Early removal of transorbital penetrating traumatic brain injury by a wooden object: a case report

Abstract

Introduction and importance:

Transorbital penetrating traumatic brain injury (TPTBI) is a rare cause of penetrating head injury, yet the diagnoses can be overlooked in some cases due to incomplete history, trivial trauma, and the absence of immediate neurologic deficits.

Case presentation:

A 4-year-old male child was admitted with a diagnosis of TPTBI by a wooden object. Noncontrast enhanced CT scan revealed a linear hypodense structure extending from the superior wall of the right orbit into the frontal lobe with displaced fragments into the brain. Additionally, cerebral contusion, pneumocephalus, and hematoma with surrounding edema were seen in the frontal lobe. Early extraction of the foreign body was performed by a multidisciplinary team of neurosurgeons and ophthalmologists. The wooden fragment of size 10 cm×1 cm×1 cm was removed by a small mini-craniotomy of the right frontal supraorbital bone with the gentle pulling of it through the dura mater and frontal cortex. The postoperative course was uncomplicated, vision was restored, and there were no neurologic deficits at the time of discharge on the seventh postoperative day with good postoperative outcomes.

Clinical discussion:

Delayed removal of TPTBI may be complicated by misidentification of entry points, extensive scarring around the foreign body, adherence to the intracranial vessels, and increasing mortality due to infectious complications. Therefore, early exploration with the help of a multidisciplinary team will most likely result in successful debridement, good neurologic outcomes, and lower morbidity and mortality.

Conclusion:

Accurate diagnosis and early intervention for TPTBI may prevent possible infectious and neurologic complications.

Background and importance

Highlights

• Transorbital penetrating traumatic brain injury (TPTBI) is a rare cause of penetrating head injury.

• Diagnosis can be overlooked in some cases due to incomplete history, trivial trauma, and the absence of immediate neurologic deficits.

• The foreign body escaping the orbit avoids injury to major nerves and vessels on the superior orbital fissure, optic canal, and inferior orbital fissure.

• Early exploration with the help of a multidisciplinary team will most likely result in successful debridement, good neurologic outcomes, and lower morbidity and mortality.

Transorbital penetrating traumatic brain injury (TPTBI) is a rare cause of penetrating head injury in adults, however, it is a more common cause of penetrating brain injury in children, comprising almost half of the cases¹. The presence of an impact object in situ makes the diagnosis quite straightforward, yet the diagnoses can be overlooked in some cases due to incomplete history, trivial trauma, and the absence of immediate neurologic deficits^1,2. Missed diagnosis due to subtle clinical presentation may be complicated by serious neurologic events months to years after the trauma³. Furthermore, delayed diagnosis and intervention could be challenged by possible edema and scarring around the foreign body, vascular complications, brain abscesses, or seizures^3,4. With timely diagnosis and intervention, the postoperative course is usually uncomplicated, but some patients may suffer from delayed neurologic events after injury⁵. Herein, we present a case of early intervention for a TPTBI by a wooden foreign body in a 4-year-old child. The patient consented to the publication of his image.

Clinical presentation

A 4-year-old male child was brought to the emergency department with a history of fall from a tree and an injury to the right eye. On admission, the child was crying and irritable, and a penetrating wooden branchlet was seen on the superior side of the right eyeball with ptosis (Fig. 1A, B). Vision and light reflexes were difficult to access due to the presence of wooden fragments. The cranial nerve examination findings were normal. The child had no motor or sensory deficits. Noncontrast enhanced CT scan revealed a linear hypodense structure extending from the superior wall of the right orbit into the frontal lobe with displaced fragments into the brain. Additionally, cerebral contusion, pneumocephalus, and hematoma with surrounding edema were seen in the frontal lobe (Fig. 2A–D). The patient was placed on analgesics, sedatives, steroids, antipyretics, antiepileptics, and antibiotics. He was immediately taken to the operating room and the exploration was performed through a supraorbital incision jointly by the doctors from the Department of Neurosurgery and Opthalmology. The wooden fragment of size 10 cm×1 cm×1 cm was removed by a small mini-craniotomy of the right frontal supraorbital bone with the gentle pulling of it through the dura mater and frontal cortex (Fig. 3A). The wooden piece entered the cranial cavity through the transorbital approach over the frontal bone on the base of the orbit, avoiding injury to major nerves and vessels on the superior orbital fissure, optic canal, and inferior orbital fissure. Similar surgical approaches have been described previously with successful removal of foreign bodies and good neurologic outcomes^4,6. Continuous irrigation of the defect site was performed by gentamycin. The penetrating site was free of any remaining pieces of branchlet. One bite of suture was placed on the dura mater and a fat graft was placed in situ. The eyeball was intact and the lid reconstruction surgery was carried out by doctors from the Department of Opthalmology (Fig. 3B). The postoperative course was uncomplicated, vision was restored, and there were no neurologic deficits at the time of discharge on the seventh postoperative day. The Extended Glasgow Outcome Scale score was 8 with upper good recovery.

