CASE REPORT

Transorbital penetrating cerebral injury caused by a woodenstick: surgical nuances for removal of a foreign body lodgedin cavernous sinus

Sachin Anil Borkar & Kanwaljeet Garg & Mayank Garg &

Bhawani Shankar Sharma

Received: 12 November 2013 /Accepted: 13 January 2014# Springer-Verlag Berlin Heidelberg 2014

AbstractPurpose Penetrating head injury (PHI) is rare in civilian pop-ulation and is mostly caused by low-velocity modes. Atransorbital penetrating intracranial injury is very rare andmore severe than traumatic brain injury.Methods We report a rare case of transorbital penetratingcranial injury caused by a wooden stick. The surgical strategywas planned as the wooden stick was lodged in the rightcavernous sinus.Results The wooden stick was successfully removed. Patientmade an uneventful recovery.Conclusions Transorbital penetrating injuries are uncommonform of injury and require a multidisciplinary approach. Noattempt should be made to remove the foreign body withoutthe backup of an operating room because of the possibility thatthe object may be tamponading an injured vessel. A carefulplanning and a strict adherence to basic perioperative princi-ples can lead to a satisfactory outcome.

Keywords Transorbital injury . Penetrating injury .

Cavernous sinus

Introduction

Transorbital penetrating injury (TPI) is a rare form of severehead injury. Two classes of projectiles are implicated in TPI,missile and non-missile, which are defined based on theirvelocity on impact [19]. Non-missile projectiles have an

impact velocity of less than 100 m/s, and injury is usuallycaused by tissue laceration and maceration, while missileprojectiles cause injury via kinetic and thermal energies also.There have been reports of unusual foreign objects that haveentered the intracranial cavity through the orbit. Major neuro-logical deficits may not manifest immediately and may beunderestimated. If the foreign body is retained in the orbit orcranial cavity, severe infectious complications may occur later.

The literature mostly describes low-velocity TPI in childrencaused by a variety of foreign bodies such as pencils or scissors.Patients with this type of injury may present dramatically, butinjuries are usually subtle andmay be occult. Authors report onesuch rare case of TPI caused by a wooden stick and discuss theimplications and management of such rare type of injury.

Case

A 10-year-old girl presented to our emergency departmentafter she fell from a tree (about 15 ft high), and a wooden stickpenetrated her head through her right eye. She complained ofpain in her right eye with loss of vision. She was conscious andoriented (Glasgow Coma Scale 15/15), and her vital parame-ters were within normal limit. Physical examination revealed aswollen and chemosed right eye with wooden stick protrudingout through themedial portion of her right eye (Fig. 1). The eyeglobe was perforated, and there was complete loss of visionand extraocular movements in the right eye. Neurologicalexamination revealed no motor or sensory deficit. Computedtomogram of the head revealed that the wooden stick enteredthe cranium through superior orbital fissure and was lodged inthe right cavernous sinus (Fig. 2). Though the foreign bodywas visible externally, it was not pulled out in view of it beinglodged in the cavernous sinus region with close proximity tointernal carotid artery and cranial nerves. The operative

S. A. Borkar (*) :K. Garg :M. Garg : B. S. SharmaDepartment of Neurosurgery, All India Institute of Medical Sciences,New Delhi, Indiae-mail: sachin.aiims@gmail.com

K. Garge-mail: kanwaljeet84@gmail.com

Childs Nerv SystDOI 10.1007/s00381-014-2364-0

procedure was carefully planned after reviewing the radiolog-ical images in different projections.

A right fronto-temporo-orbital craniotomy was performed.The orbital roof was found to be intact. Bony exposure was doneup to the orbital apex with extradural drilling of anterior clinoidprocess. Duramater was then opened, and cerebrospinal fluidwas drained from basal cisterns. Right internal carotid artery(ICA) was identified, and there was no evidence of ICA injury.The wooden stick had entered the intracranial compartmentthrough superior orbital fissure lateral to the anterior clinoidprocess and ICA. It had traversed the temporal lobe below thesylvian fissure and was lodged in the right cavernous region.Since it was densely stuck in the cavernous sinus, moving itfreely was not possible. The foreign body was amputated at thesuperior orbital fissure by drilling it. The inner portion of theforeign body was then taken out. There was brisk bleeding fromthe cavernous sinus following the removal of foreign body andwas managed with Gelfoam packing. Ophthalmology col-leagues, who also performed evisceration of the right eye, pulledthe outer portion from the exterior. Duramater was carefullyrepaired with fascia and glue. Patient was given broad-spectrum antibiotics in antimeningitic dosages. She had anuneventful postoperative course and was discharged on the10th postoperative day. Postoperative CT scan done at the time

of discharge revealed no foreign body, hematoma or infarct(Fig. 3). At 2 months of follow-up, patient was conscious andoriented. Her Glasgow Coma Scale score was 15/15 and mini-mental state examination score was 29/30. Higher mental func-tions like speech, memory, personality, and abstract thoughtwere not impaired. She was afebrile and wound was healthy.There was no evidence of infection. The left eye, i.e., the non-injured eye, was perfectly fine with no vision or extraocularmovement impairment.

