorbital assault with a 13 centimeter long knife which got broken from the handle and the blade was retained. The interesting aspect is that there was no neurological deficit on presentation or after removal.
Trauma and foreign body residue occurring in different settings are common in the neck. Some small injuries go unrecognized, and vascular injuries caused by the sharp penetrating trauma of a foreign body are very dangerous. Without early diagnosis and treatment, foreign body residue remains a major cause of mortality.
A six-cm piece of wooden chopstick was not initially detected in the neck of a 24-year-old Chinese man presenting with a slight bleeding wound after a brawl accident. Three days later, the patient had an expanding neck hematoma and shortness of breath. Computed tomography revealed a dense shadow in the soft tissue of the left side of the patient’s neck, and surgical exploration found that a residual broken chopstick had resulted in a delayed rupture of the common carotid artery and internal jugular vein.
A residual foreign body should be seriously considered after neck trauma because it can result in a lethal hemorrhage originating from a delayed rupture of blood vessels.
Common carotid; Foreign body; Internal jugular vein; Trauma
We report our findings in a case of ophthalmoplegia caused by a transorbital penetrating brainstem injury. An 8-year-old boy was accidentally injured by a broken fishing fiberglass pole which penetrated through the right orbit and entered the brainstem. Magnetic resonance imaging showed a linear wound that entered and passed through the pons obliquely and reached the fourth cerebral ventricle and cerebellar vermis. He had a left-sided hemiplegia and left facial nerve palsy and was diagnosed with “one-and-a-half syndrome”. His hemiplegia and left facial nerve palsy resolved in 2 weeks leaving only a left abducens nerve palsy. The eye position and eye movements fully recovered within 3 months. These findings suggest a good prognosis for this type of trauma unless life-threatening changes develop.
penetrating orbitocranial trauma; trauma; penetrating orbitocranial injury
Intracranial injury resulting from transorbital penetrating objects is rare in a noncombat setting. As such there is a significant lack of data pertaining to the management of non-projectile traumatic brain injuries due to foreign bodies entering the brain. Intracranial complications can include intracerebral hematoma, cerebral contusion, intraventricular hemorrhage, pneumocephalus, brain stem injury, and carotid cavernous sinus fistula. This is the first report of a transorbital penetrating intracranial injury caused by a Sheppard’s hook, which was managed utilizing a multi-disciplinary, non-operative approach.
We describe an unusual case of a foreign body penetrating the skull base and lodging in the posterior fossa. A 38-year-old woman fell onto a chopstick while eating, causing it to impact into her mouth. The chopstick penetrated the oropharynx and the occipital bone via the jugular foramen to enter the posterior fossa intracranially, piercing the tentorium cerebelli and leaving a fractured tip in the occipital lobe. Three-dimensional reconstructive computed tomographic scans were obtained to view the trajectory and position of the chopstick. Reconstructed angiography revealed the proximity of the carotid artery and the jugular vessels to the foreign object. Safe access to the chopstick was via an occipital craniotomy to retrieve the distal portion and an ipsiplateral retrosigmoid craniectomy to remove the proximal end. Provision was made to gain proximal control of all major nearby vessels in the event of any hemorrhage. Trauma causing penetration of a foreign body into the posterior fossa of the skull is rare due to its surrounding thick bone. Appropriate preoperative planning, including 3-D computed tomographic images and angiograms, are integral in the surgical approach for the safe removal of such objects.
Chopstick; penetrating trauma; posterior fossa; skull base
Penetrating brain injury (PBI) is rare and the severest form of head injury with a high morbidity and mortality. A 3.5-year-old girl presented with PBI with a wheel spoke. Computerized tomography scan with three-dimensional skull reconstruction depicted its extent from the medial side of the roof of the right orbit to the right frontal lobe with a cavitation around the spoke. The spoke was removed by manipulation under general anesthesia from the entry site without a formal craniotomy. Postoperative outcome was uneventful.