Figure 1.

A, B: Images of transorbital injury with foreign body in situ. A: anterior view; B: lateral view.

Figure 2.

A–D: CT images demonstrating a wooden foreign body penetrating the frontal lobe through transorbital injury. A, B: axial planes; C: saggital plane; D: coronal plane.

Figure 3.

A: Extracted foreign body; B: lid reconstruction following foreign body removal.

Discussion

Despite being a rare cause of traumatic brain injury, early neuroimaging and diagnosis, immediate debridement, seizure prophylaxis, and judicious antibiotic therapy can prevent the possible complications of TPTBI. The major concerns in management are overlooked diagnosis, immediate complications (cerebral contusion, hematoma, pneumocephalus, CSF leak, and cerebrovascular injuries), retained foreign body, infectious complications, and neurologic deficits^7–9. Presentation depends on the size, orientation, trajectory, depth of penetration, and the involvement of orbital fissures or optic canals containing major neurovascular structures.

Noncontrast CT is the primary imaging modality in TPTBI, and CT angiography can be useful in investigations in cases with suspected vascular injuries¹⁰. In our case, a noncontrast-enhanced CT scan detected the trajectory of the foreign body, and the involvement of vascular structures was not suspected. We performed early removal of the penetrating wooden fragment as there is an increased risk of bacterial meningitis and abscesses as long as the foreign body remains intracranially^11,12. Delayed removal of foreign bodies could be complicated by several local and neurologic complications. Delayed surgery may be complicated by misidentification of entry points, extensive scarring around the foreign body, adherence to the intracranial vessels, and increasing mortality^3,4. Moreover, careful inspection is necessary, as retention of foreign bodies is associated with infectious complications like abscesses and meningitis¹³. The wooden piece entered the cranial cavity through the frontal bone on the base of the orbit, which avoided the injury to major nerves and vessels on the superior orbital fissure, optic canal, and inferior orbital fissure¹⁴. This escape not only prevented major neurovascular injury but also prevented the risk of possible additional intracranial penetration. We believe, all of the above-mentioned injury sequelae prevented major injury and led to good outcomes after surgery.

Cautious debridement of contaminated tissue and prophylactic broad-spectrum antibiotics is crucial to prevent infectious complications¹⁵. Adherence to the guidelines for the management of penetrating brain injury by the Journal of Trauma and Acute Care Surgery is highly recommended for higher treatment success rate and minimizing complications^15–17. Finally, multidisciplinary management through the collaboration between neurosurgeon and ophthalmologist should be considered to access the zone of orbital penetration and their associated damage, anticipate the accurate location and determine surgical approaches, improve visual outcomes, and decrease mortality^18,19.

Conclusion

With the help of readily available imaging techniques, the diagnosis of TPTBI is rarely missed. Early exploration with the help of a multidisciplinary team including neurosurgeons and ophthalmologists will most likely result in successful debridement, good neurologic outcomes, and lower morbidity and mortality. Strict adherence to the penetrating brain injury management guidelines of the Journal of Trauma and Acute Care Surgery is necessary to improve outcomes.

Ethical approval

Not applicable.

Consent

Written informed consent was obtained from the patient’s parents for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Source of funding

Not applicable.

Author contribution

P.R., A.D., and S.B.: study design, concept, and original draft (writing of manuscript); P.R., A.D., S.B., and S.N.K.: data collection and surgical therapy for the patient; P.R., A.D., S.B., S.N.K., S.M.R., and A.P.: review and edit.

Conflicts of interest disclosure

All authors declare no conflicts of interest.

Guarantor

Alok Dahal.

Data availability statement

All data generated during this study are included in the article.

Provenance and peer review

Not applicable.

Reporting checklist

The authors have completed the CARE checklist.