Penetrating stab injury extending from the temporal region to the orbital apex and ethmoidal cells – A unique case report and review of the literature

Abstract

Background:

Nonmissle penetrating brain injuries (PBIs) are rare in civilian settings and present significant diagnostic and surgical challenges, particularly when involving the skull base and orbit.

Case Description:

A 28-year-old male sustained a penetrating stab wound to the left temporal region following an interpersonal assault. Imaging revealed a transcranial trajectory extending to the orbital apex and ethmoidal cells in proximity to the internal carotid artery and optic nerve, without definitive vascular injury. The patient underwent emergency frontotemporal craniotomy with controlled removal of the foreign body and evacuation of intracranial hematoma. Postoperatively, neurological deterioration necessitated reoperation and placement of an external ventricular drain. Following intensive care management, the patient stabilized and was transferred to a specialized rehabilitation center.

Conclusion:

PBIs require rapid imaging, careful surgical planning, and multidisciplinary management. Even in the absence of major vascular injury, involvement of the skull base necessitates vigilant monitoring for complications.

INTRODUCTION

Penetrating brain injury (PBI) represents an uncommon subset of traumatic brain injury in Europe, including Germany.[5,8] In contrast to high-velocity trauma, nonmissile PBI, most commonly caused by stab wounds or sharp objects, results from low-energy mechanisms and produces localized but highly variable injury patterns that depend primarily on the trajectory of the penetrating object.[1,4]

Recent data from Germany demonstrate an increase in violence-associated penetrating trauma, particularly in urban settings, suggesting a growing clinical relevance of such injuries in civilian practice.[6] Although cranial involvement remains uncommon, such injuries are associated with substantial morbidity due to their proximity to critical neurovascular structures, particularly in skull base and orbitocranial trauma.[1,3]

Orbitocranial and skull base injuries represent a complex subgroup due to the involvement of critical neurovascular structures and paranasal sinuses.[1,3] Computed tomography (CT) combined with CT angiography (CTA) is essential for evaluating injury trajectory and vascular integrity in PBI and forms the basis for surgical planning.[3,4] We present a rare case of a penetrating stab injury with temporal entry and extension toward the orbital apex and ethmoidal cells, highlighting the importance of trajectory rather than entry site in determining clinical risk.

CASE DESCRIPTION

A 28-year-old male was found at home with a knife penetrating the left temporal region [Figure 1] following an interpersonal assault. On initial assessment, he was awake with a Glasgow Coma Scale (GCS) score of 15 but developed progressive deterioration of consciousness and vomiting, necessitating endotracheal intubation. Ophthalmological examination revealed swelling of the left upper and lower eyelids with lagophthalmos, without prolapse of orbital contents. Purulent discharge from the left eye was noted, consistent with early conjunctivitis. The pupils were round, equal, and reactive to light.

Figure 1:

The patient in supine position, preoperatively, with the knife stuck into his left temporal region.

Imaging demonstrated a penetrating skull fracture in the left pterional region with a trajectory extending through the sphenoid bone toward the orbital apex [Figure 2]. The object passed inferior to the optic nerve and continued into the ethmoidal cells and sphenoid sinus. The tract traversed the temporal lobe in proximity to the internal carotid artery without evidence of vascular injury. Associated findings included subarachnoid hemorrhage, subdural hematoma, midline shift, and ventricular compression.

Figure 2:

(a) Preoperative head computed tomography showing the knife penetrating the skull in the left pterional region with a trajectory extending through the sphenoid bone toward the orbital apex, (b) Preoperative computed tomography angiography (coronal view) showing the knife extending approximately 50 mm into the skull base, (c) Three-dimensional reconstruction demonstrating the trajectory of the knife, (d) Preoperative x-ray (sagittal view, supine position).

