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LETTER TO EDITOR
Year : 2020  |  Volume : 68  |  Issue : 4  |  Page : 937-938

Transorbital Penetrating Brain Injury by a Knife: A Neurological Singularity


1 Department of Neurosurgery, Medical Trust Hospital, Cochin, Kerala, India
2 Department of Radiology, Medical Trust Hospital, Cochin, Kerala, India
3 Department of Anesthesia, Medical Trust Hospital, Cochin, Kerala, India

Date of Web Publication26-Aug-2020

Correspondence Address:
Dr. Harish Srinivasan
Department of Neurosurgery, Medical Trust Hospital, Cochin, Kerala; 6B City Nest Apartments, Shenoy Road, Kaloor Kathrikadavu, Ernakulam, Kochi, Kerala - 682 017
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.293490

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How to cite this article:
Srinivasan H, Pillay HM, Kheradia D, Theerth KA. Transorbital Penetrating Brain Injury by a Knife: A Neurological Singularity. Neurol India 2020;68:937-8

How to cite this URL:
Srinivasan H, Pillay HM, Kheradia D, Theerth KA. Transorbital Penetrating Brain Injury by a Knife: A Neurological Singularity. Neurol India [serial online] 2020 [cited 2020 Sep 30];68:937-8. Available from: http://www.neurologyindia.com/text.asp?2020/68/4/937/293490




Sir,

Penetrating brain injuries constitute about 0.4% of all head injuries.[1] They can be caused by high-velocity (HVO) or low-velocity objects (LVO). LVOs such as knives, screwdrivers, nails, etc.[2] cause tissue disruption limited to the path traversed by the object; whereas, HVOs include missiles which cause tissue cavitation and shock waves that extend the injury well beyond the tract of the penetrating objects. Although low-velocity penetrating head injuries have a lower incidence of morbidity and mortality, the impact of brain damage remains high in both types of injury.[3] The adult calvarium, in most areas, is a sturdy barrier, however, certain regions such as the squamous part of the temporal bone, skull base foramina and the orbit act as sites of weakness through which penetrating injuries mainly occur. This article elaborates on a rare case of transorbital penetrating brain injury with a wholly intact neurological scenario and the mode of evaluation and novel approach of management that allowed the patient to remain in such a state throughout the course of treatment.

A 31-year-old gentleman presented to our hospital with a stab injury. In history, the patient was allegedly stabbed with a knife in the left eye. On examination, the patient was fully conscious, had a Glasgow Coma Scale of 15/15, pupils were bilaterally equal and reacting to light with intact vision. A lacerated wound was present on the medial aspect of the left orbit through which the knife was passing. The rest of the neurological examination was normal.

The immediate radiological examination helps in determining the extent of the injury, location of the penetrating object, and the need for surgical intervention.[3] Our patient was evaluated with computed tomography (CT) scan, which showed the knife piercing through the left medial orbital wall, with the body of knife passing through the ethmoid and sphenoid sinuses [Figure 1] and right frontal contusions. Further evaluation with digital subtraction angiography (DSA) showed that the knife was embracing the anterior communicating artery complex (ACOM complex) and A1 segment of the right anterior cerebral artery (ACA) with no vascular injury [Figure 2].
Figure 1: Computed tomography (CT) image showing the path of penetrating knife and evidence of right frontal contusions

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Figure 2: Pre-procedure angiogram showing the location of the knife with its proximity to the anterior communicating artery complex (ACOM). The black arrow shows the position of the non-inflated balloon catheter within the ACOM

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After obtaining informed consent and explaining all the risks and complications, the patient was shifted to the catheterization laboratory (Cath Lab). Based on radiological imaging, the potential site for vascular injury during knife removal was predicted to be the ACOM complex; hence, the decision was made to carry out the procedure in Cath Lab. A temporary endovascular balloon was inserted into the ACOM complex across right A1 and kept deflated, with a plan to inflate and perform coiling in case of any inadvertent injury to the ACOM complex. The procedure was conducted in collaboration with a neuro-interventionist, under fluoroscopic guidance. Under aseptic precautions, the knife was gently removed in a direction opposite to that of its entry, while simultaneously avoiding rocking movement, thus, preventing any further tissue or vascular damage.[4] Immediately after the removal of the knife, an angiogram was taken [Figure 2] which fortunately revealed no evidence of vascular injury. In addition to bilateral internal carotid arteries, external carotid arteries were also screened during an angiogram to rule out possible injury to branches of external carotid arteries.

The post-procedure patient was evaluated with CT brain [Figure 3] which showed no new intracranial hemorrhages. He was treated with levetiracetam as prophylaxis for seizure, along with a 7-day course of intravenous antibiotics to prevent meningitis. He was successfully discharged in a stable condition without any neurological sequelae. Follow-up CT angiography done three months later did not reveal any pseudoaneurysm formation.
Figure 3: Post-procedure angiogram showing no evidence of vascular injury

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Considering the rarity of penetrating brain injuries and the different injury patterns in each scenario, there are no standardized guidelines for the management of such injuries. However, the availability of neuroimaging modalities including CT, MRI, and DSA has enabled us to know the exact pattern of injury, amount of tissue damage including hemorrhage, the trajectory of the weapon, and any associated vascular injury. Management of penetrating brain injuries, in the majority of cases involves craniectomy or sometimes craniotomy, followed by removal of the foreign body in a direction opposite to that of the entry and then thorough wash/debridement of the wound with meticulous closure.

The advantages of the endovascular management over surgical intervention include a) temporary control and if necessary permanent occlusion of the carotid artery with endovascular balloons; b) avoidance of craniotomy, blood loss associated with inadvertent carotid artery injury during surgical dissection; c) early post-procedure recovery. The disadvantages of the endovascular procedure include a) intracranial hemorrhage while retrieving the foreign object; b) ischemic stroke resulting from occlusion of the carotid artery if it has to be sacrificed.[5]

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.
Mzimbiri JM, Li J, Bajawi MA, Lan S, Chen F, Liu J. Orbitocranial low-velocity penetrating injury: A personal experience, case series, review of the literature, and proposed management plan. World Neurosurg 2016;87:26-34.  Back to cited text no. 1
    
2.
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. 2
    
3.
Moussa WM, Abbas M. Management and outcome of low velocity penetrating head injury caused by impacted foreign bodies. Acta Neurochir (Wien) 2016;158:895-904; discussion 904.  Back to cited text no. 3
    
4.
Domingo Z, Peter JC, de Villiers JC (1994) Low-velocity penetrating craniocerebral injury in childhood. Pediatr Neurosurg 2011;6:39-44.  Back to cited text no. 4
    
5.
Cunningham EJ, Albani B, Masaryk TJ, Rasmussen PA. Temporary balloon occlusion of the cavernous carotid artery for removal of an orbital and intracranial foreign body: Case report. Neurosurgery 2004;55:1225.  Back to cited text no. 5
    


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