Discussion

Penetrating brain injuries constitute about 0.4 % of all headinjuries and are usually the result of falls, motor vehicle collisions,and explosions [4, 17]. Orbitocranial penetrating injuries causedby low-velocity traumawith a wooden foreign body are rare [16].Penetrating head injuries (PHI) are more severe than closed headinjuries and have higher mortality and morbidity than blunttrauma. PHI is historically seen in military settings, but over thepast 20 years, several civilian cases of PHI have been described[20]. PHI are usually high-velocity type inmilitary setup and low-velocity type in civilian setup. The common objects causing non-missile PHI include knives and bicycle handle.Wooden stick is anuncommon causative agent. Due to thickness of cranial vault, PHIare rare in civilian setup and most such cases involve orbital roofand temporal bone, as bone is relatively thinner in these parts [5].Wooden foreign bodies that penetrate through the orbit such asperiorbital penetration are not uncommon in children, buttransorbital intracranial injuries due to wooden foreign bodiesvia the natural openings of orbit are rare.

The unique anatomy of the orbit and the angle of thepenetrating object determine the intracranial trajectory of apenetrating foreign body [8, 19]. Most commonly, objectspenetrate the roof of the orbit because of the angle of penetra-tion (patients will often fall onto objects directing the pene-trating object at an upward angle), thus resulting in frontallobe injury [11]. The next most common trajectory is via thesuperior orbital fissure as in our case. The objects that enter theorbit at a low velocity are directed by the bony anatomytoward the superior orbital fissure [13] directing it laterallyto the cavernous sinus, beneath the frontal and medial to the

Fig. 1 Clinical photograph of the patient showing swollen and chemosedright eye with wooden stick protruding out through the medial portion ofthe right eye (white arrow)

Fig. 2 Computed tomogram of the head showing a foreign body in the medial part of the right orbital cavity entering the cranium through superiororbital fissure and lying in the right parasellar area (a, b, c)

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temporal lobe, above the petrous ridge, and up to the lateralpart of the brain stem [10]. Sometimes, the object can pene-trate the cavernous sinus and/or the brain stem, causing life-threatening injury. A third trajectory of penetration is the opticcanal, where the object is directed into the suprasellar cistern,close to the optic nerve and ICA [11].

Objects entering into the cranium through or close to thesuperior orbital fissure, as in the present case, may cause injuryto the optic nerve, cavernous sinus, carotid artery, or brain stem.Injury to the carotid artery can result in a carotid-cavernousfistula [9]. Our patient was lucky to have escaped with just asmall rent on lateral wall of cavernous sinus.

Patients may present in an unconscious state, and sometimes,a patient who is conscious at the time of presentation can deteri-orate very fast. This indicates that the GCS score at admission isnot always a good predictor. However, our patient was fortunateto be conscious throughout the hospital course. Clinically, amajorneurological symptom may be absent on first examination inchildren in particular when the penetration is not via the superiororbital fissure or optic canal and the eyeball is not injured.

A patient suspected to have an orbitocranial PHI should beevaluated thoroughly including thorough physical and neuro-logical examination. CT is ideal for evaluating fractures of theorbital walls and any associated intracranial lesions, but it haslittle value in detecting wooden foreign bodies. The CT den-sity of wood is approximately −500 to −200 HU but may varyfrom −649 to −8 HU as per an experimental study by Hansenet al. [6]. Dry wood density is similar to air, while hydratedwood often appears like soft tissue in noncontrast CT [14].The density of wood may increase with time which could bedue to granulation along the foreign body [1] or precipitationof calciumwithin the wood [3].MRI is superior to CTscan fordetecting retained wooden pieces as CT misses 42 % of thenonmetallic foreign bodies [20]. In acute stage, wooden bod-ies appear hypointense on both T1- and T2-weighted images

while they are isointense on T1-weighted images andhypointense on T2-weighted images in the chronic stage,suggesting that the wooden fragments contain lot of water[7]. Careful planning is needed before surgery in such casesbecause of close proximity to ICA and cavernous sinus.