Frontal lobe injury; penetrating brain injury; wheel spoke
A transorbital penetrating intracranial injury is a rare and severe traumatic brain injury. Patients with this type of injury may present dramatically, but often the injury is subtle and therefore easily overlooked and not recognized in the first place. We present the case of a 45-year-old female admitted to the emergency department after she fell with her bike and the bicycle brake handle penetrated her left eye. A computerized tomography of the cerebrum showed a fracture of the superior orbital roof with multiple bone fragments extending into the brain near the circle of Willis. A pneumocephalus and traumatic frontobasal, intraventricular and subdural hemorrhage was seen. The patient deteriorated suddenly and was transferred to a neurosurgical center where she underwent an emergency craniotomy with evacuation of the intracerebral hematoma and an intraventricular drain was placed. After surgery, the patient’s condition deteriorated, and total compression of the brain stem occurred, upon which the patient was declared brain dead. Our case report shows that the Glasgow Coma Scale score at admission is not always a good predictor of the severity of the injury. Even when there is minimal suspicion of a penetrating intracranial injury, a computerized tomography should be performed immediately, independent of the patient’s Glasgow Coma Scale score. A direct transfer to a specialized neurosurgical center is recommended because this injury often results in death due to fatal complications such as intracerebral hemorrhage, pneumocephalus and brain stem injury.
Transorbital penetrating intracranial injury; Bicycle hand brake; Glasgow Coma Scale score
Oscular and orbital injuries due to stab wounds may mask underlying serious intracranial damage. The correct clinical assessment and treatment of such cases require the attention of a team comprising a neurosurgeon, ophthalmologist, otolaryngologist, and plastic surgeon.
Penetrating injury of the skull and brain are relatively uncommon events, representing about 0.4% of all head injuries. Transorbital penetrating brain injury is an unusual occurrence in emergency practice and presents with controversial management. We report the case of a 10-year-old boy who fell forward on a bamboo stick while playing with other children, causing a penetrating transorbital injury, resulting in meningitis. We performed a combined surgical approach with neurosurgeons and ophthalmogic surgeons. Upon discharge, the patient had a Glasgow Coma Scale score of 15, no motor deficit and no visual loss. We discuss the management of this case and review current literature.
transorbital penetrating brain injury; brain trauma; penetrating head trauma
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.
Eyelid or periocular wounds may be the only initial sign of occult, penetrating intracranial trauma. As in this case, the failure to recognize the injury may contribute to serious and potentially life-threatening complications. The discussion emphasizes that a high degree of suspicion and knowledge of patterns of occult penetrating orbito-cranial injury may help direct appropriate radiological imaging and lead to earlier, accurate diagnosis.
Intracrancial penetration; transorbital; orbito-cranial
The management of craniocerebral penetrating injury currently represents a challenge for neurosurgeons and neuroradiologists and requires innovative planning. This report describes the case of a worker admitted to hospital with an intracranial piece of concrete-cutting saw stuck through the right eye. At the time of admission the patient was conscious and this fact influenced the choice of a particular approach. This patient escaped without neurological deficit or complications, except for the inevitable removal of an eye.
transorbital penetrating injury, craniocerebral injury, intracranial foreign body, accidents at work
Foreign body ingestion is an emergency or acute situation that commonly occurs in children or adults and involves the ingestion of one or more objects. Moreover, once the discovery of swallowed foreign bodies has been made, families are typically very anxious to have the patient see a doctor. If the foreign object becomes embedded in the digestive tract, it must be removed; in emergencies, this is done by endoscopy or surgery. This case report presents the successful endoscopic retrieval of a chopstick with both sides embedded 4 cm into the esophageal wall for > 10 mo in a male patient following automutilation in an attempt to be released from a psychiatric hospital. Hot hemostatic forceps were used to open the distal esophageal mucosa in which the chopstick was embedded. The procedure was performed under intravenous general anesthesia and took approximately 7 h.
Foreign body; Esophagus; Endoscopy; Chopstick; Gastroscope; Hot hemostatic forceps
Background Access to the intraorbital optic nerve segment can be facilitated via a transcranial approach that allows access to the entire orbital cavity. The endoscopic endonasal approach (EEA) combined with a transconjunctival-medial orbitotomy represents an alternative technique to achieve the same goal.
