PENETRATING ORBITOCRANIAL INJURY

Abstract

SUMMARY – A case of a 37-year-old female patient is presented. The patient was admitted to the Surgical Emergency Unit after accidental fall on a metal rod when she had sustained stab injury of the right orbit with penetration into the right frontal brain lobe. Multi-slice computed tomography (MSCT) showed penetrating injury and fracture of the right orbital roof without eyeball damage and endocranial impressed bone fragments into the right frontal brain lobe. Urgent surgical intervention was performed by a maxillofacial surgeon and neurosurgeon, including reposition of bone fragments of the orbital roof and cranioplasty. Reconstruction of Tenon’s capsule of the right eyeball was performed by an ophthalmologist. From the intraoperative wound swab of the orbit, Bacillus cereus was isolated, therefore the patient was administered ciprofloxacin and rifampicin as recommended by an infectious disease (ID) specialist. Follow up brain MSCT at 15 days and magnetic resonance imaging of the brain at 25 days showed brain edema in the right frontal area and signs of local brain abscess. Intravenous administration of the ciprofloxacin and metronidazole antibiotics with corticosteroids for edema suppression were ordered by the ID physician. Fourteen weeks after this therapy, brain MSCT showed complete abscess regression and no neurologic deficit with only mild psychomotor changes.

Introduction

Penetrating orbitocranial injuries are very rare in the civilian population and account for only 0.4% of all head injuries but with a high mortality rate (1-3). These injuries are also present in war. In a large series of 351 head injuries in the Vietnam War, orbital penetration was noted in 0.6% of cases (4). In 1999 in Udhampur, 60 patients with missile injuries of the head were admitted to the Command Hospital (Northern Command); orbitocranial/faciocranial injuries with penetration were found in 25% of patients (5).

Penetrating orbital injuries can cause heavy brain damages via orbital roof, superior orbital fissure and optical nerve (3). Intracranial complications can lead to temporary or permanent neurologic deficits and vascular complications such as hemorrhage, thrombosis, or occlusion (2, 3). Laceration of the eyeball, retrobulbar hematoma, proptosis and damage to the optic nerve with visual impairment can occur. The most common complication is infection, which mostly appears subsequently (3).

Penetrating injuries caused by high velocity objects, following a trajectory perpendicular to the orbital wall, result in direct bone fractures. Vertically directed objects may pierce the orbital roof and cause damage to the frontal lobe. Horizontally directed penetrating objects may cause ethmoid bone or posterior orbital wall fractures. The most frequent pattern of injury (68%) involves the cavernous sinus, temporal lobe, and brainstem. In low velocity injuries, when the penetrating object hits the orbit at a small angle, the object follows a path along the wall of the orbit. Penetrating objects, entering the orbit close to the horizontal plane, tend to follow the orbital funnel towards the apex (6).

A case of a 37-year-old female patient is presented, who had fallen on a metal rod and sustained injury of the right orbit with penetration into the right frontal brain lobe.

Case Report

After accidental fall on a metal rod in the field, the 37-year-old female patient had sustained orbital and intracranial penetrating wound. The wire, a concrete wall wire mash, was 8 mm in diameter and the patient had taken it out immediately. The patient did not lose consciousness, but vomited twice.

Initial multi-slice computed tomography (MSCT) performed at another medical institution showed penetrating wound of the right orbital roof without affection of the right bulbus, and endocranial impressed bone fragments into the right frontal brain lobe with pneumocephalus and minimum hemorrhage (Figs. 1 and 2). There were no signs of brain edema, but proptosis, ptosis and leakage of the cerebrospinal fluid from conjunctival lesion were observed.

Fig. 1.

Computed tomography of the brain (anteroposterior projection) showing perforating wound of the right orbital roof without affection of the right bulb, and endocranial impressed bone fragments into the right frontal brain lobe.

Fig. 2.

Computed tomography of the brain (lateral projection) showing frontal brain lobe with pneumocephalus and minimum hemorrhage.

Upon arrival to the Surgical Emergency Unit, Split University Hospital Center, the patient was conscious, contacted easily, carried out orders without any sign of lateralization, and Glasgow coma scale score was 15. There was significant but localized edema of both right eyelids, less pronounced in the left periorbital area, and painful terminal neck flexion with correct x-ray of the neck spine (Fig. 3). Follow up MSCT of the brain, obtained at the Split University Hospital Center, showed stationary finding without any signs of intracranial complication.

Fig. 3.

Patient at the Surgical Emergency Unit. Significant edema of both right eyelids was localized, with less pronounced edema of the left periorbital area.

The care of the patient was interdisciplinary. An ophthalmologist performed debridement of conjunctiva laceration and reconstruction of Tenon’s capsule of the right eye bulb. A neurosurgeon and maxillofacial surgeon performed supraorbital right-side ‘key hole’ craniotomy, through which bone fragments of the orbital roof were replaced and fixed (Fig. 4). Defect of the dura was closed by Tachosil and fibrin glue. Cranioplasty was performed by titanium net.

