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
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
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
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
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
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
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
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.
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
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.
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
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.
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
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
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
Transnasal endoscopic surgery has remained at the forefront of surgical management of sinogenic complications involving the frontal sinus, orbit, and anterior skull base. However, the difficulty in accessing certain areas of these anatomical regions can potentially limit its use. Transorbital neuroendoscopic surgery (TONES) was recently introduced to transgress the limits of transnasal endoscopic surgery; the access that it provides could add additional surgical pathways for treating sinogenic complications involving the frontal sinus, orbit, and anterior cranial fossa. We describe a prospective series of 13 patients who underwent TONES for the management of various sinogenic complications, including epidural abscess, orbital abscess, and fronto-orbital mucocele or mucopyocele, as well as subperiosteal abscess presenting with orbital apex syndrome. The primary outcome measurement was the efficacy of TONES in treating these pathologies. TONES provided effective access to the frontal sinus, orbit, and the anterior cranial fossa. All patients demonstrated postoperative resolution of initial clinical symptoms with well-hidden surgical scars. There were no ophthalmologic complications or recurrence of pathology. Based on our experience, TONES appears to provide a valuable addition to the current surgical armamentarium for treating selected complications of sinusitis.
transorbital; transpalpebral; transconjunctival; skull base; endoscopic; sinusitis complications; epidural abscess; orbital abscess; frontal sinus abscess; mucocele; mucopyocele; multiportal
Measurement of optic nerve sheath diameter (ONSD) by ultrasound is increasingly used as a marker to detect raised intracranial pressure (ICP). ONSD varies with age and there is no clear consensus between studies for an upper limit of normal. Knowledge of normal ONSD in a healthy population is essential to interpret this measurement.
In a prospective observational study, ONSD was measured using a 15 MHz ultrasound probe in healthy volunteers in Chittagong, Bangladesh. The aims were to determine the normal range of ONSD in healthy Bangladeshi adults and children, compare measurements in males and females, horizontal and vertical beam orientations and left and right eyes in the same individual and to determine whether ONSD varies with head circumference independent of age.
136 subjects were enrolled, 12.5% of whom were age 16 or under. Median ONSD was 4.41 mm with 95% of subjects in the range 4.25–4.75 mm. ONSD was bimodally distributed. There was no relationship between ONSD and age (≥4 years), gender, head circumference, and no difference in left vs right eye or horizontal vs vertical beam.
Ultrasonographic ONSD in Bangladeshi healthy volunteers has a narrow bimodal distribution independent of age (≥4 years), gender and head circumference. ONSD >4.75 mm in this population should be considered abnormal.
We report the successful removal of a retrobulbar foreign body using a transcranial approach in a 63-year-old patient with a penetrating injury to the left eye. Initial ocular examination revealed a corneoscleral laceration, hyphema, a traumatic cataract, and vitreous hemorrhage. Visual acuity consisted only of the perception of hand motion. Computed tomography demonstrated an orbital foreign body in the retrobulbar area. Emergency corneoscleral suturing, phacoemulsification of the cataract, and vitrectomy with posterior vitreous detachment were performed. Fifteen days after the emergency operation, we successfully removed the orbital foreign body using a transcranial approach, although the foreign body was very close to the optic nerve. On fundus examination 6 months later, a white, fibrous lesion was seen inferior to the optic disc, and the corrected visual acuity was 20/30. These positive results may be due to the complete vitrectomy at the correct time performed by a retina specialist and the minimal pressure on the eyeball while removing the foreign body, which resulted from the use of a transcranial approach.
Retrobulbar foreign body; transcranial approach
An 86-year-old man presented with left hand numbness and weakness 10 days after a resection of squamous cell carcinoma of the right side of the scalp. A CT head scan identified a right-sided, hypodense subdural collection without midline shift, with associated pneumocephalus. When the images were reviewed on bony settings, minute drill holes were identified penetrating the outer tables as expected, but also the inner table of the calvarium. With this knowledge, the initial clinical diagnosis altered significantly from that of a transient ischaemic attack to a working diagnosis of a subdural haematoma as a complication of the penetrating injury to the cranium, in a patient with an elevated international normalised ratio.
This case report describes a patient who had a foreign body in transverse sinus. A 35-year-old Korean-Chinese man visited the emergency room with lacerated wound in left eyelid and a foreign body which was stumbled upon in the skull. On examination, there was right side hemianopsia in his left eye. He did not complain any headache or show any abnormal neurological signs, but there was a foreign body at left transverse sinus in computed tomography which was taken at another hospital. There was no intracranial abnormality except the foreign body in computed tomography. Because of the financial problem, additional evaluations were not possible. We herein report a strange case in which the pathway of a foreign body to locate in transverse sinus was ambiguous, and suggest that the foreign body located in transverse sinus might have been the penetrated along the anterior fontanelle and passed through the superior sagittal sinus.
Foreign body; Skull; Accident; Fontanelle; Sinus
Although children may dislike and/or resist oral and pharyngeal examination with a tongue depressor, they enjoy lollipops on sticks, eating with spoons, forks, and chopsticks, and brushing their teeth. Many reports have noted this apparent contradiction, since paediatric patients are often treated after toothbrushes or chopsticks penetrate the pharyngeal wall.
We therefore developed a novel device to observe the inside of the mouth without using a flashlight, tongue depressor or head mirror.
We previously developed the AWS for tracheal intubation through the mouth for anaesthesia and emergency situations, along with a new device to observe the inside of the oral cavity simultaneously. We have developed a new attachment to the AWS for observations inside the oral cavity and pharynx.
Our newly developed oral and pharyngeal examination system is a useful tool for diagnostic examinations and may also enable treatment without causing discomfort or distress to patients and their families.
OBJECTIVE: To emphasise the value of computed tomography even in the absence of symptoms in a case of penetrating injury of the upper eyelid. METHODS: Case report. RESULTS: Although clinically asymptomatic, penetration of upper eyelid was associated with intracranial penetration that left a track in the brain parenchyma. CONCLUSIONS: Computed tomography of orbit and brain is an important investigation, even in seemingly trivial eyelid injury, to reveal the full extent of the damage.
Most penetrating skull injuries are caused by gun shot wounds or missiles. The compound depressed skull fracture represents an acute neurosurgical emergency. Management and diagnosis of such cases have been described, but its occurence following a fall onto a piece of wood is quite unusual. A 75-year-old female fell onto a piece of wood that penetrated her skull on the left frontal region and was treated in our department. The patient had no neurological deficits during presentation. She was managed surgically and removal of the wooden object was performed to prevent early or late infection complications. Wooden foreign bodies often pose a different set of challenges as far as penetrating injuries to the brain are concerned. Radiological difficulties and increased rates of infection due to its porous nature make these types of injuries particularly interesting. Their early diagnosis and appropriate treatment can minimize the risk of complications.
Penetrating injury; skull fracture; wood object