Objective Report a surgical technique that allows total resection of the intraorbital optic nerve with minimal trauma and excellent results. Further extend and define the limits and indications of the EEA to orbital surgery.
Methods A patient with rapidly progressive, but asymmetric, vision loss underwent EEA for optic nerve biopsy. Due to the undetermined histopathological diagnosis and complete unilateral vision loss, diagnostic total optic nerve resection was indicated. The entire intraorbital length of the nerve was resected via an endoscopic endonasal transorbital approach combined with transconjunctival-medial orbitotomy.
Results A 2-cm intraorbital nerve segment was sent for pathological examination. The patient maintained normal extraocular movements and experienced no complications. The postoperative course was uneventful and the patient was discharged the next day.
Conclusion The EEA provides another option for access to the entire optic nerve. It is a safe and effective technique lacking cosmetic defects and providing an alternative corridor to traditional transcranial approaches to the orbit.
endoscopic endonasal approach; optic nerve resection; orbital surgery; transconjunctival-medial orbitotomy
An eight-year-old male child presented with drooping of the left eyelid with a history of penetrating injury of hard palate by an iron spoon seven days ago, which had already been removed by the neurosurgeon as the computed tomography scan revealed a spoon in the left posterior ethmoid and sphenoid bone penetrating into the middle cranial fossa. On examination, visual acuity was 20/20 in each eye and left eye showed total ophthalmoplegia. Oral cavity revealed a hole in the left lateral part of the hard palate. We managed the case with tapering dose of systemic prednisolone. The total ophthalmoplegia was markedly improved in one month. Cases of foreign bodies in the orbit with intracranial extension are not unusual, but the path this foreign body traveled through the hard palate without affecting the optic nerve, internal carotid artery or cavernous sinus makes an interesting variation.
Intracranial foreign body; superior orbital fissure syndrome; traumatic ophthalmoplegia.
Intrinsic functional connectivity from resting state functional magnetic resonance imaging (rsfMRI) has increasingly received attention as a possible predictor of cognitive function and performance. In this study, we investigated the influence of practicing skillful tool manipulation on intrinsic functional connectivity in the resting brain. Acquisition of tool-use skill has two aspects such as formation of motor representation for skillful manipulation and acquisition of the tool concept. To dissociate these two processes, we chose chopsticks-handling with the non-dominant hand. Because participants were already adept at chopsticks-handling with their dominant hand, practice with the non-dominant hand involved only acquiring the skill for tool manipulation with existing knowledge. Eight young participants practiced chopsticks-handling with their non-dominant hand for 8 weeks. They underwent functional magnetic resonance imaging (fMRI) sessions before and after the practice. As a result, functional connectivity among tool-use-related regions of the brain decreased after practice. We found decreased functional connectivity centered on parietal areas, mainly the supramarginal gyrus (SMG) and superior parietal lobule (SPL) and additionally between the primary sensorimotor area and cerebellum. These results suggest that the parietal lobe and cerebellum purely mediate motor learning for skillful tool-use. This decreased functional connectivity may represent increased efficiency of functional network.
tool-use; practice; functional connectivity; resting state; parietal areas; plasticity
Craniocerebral injuries caused by penetration of metallic foreign bodies present a significant challenge to neurosurgeons as an extensive surgery may be required, leading to high morbidity and mortality.
We describe a unique case of penetrating brain injury (PBI) caused by a T-shaped metallic spanner in an assault victim. The patient presented with profuse bleeding from the scalp and necrotic brain tissue evident at the point of entry of the retained short arm of the spanner. Skull X-ray and head computerized tomography (CT) revealed the short arm of spanner penetrating the left parieto-occipital lobe of the brain, extending up to the contralateral occipital lobe. Safe removal of the retained spanner was achieved with a craniectomy and durotomy. Postoperative CT revealed no residual metallic foreign body, and patient had a good functional and neurological outcome at six months’ follow up.
