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Table of Contents    
LETTER TO EDITOR
Year : 2020  |  Volume : 68  |  Issue : 2  |  Page : 509-511

Management Strategy of a Transorbital Penetrating Injury by a Wooden Stick


Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China

Date of Web Publication15-May-2020

Correspondence Address:
Chao You
Department of Neurosurgery, West China Hospital, Sichuan University, 37# Guo Xue Xiang Street, Chengdu, Sichuan 610041
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.284364

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How to cite this article:
Ren Y, You C. Management Strategy of a Transorbital Penetrating Injury by a Wooden Stick. Neurol India 2020;68:509-11

How to cite this URL:
Ren Y, You C. Management Strategy of a Transorbital Penetrating Injury by a Wooden Stick. Neurol India [serial online] 2020 [cited 2020 Jun 4];68:509-11. Available from: http://www.neurologyindia.com/text.asp?2020/68/2/509/284364




Sir,

Transorbital penetrating injuries are relatively uncommon, accounting for only about one-fourth of penetrating head trauma cases in adults and one-half of those in children.[1] Here, we report yet another such rare case.

A 22-year-old man was brought to the emergency department 15 h after sustaining a penetrating injury to his left orbit with a 14-cm wooden stick, without any residual outside [Figure 1]a. No loss of consciousness was observed, the Glasgow Coma Score was 15/15 on admission, and his vital signs remained stable. A significant periorbital edema of the left eyelid made the assessment of vision difficult. The diameter of his left pupil was 3 mm, and light reflex was slow. Other neurologic deficits were not observed.
Figure 1: (a) Photograph showing a wooden stick penetrated into the man's left lower eyelid, without any residual outside (white arrow). (b and c) Axial and sagittal CT scan showing the wooden stick penetrated through the left orbitoethmoidal region and embedded deep within the brain. (d) A 3D reconstruction based on the CT scan showing the penetration site in the anterior skull base (black arrow). Intraoperative photographs showing that (e) the wooden stick (white arrow) was located between the anterior skull base and the frontal lobe. (f) The wooden stick was removed surgically

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A CT scan of the head showed the wooden stick traversing the orbit 10 cm intracranially region without hemorrhage [Figure 1]b and c]. A three-dimensional (3D) reconstructed CT scan demonstrated the wooden stick penetrating the anterior skull base [Figure 1]d.

The patient was taken to the operating room. He underwent a coronary craniotomy for extracting the wooden stick 16 h after the injury. A subfrontal dissection was performed with the visualization of the wooden stick as it transgressed the floor of the anterior fossa [Figure 1]e. The wooden stick was cautiously removed along the same trajectory to avoid any new injury [Figure 1]f. After clearing the bone fragments, the anterior fossa floor was repaired using human fibrin sealant and a pedicled pericranial flap. Finally, the area was washed repeatedly, and a drainage tube was placed in the wound cavity.

The patient was managed in the intensive care unit and weaned from mechanical ventilation. The drainage tube was extracted on a postoperative day 2. He underwent a CT scan one week after the operation, which revealed no bleeding within the injury bed [Figure 2]. He received anti-infection treatment (ceftriaxone 1 g/d i.v.) for two weeks and was then discharged home. He was neurologically intact at the 5-year follow-up.
Figure 2: Postoperative CT scan showing no bleeding and abscess within the injury bed one week after the operation

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Transorbital penetrating head injuries (PHIs) have been caused by many objects, including wood, metal body, and plastic.[2] We present the case of a severe craniocerebral penetrating injury successfully management at our center. A thorough examination is necessary for any patient with a scalp wound, as penetrating foreign bodies may be obvious or occult.[3],[4] Radiological measurements, including CT, magnetic resonance imaging (MRI), plain radiographs, and DSA, are selectively applied based on the purpose. Head CT scan is the most valuable means for the initial evaluation of foreign objects and the extent of injury caused by them. However, it may not evaluate a plastic or wooden object; MRI is a better choice in such cases.[4],[5] Plain radiographs are useful for the intracranial localization of metallic foreign bodies when CT scans are limited by artifacts.[6] DSA or computed tomography angiography is required to evaluate the suspected vascular injury.[7]

The selection of surgical approaches is important and should be based on the location of the entry point and tip of the foreign body. Transorbital PHIs by foreign bodies, which are directed into different cerebral structures, are a threat to ocular and cerebral structures. Different approaches may be used to remove foreign objects along various trajectories, such as coronary, frontolateral, frontotemporal, subtemporal, and frontal orbitozygomatic approaches.[8] A coronary approach can be used when the tip of the foreign body is located in the supratentorial region close to the cerebral falx, as our case, or across the bilateral cerebral hemisphere.

