Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.284364
Source of Support: None, Conflict of Interest: None
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. 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.
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.
Transorbital penetrating head injuries (PHIs) have been caused by many objects, including wood, metal body, and plastic. 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., 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., Plain radiographs are useful for the intracranial localization of metallic foreign bodies when CT scans are limited by artifacts. DSA or computed tomography angiography is required to evaluate the suspected vascular injury.
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. 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. 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. The postoperative CSF leakage rate has reduced with the use of vascular pedicled flaps and advanced suturing techniques in recent years. The vascular complications should be monitored by angiography repeatedly, and prophylactic anticonvulsants are recommended for the first seven days after injury.,
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.
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[Figure 1], [Figure 2]