Management includes removal of the wooden material andintracranial hematoma (if any). If not removed in time, seriouscomplications like discharging sinus and fulminant meningitismay occur days, months, or even years after initial trauma [21].Infective complications are more common and usually occurlate. In a literature review of 42 retained intracranial woodenforeign bodies, Miller et al [16] reported brain abscesses innearly half of the cases and a mortality rate of 25 % in 28 casesin the post-antibiotic era. Awooden foreign body is very infec-tious, because porous organic material provides a natural reser-voir and good culture medium for microbial agents [15]. Duringimpact, organisms present on the wood or skin could betransported intracranially [12]. Broad spectrum antibiotics mustbe started specifically covering against Staphylococcus,Bacillus, and Clostridium species [2]. Appropriate tetanus im-munization is important, because the wood is often contaminat-ed with Clostridium tetani [6]. In view of the risk of infections,early removal of the wooden foreign body with thorough irri-gation of the abscess cavity to wash out the debris is essential.

The general principle guiding surgical treatment of such pa-tients is considered to be “open and see” [3]. Traditionally, threesurgical approaches have been described to remove a foreignbody: frontotemporal craniotomy, subcranial craniotomy, andanterior orbitotomy [19]. Frontotemporal and subcranial craniot-omies can be donewith a bicoronal incision and flap. Craniotomyis indicated only when intracranial injury is anticipated as decom-pression of neural structures and repair of bony and dural defectsis possible. A frontotemporal approach is used when a wideexposure is necessary due to extensive injury and/or involvesthe middle fossa. The subcranial approach is used for anterior

Fig. 3 Postoperative CTfollowing removal of woodenstick

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fossa injuries, which require wide exposure. Anterior orbitotomyis used to repair orbital roof fractures if there is no evidence ofvascular injury on CT scans. Compared to craniotomy,orbitotomy is faster, less invasive, and has a shorter recoverytime. A fourth approach is also documented: the transpalpebralapproach to repair injuries sustained from traumatic orbital rooffracture that result in dural lacerations in the area of the orbitalroof. Their advantages are that it is minimally invasive, shorterhospital stay, and with good cosmetic results.

The initial goal of surgery is removal of the foreign bodyunder direct visualization and decompression of neurovascularstructures. After the foreign body is out, the focus shifts todebridement of involved parenchyma, removal of impactedbone pieces, fracture repair, hemostasis, and dural closure [11,18]. Watertight dural closure is important in management ofpenetrating brain injuries as it prevents cerebral fungus andreduces the incidence of CSF leak. After intracranial repair, theglobe is evaluated for injury and further operativemanagement.Postoperatively, CT scan or MRI is done to rule out any new/missed hematoma or retained object [18].

Postoperative complications include CSF leak, meningitis,cerebral abscess, carotid-cavernous fistula, traumatic aneurysm,and progressive intravascular thrombosis [19]. Cerebrospinal flu-id leaks are initially treated with CSF diversion via lumbar drain,but persistent leaks may require surgical management. Retainedforeign bodies can lead to cerebral abscess later on. Our patientwas fortunate to have escaped all these complications till the timeof last follow-up. However, the patient was advised to stay underclose follow-up as many of the complications can appear later on.

Postoperative follow-up must include MR angiography orCT angiography 1–3 months after the injury to rule out thedevelopment of a pseudoaneurysm.

Conclusion

TPIs are uncommon form of injury and require multidisciplinaryteam consisting of neurosurgeons, otolaryngologists, ophthal-mologists, and maxilla-facial surgeons. No attempt to removeforeign bodymust bemadewithout backup of an operating roombecause of the possibility that the object may be tamponading aninjured vessel. Initial preoperative imaging, including angiogra-phy if indicated, must be obtained to assess extent of injury andplan the surgery. Degree of permanent neurologic deficit dependson the degree and location of the initial injury, the rapidity ofsurgical exploration and debridement, and avoidance of delayedsecondary injury. If basic perioperative and intraoperative prin-ciples are precisely followed in managing such frequently fatalinjuries, a satisfactory functional outcome can be achieved.

Disclosure The authors have no personal financial or institutionalinterest in any of the drugs, materials, or devices described in this article.

The authors report no conflict of interest concerning the materials ormethods used in this study or the findings specified in this paper.

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