Several complications may occur after PHIs, such as infection, Cerebrospinal Fluid (CSF) leakage, vascular vasospasm, traumatic aneurysms, pseudoaneurysms, and seizures.[4] Infection is the most common and life-threatening complication in such cases. Removal of necrotic debris around the injury site is a critical step, and the prolonged administration of broad-spectrum antibiotic treatment has been recommended.[9] The postoperative CSF leakage rate has reduced with the use of vascular pedicled flaps and advanced suturing techniques in recent years.[10] The vascular complications should be monitored by angiography repeatedly, and prophylactic anticonvulsants are recommended for the first seven days after injury.[11],[12]

In conclusion, a comprehensive preoperative examination, an emergent surgery, a suitable approach, removal of necrotic debris, and strict postoperative management are helpful to achieve a good outcome in the presence of a transorbital penetrating injury.

Supplemental data

Consent from the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arslan M, Eseoglu M, Gudu BO, Demir I. Transorbital orbitocranial penetrating injury caused by a metal bar. J Neurosci Rural Pract 2012;3:178-81.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Sun G, Yagmurlu K, Belykh E, Lei T, Preul MC. Management strategy of a transorbital penetrating pontine injury by a wooden chopstick. World Neurosurg 2016;95:622.e7-622.  Back to cited text no. 2
    
3.
Mzimbiri JM, Li J, Xia Y, Yuan J, Liu J, Liu Q. Surviving penetrating brainstem injury by bamboo sticks: Rare case reports and a brief review of literature. Neurosurgery 2016;78:E753-60.  Back to cited text no. 3
    
4.
Zyck S, Toshkezi G, Krishnamurthy S, Carter DA, Siddiqui A, Hazama A, et al. Treatment of penetrating nonmissile traumatic brain injury. Case series and review of the literature. World Neurosurg 2016;91:297-307.  Back to cited text no. 4
    
5.
Alafaci C, Caruso G, Caffo M, Adorno AA, Cafarella D, Salpietro FM, et al. Penetrating head injury by a stone: Case report and review of the literature. Clin Neurol Neurosurg 2010;112:813-6.  Back to cited text no. 5
    
6.
Gutierrez-Gonzalez R, Boto GR, Rivero-Garvia M, Perez-Zamarron A, Gomez G. Penetrating brain injury by drill bit. Clin Neurol Neurosurg 2008;110:207-10.  Back to cited text no. 6
    
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Testerman GM, Dacks LM. Multiple self-inflicted nail gun head injury. South Med J 2007;100:608-10.  Back to cited text no. 7
    
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Gupta SK, Umredkar AA. Juxtapontine abscess around a retained wooden fragment following a penetrating eye injury: Surgical management via a transtentorial approach. J Neurosurg Pediatr 2012;9:103-7.  Back to cited text no. 8
    
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Bayston R, de Louvois J, Brown EM, Johnston RA, Lees P, Pople IK. Use of antibiotics in penetrating craniocerebral injuries. “Infection in neurosurgery” working party of british society for antimicrobial chemotherapy. Lancet 2000;355:1813-7.  Back to cited text no. 9
    
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Eloy JA, Kalyoussef E, Choudhry OJ, Baredes S, Gandhi CD, Govindaraj S, et al. Salvage endoscopic nasoseptal flap repair of persistent cerebrospinal fluid leak after open skull base surgery. Am J Otolaryngol 2012;33:735-40.  Back to cited text no. 10
    
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Kazim SF, Shamim MS, Tahir MZ, Enam SA, Waheed S. Management of penetrating brain injury. J Emerg Trauma Shock 2011;4:395-402.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Williams JR, Aghion DM, Doberstein CE, Cosgrove GR, Asaad WF. Penetrating brain injury after suicide attempt with speargun: Case study and review of literature. Front Neurol 2014;5:113.  Back to cited text no. 12
    


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