To the best of our knowledge, the successful surgical treatment of a PBI caused by a similar metallic object has not been reported in scientific literature previously. The case is also unique considering the fact that it was managed within the medical and diagnostic constraints of an East African country.
East Africa; metallic foreign body; neurosurgical management; penetrating brain injury
Streptococcus pyogenes is a beta-hemolytic bacterium that belongs to Lancefield serogroup A, also known as group A streptococci (GAS). There have been five reported case in terms of PubMed-based search but no reported case of brain abscess caused by Streptococcus pyogenes as a result of penetrating skull injury. We present a patient who suffered from penetrating skull injury that resulted in a brain abscess caused by Streptococcus pyogenes.
The patient was a 12-year-old boy who fell down from his bicycle while cycling and ran into a tree. A wooden stick penetrated his skin below the right lower eyelid and advanced to the cranium. He lost consciousness on the fifth day of the incident and his body temperature was measured as 40℃. While being admitted to our hospital, a cranial computed tomography revealed a frontal cystic mass with a perilesional hypodense zone of edema. There was no capsule formation around the lesion after intravenous contrast injection. Paranasal CT showed a bone defect located between the ethmoidal sinus and lamina cribrosa.
Bifrontal craniotomy was performed. The abscess located at the left frontal lobe was drained and the bone defect was repaired.
Any penetrating lesion showing a connection between the lamina cribrosa and ethmoidal sinus may result in brain abscess caused by Streptococcus pyogenes. These patients should be treated urgently to repair the defect and drain the abscess with appropriate antibiotic therapy started due to the fulminant course of the brain abscess caused by this microorganism.
Brain abscess; Skull base repairing; Penetrating head injury; Streptococcus pyogenes; Surgical evacuation
Penetrating cranial injury is a potentially life-threatening condition. Injuries resulting from the use of angle grinders are numerous and cause high-velocity penetrating cranial injuries. We present a series of two penetrating head injuries associated with improper use of angle grinder, which resulted in shattering of disc into high velocity missiles with reference to management and prevention. One of those hit on the forehead of the operator and the other on the occipital region of the co-worker at a distance of five meters. The pathophysiological consequence of penetrating head injuries depends on the kinetic energy and trajectory of the object. In the nearby healthcare center the impacted broken disc was removed without realising the consequences and the wound was packed. As the conscious level declined in both, they were referred. CT brain revealed fracture in skull and changes in the brain in both. Expeditious removal of the penetrating foreign body and focal debridement of the scalp, skull, dura, and involved parenchyma and Watertight dural closure were carried out. The most important thing is not to remove the impacted foreign body at the site of accident. Craniectomy around the foreign body, debridement and removal of foreign body without zigzag motion are needed. Removal should be done following original direction of projectile injury. The neurological sequelae following the non missile penetrating head injuries are determined by the severity and location of initial injury as well as the rapidity of the exploration and fastidious debridement.
Angle grinder; Occupational accident; penetrating head injury; traumatic brain injury
Single-port laparoscopic parastomal hernia repair with a modified Sugarbaker technique is suggested to be feasible and safe and provides an alternative to multi-port surgery.
Laparoscopic parastomal hernia repair with modified Sugarbaker technique has become increasingly the operation of choice because of its low recurrence rates. This study aimed to assess feasibility, safety, and efficiency of performing the same operation with single-incision laparoscopic surgery.
Materials and Methods:
All patients referred from March 2010 to February 2013 were considered for single-port laparoscopic repair with modified Sugarbaker technique. A SILS port (Covidien, Norwalk, Connecticut, USA) was used together with conventional straight dissecting instruments and a 5.5- mm/52-cm/30° laparoscope. Important technical aspects include modified dissection techniques, namely, “inline” and “chopsticks” to overcome loss of triangulation, insertion of a urinary catheter into an ostomy for ostomy limb identification, safe adhesiolysis by avoiding electocautery, saline -jet dissection to demarcate tissue planes, dissection of an entire laparotomy scar to expose incidental incisional hernias, adequate mobilization of an ostomy limb for lateralization, and wide overlapping of defect with antiadhesive mesh.