Surgery

Emergency surgical intervention was performed with a left frontotemporal craniotomy for controlled removal of the knife and evacuation of intracranial hematoma. No major vascular injury was identified intraoperatively; however, diffuse parenchymal bleeding required meticulous hemostasis and dural reconstruction. To seal the ethmoidal air cells and the sphenoid sinus and prevent cerebrospinal fluid (CSF) leakage, a fibrin-coated muscle patch was applied.

Postoperatively, the patient was initially stabilized and extubated without focal neurological deficits. However, he subsequently experienced neurological deterioration, with a decline in the level of consciousness to a GCS score of 8 and the development of anisocoria. CT imaging revealed a progressive left-sided subdural hematoma causing compression of the left lateral ventricle [Figure 3]. The patient underwent urgent reoperation for hematoma evacuation, and an external ventricular drain was placed for intracranial pressure monitoring and control.

Figure 3:

Postoperative head computed tomography scan after the first surgery in the axial plane progressing from (a) superior to (b) inferior. (a) Progressive left-sided subdural hematoma (b) Cerebral edema with compression of the left lateral ventricle and rightward midline-shift of approx. 3 mm.

Postoperative intensive care course

Due to wound contamination and the need for meningitis prophylaxis, empiric antibiotic therapy with ceftriaxone and metronidazole was initiated. During the subsequent days, the patient did not develop any clinical signs of meningitis, and serial CSF analyses showed no evidence of infection. Consequently, antibiotic therapy was discontinued. Follow-up CTA [Figure 4] demonstrated no evidence of pseudoaneurysm formation or dissection of the left internal carotid artery or ophthalmic artery. The left-sided conjunctivitis was successfully treated with topical antibiotics and corticosteroid eye drops. Following intensive care management, the patient’s clinical condition improved, and he was subsequently transferred to a neurological rehabilitation facility.

Figure 4:

(a) Coronal plane postoperative computed tomography angiography in the vascular window setting without signs of a pseudoaneurysm or dissection of the internal carotid artery, and (b) Axial plane showing the left frontotemporal craniotomy.

DISCUSSION

Injury pattern and epidemiological context

Nonmissile PBIs result in injury patterns that are primarily determined by anatomical trajectory rather than the external wound appearance.[1,4] The clinical relevance of such injuries in Europe and Germany may be increasing, as reflected by rising rates of violence-associated penetrating trauma.[6] Epidemiological data from European and German cohorts further demonstrate evolving patterns of traumatic brain injury requiring specialized neurosurgical management.[5,8]

Orbitocranial injuries most commonly occur via transorbital trajectories; however, alternative entry sites, such as the temporal region in the present case, may result in comparable involvement of the skull base and anterior cranial fossa. Independent of the entry point, proximity to critical neurovascular structures remains a major determinant of injury severity and outcome.[1,4]

Comparison with reported cases

Favorable outcomes have been reported in nonmissile PBIs when major vascular injury is absent, and early surgical management is achieved [Table 1].[1,2,7,9] Ebeling et al. described survival after a bihemispheric transcranial stab injury with good neurological recovery following operative treatment.[2] Similarly, Yousif et al. reported excellent recovery in a pediatric patient, emphasizing the importance of timely intervention.[9]

Table 1:

Comparison of reported non-missile penetrating brain injury cases.

Further reports support these findings. Xue et al. described a deep PBI caused by a rebar with a favorable outcome after surgical removal.[7] In addition, systematic analyses of anterior skull base injuries demonstrate that even complex trajectories involving paranasal sinuses can result in favorable outcomes when managed appropriately.[1]

CONCLUSION

PBIs remain rare but complex entities in civilian neurosurgery. This case reinforces that the trajectory rather than the entry site determines injury severity and clinical risk. Even in injuries involving the skull base and paranasal sinuses, favorable outcomes can be achieved with timely surgical intervention and careful postoperative management.

Ethical approval:

The Institutional Review Board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for their images and other clinical information to be reported in the journal. The patient understands that the patient’s 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.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that AI-assisted technology was used only for minor language editing and it did not influence the scientific content, interpretations, or conclusions of the manuscript.

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