Fig. 4.

The neurosurgeon and maxillofacial surgeon performed supraorbital right side ‘key hole’ craniotomy, through which bone fragments of the orbital roof were replaced and fixed.

Bacillus cereus was isolated in the intraoperative microbiological sample of the orbit area and the patient was administered oral therapy with a combination of ciprofloxacin 2x500 mg and rifampicin 2x300 mg.

Postoperatively, the patient was subfebrile (37.4 °C), her general condition was good, she was fully conscious, without character changes, and with normal cardiobronchial and somatic status. Edema of the right eyelid was localized, and there was ptosis of the upper right eyelid and protrusion of the right bulbus. Postoperative wound healing was neat.

Follow up magnetic resonance imaging (MRI) of the brain was performed at 14 weeks of oral antibiotic therapy. In the right frontal lobe around the penetrating canal, extensive edema was found. Within it there was an abscess of 20x14 mm in size with a ring edged opacification and compressive effect on the right frontal horn. Supraorbitally, along with the bone defect, a smaller epidural abscess of 14 mm in diameter was seen.

Laboratory testing showed elevated erythrocyte sedimentation rate (ESR; 50 mm/3.6 ks) and C-reactive protein (CRP; 40.5 mg/L), while other findings were normal.

Intravenous therapy, a combination of ciprofloxacin 2x400 mg and metronidazole 3x500 mg, with antiedema therapy with dexamethasone 2x4 mg was introduced. Drug dosage was gradually decreased and antiedema therapy was discontinued after 21 days.

Five weeks after intravenous antibiotic therapy, brain MRI showed stationary abscess on the right side, frontally around the perforated canal, and regression of epidural accumulation.

Inflammatory parameters were normalized (ESR 17 mm/3.6 ks, CRP 0.8 mg/L), intravenous therapy was discontinued, and oral therapy with a combination of ciprofloxacin 3x500 mg and metronidazole 3x500 mg was administered.

Brain MRI showed small regression of the intracerebral abscess and partial gliosis nine weeks after antibiotic therapy. Fourteen weeks after antibiotic therapy, MSCT was performed again and showed complete regression of intracerebral abscess with gliosis, no edema but still visible edema of the orbit and proptosis of the eye bulb. There was exophthalmos on the right and ptosis of the right upper eyelid. Antibiotic therapy was discontinued fourteen weeks later.

Follow up brain MRI at six months after the operation showed normal intracranial finding.

The patient’s general condition, somatic and neurologic status were finally normal, after the operation and antibiotic therapy, with only mild psychomotor changes.

Discussion

Our 37-year-old patient had sustained penetrating orbitocranial wound and intracranial injury due to falling on a metal rod. Searching the world’s literature we found similar case reports in civilians. Kim et al. studied craniofacial injuries in 82 patients from 2002 till 2010. All patients had postoperative complications (1). Miscusi et al. describe a case of a 35-year-old patient who fell from the height of 5 meters on an iron fence; she was successfully operated on, with very good results (2). Singh et al. had a 35-year-old patient who fell on wooden sticks and one hour after that, protrusion of the left bulb developed. Apart from mild headache, she did not have any neurologic deficit (3). Domenicucci et al. report on a case of a young person who had an accident and was admitted with a plastic cap metal rod, two centimeters perforating into the orbit. After treatment, she had neither neurologic nor ophthalmologic deficit (7). Chibaro et al. retrospectively observed 18 cases and found that results were good if diagnosis and treatment were attempted early (8).

Reports on wartime research show the severity of orbitocranial wounds. A 12% mortality rate was found among 42 patients with orbitocranial wounds treated during World War II, as reported by Webster et al. (9). Rish et al. analyzed a population of 1221 patients with penetrating craniocerebral trauma from the Vietnam War. The incidence of brain abscess was 3% and mortality rate 54%. Of the patients that survived, 82% had significant morbidity (10). In the Desert Storm operation, mortality rate of orbitocranial injuries was approximately 12% (11). Janković et al. analyzed 14 patients with orbitocranial war injuries treated during the war in Croatia and Bosnia and Herzegovina. One patient died in the hospital, blindness was present in eight patients, light perception positivity and projection positivity were present in four patients, and visual acuity was 0.1 in one patient. Several days after initial treatment, complications such as cerebrospinal fluid leaking, cerebral abscess, meningitis or epilepsy appeared in some patients (12).

In this case report, the patient recovered well, apart from mild psychomotor changes but no neurologic deficit.

Conclusion

Penetrating orbitocranial wound is a life-threatening condition that demands interdisciplinary approach and treatment. After having been operated by a maxillofacial surgeon, an ophthalmologist and a neurosurgeon, our patient recovered very well. Local abscess that occurred subsequently was successfully treated by antibiotic therapy, and apart from mild psychomotor changes, the patient had no neurologic deficit. It should be noted that such wires should have safety measures such as plastic balls to prevent such injuries.