Of 6 patients, 5 underwent single-port laparoscopic repair, and 1 (whose body mass index [BMI] of 39.4 kg/m2 did not permit SILS port placement) underwent multiport repair. Mean defect size was 10 cm, and mean mesh size was 660 cm2 with 4 patients having incidental incisional hernias repaired by the same mesh. Mean operation time was 270 minutes, and mean hospital stay was 4 days. Appliance malfunction ceased immediately, and pain associated with parastomal hernia disappeared. There was no recurrence with a follow-up of 2 to 36 months.
Compared with multiport repair, single-port laparoscopic parastomal repair with modified Sugarbaker technique is safe and efficient, and it may eventually become the standard of care.
Parastomal hernia; Single-incision laparoscopic surgery (SILS); Modified Sugarbaker technique
Penetrating injuries to the hand are a common occurrence in the emergency room, and embedment of foreign bodies is suspected in many of these cases. The existing literature offers little information on retained foreign bodies. The aim of this study was to identify characteristics, determine prevalence, and observe outcomes for retained foreign bodies in the wrist and hand.
Four hundred thirty-seven consecutive hand and wrist radiographs in 437 patients from the emergency department of a level 1 trauma center were reviewed for the presence of retained foreign bodies. Location, size, number, and type of foreign body were recorded. Patient demographics, mechanism of injury, associated injuries, and treatment were obtained from medical records. All subsequent hospital and outpatient encounters were reviewed. Follow-up period was 18 months (range, 1–40).
Of 437 cases, 65 patients (15 %) had at least one retained foreign body. Nineteen patients underwent removal of foreign body at initial presentation. The average size of foreign bodies removed was 6 mm, compared to 3 mm for those retained. Of 46 patients where the foreign body was left in situ, two (4 %) developed symptoms directly related to the retained foreign body. One of these patients underwent removal.
This study supports the safe removal of foreign bodies which are easily accessible or when part of a broader procedure to repair injured structures. Otherwise, we advocate expectant management for all other patients, as the likelihood of persistent symptoms is low and only 2 % of retained foreign bodies required removal later.
Foreign body; Hand; Wrist; Treatment
Blank cartridge guns are generally regarded as being harmless and relative safe. However recent published articles demonstrated that the gas pressure from the exploding propellant of blank cartridge is powerful enough to penetrate the thoracic wall, abdominal muscle, small intestine and the skull. And there has been a limited number of case reports of ocular trauma associated with blank cartridge injury. In addition, no report on case with split extraocular muscle injury with traumatic cataract and penetrating corneoscleral wound associated with blank cartridge has been previously documented. This report describes the case of patient who sustained penetrating ocular injury with extraocular muscle injury by a close-distance blank cartridge that required surgical intervention.
A 20-year-old man sustained a penetrating globe injury in the right eye while cleaning a blank cartridge pistol. His uncorrected visual acuity at presentation was hand motion and he had a flame burn of his right upper and lower lid with multiple missile wounds. On slit-lamp examination, there was a 12-mm laceration of conjunctiva along the 9 o'clock position with two pinhole-like penetrating injuries of cornea and sclera. There was also a 3-mm corneal laceration between 9 o'clock and 12 o'clock and the exposed lateral rectus muscle was split. Severe Descemet's membrane folding with stromal edema was observed, and numerous yellow, powder-like foreign bodies were impacted in the cornea. Layered anterior chamber bleeding with traumatic cataract was also noted. Transverse view of ultrasonography showed hyperechoic foreign bodies with mild reduplication echoes and shadowing. However, a computed tomographic scan using thin section did not reveal a radiopaque foreign body within the right globe.
To our best knowledge, this is the first case report of split extraocular muscle injury with traumatic cataract and penetrating ocular injury caused by blank cartridge injury. Intraocular foreign bodies undetectable by CT were identified by B-scan ultrasonography in our patient. This case highlights the importance of additional ultrasonography when evaluating severe ocular trauma. And ophthalmologists should consider the possibility of penetrating injury caused by blank ammunition.
Blank ammunition; Blank cartridge; Ocular trauma; Ultrasonography