Transorbital Intracranial Penetrating Injury from a Homemade Gun: A Case Report

Abstract

A transorbital intracranial penetrating injury (TOPI) is an unusual traumatic brain injury that requires multidisciplinary management. TOPI may cause traumatic cerebrovascular injury (TCVI) and fatal brain damage with a high mortality rate. Herein, the authors described an 8-year-old male patient who was injured from a handmade gun; a projectile (marble) had penetrated the left frontal base via the left orbit. TOPI caused left anterior cerebral artery compression. A transorbital approach with an intraoperative transcranial approach on standby was performed to remove the foreign body. Postoperative intensive broad-spectrum antibiotics were administrated, and the patient made an uneventful recovery. In summary, TOPI is an uncommon TBI that risks TCVI. Intracranial vascular investigation should be performed before surgical management, and postoperative complications, such as meningitis, brain abscess, and delayed pseudoaneurysm, should be monitored.

Keywords

penetrating brain injury - orbital injury - traumatic cerebrovascular injury - traumatic brain injury

Introduction

A transorbital intracranial penetrating injury (TOPI) is an unusual traumatic brain injury (TBI) that could be fatal. From the literature review, TOPI was found in 0.04% of all TBI cases.[1] TOPI leads to serious damage when a foreign object penetrates the cranium, thus requiring multidisciplinary management. Traumatic cerebrovascular injury (TCVI), accounting for 0.8 to 1.7% of TBI, is one of the injuries that should be concerned in TOPI.[2] [3] The authors report on a case of TOPI due to a penetrating injury from a handmade gun that caused a projectile to enter through the left orbit and compress the left anterior cerebral artery.

Case Presentation

An 8-year-old male patient was transferred to our hospital because of TOPI caused by a handmade gun that penetrated through the left orbit. Examination showed mild ptosis with blindness in the left eye. There was no neurological deficit. A computerized tomography (CT) scan of the brain revealed a round-shaped foreign body through the left medial orbit plane that caused a left orbital fracture and entered the left frontal lobe, as shown in [Fig. 1A]. In addition, CT angiography of the brain that was performed for evaluation of TCVI demonstrated the foreign body had compressed the left anterior cerebral artery, as shown in [Fig. 1B]. In addition, extravasation of contrast was not seen from images. We chose a transorbital approach with an intraoperative transcranial approach on standby to remove the foreign body. Firstly, enucleation of the left eye was performed by an ophthalmologist. Consequently, the foreign body was observed on the medial side of the left orbit and removed by a neurosurgeon, as shown in [Fig. 2A]. The foreign body was a marble 1.5 centimeter in diameter that was used as a projectile, as shown in [Fig. 2B]. Fibrin glue was applied at the surgical site although no cerebrospinal fluid leakage was apparent. After the procedure, antibiotics were administered continuously for 14 days, and there were no complications such as cerebrospinal fluid leakage. At a 3-month follow-up, the patient appeared to have had an uneventful recovery and there was no delayed pseudoaneurysm on the CTA of the brain.

Fig. 1 Image of a patient injured by a handmade gun. (A) Axial computed tomography (CT) head bone-window image showing a round-shaped foreign body through the left orbit that entered the left frontal lobe. (B) Three-dimensional (3D)-reconstruction CTA of the brain showing a foreign body (green arrow) that caused a left orbital fracture and compressed left anterior cerebral artery (red arrow).

Fig. 2 Image of intraoperative findings. (A) The projectile placed at the left medial orbit (arrow). (B) Marble projectile 1.5 centimeter in diameter removed via the transorbital approach.

Discussion

TOPI following a penetrating injury is uncommon in TBI. From a prior study, the incidence of TOPI has been reported in 0.04% of TBI cases. Various foreign bodies have been reported to have entered through the orbit to the cranium, including metal bars[4] [5] and wooden sticks.[6] Complete ophthalmological and neurological examinations are important in TOPI. Because patients with TOPI can present both obvious and occult ocular injuries, intracranial injury cannot be excluded.[7]

CT scan imaging is important for the evaluation of the trajectory of a projectile and orbitocranial injuries, while magnetic resonance imaging (MRI) of the brain is useful for evaluating injuries caused by wooden foreign bodies.[4] [8] [9] Cerebral angiography should be concerned when a projectile or foreign body has entered the adjacent base of the skull, orbit, and facial bones.[5] [8] [9] Therefore, TOPI is a high risk to TCVI from the penetrating mechanism. Moreover, a foreign body is often positioned near intracranial vessels. In an acute setting, less invasive investigations such as CT angiography may be appropriate for the initial preoperative evaluation of TCVI.[10] [11]

The most common trajectory of entry is the superior orbital roof, which may cause injury to the frontal lobe and intracranial vessel. If such penetration has sufficient force, deep intracranial structures may be damaged such as the cavernous sinus, temporal lobe, and brainstem. Arslan et al reported a fatal case of TOPI, which involved a long metal bar penetrating from the right orbit to the left occipital bone.[1]

Management of TOPI typically involves foreign body removal that may lead to serious intracranial infection later. However, intraoperative bleeding from the intracranial vessel should be considered because the foreign body compresses and adheres to vascular structures during foreign body removal. Three surgical approaches have been described to remove a foreign body: anterior orbitotomy, subcranial craniotomy, and frontotemporal craniotomy.[8] The surgical approach is selected depending on the location of the foreign body.

In the present case, we removed the marble projectile via the transorbital approach with a transcranial approach ready if active bleeding occurred following the removal of the foreign body. If the foreign body mainly involves intracranial structures, the transcranial approach would be preferable in this situation.[9] [10] Additionally, debridement of bone fragments, hematoma evacuation, control bleeding, and repair of dural defects are required to avoid potentially infectious complications later.

Postoperative intensive broad-spectrum antibiotics should be administered to prevent subsequent infection. Staphylococcus, Bacillus, and Clostridium species have been reported TOPI cases. Therefore, appropriate tetanus immunization is needed.[12] [13] For long-term complications, postoperative cerebral angiogram or less-invasive vascular studies including MR angiography or CT angiography should be performed 1 to 3 months after the injury to evaluate delayed pseudoaneurysm.[9] [10]

Conflict of Interest

None declared.

Acknowledgment

The authors would like to offer their special thanks to Dr. Wantanee Dangboon for advice about manuscript preparation.

Authors' contributions

KS: admitted and investigated the case. AT: investigated the case. KS: wrote the case report. AT: wrote and edited the case report. KS: revised, edited, and wrote the case report. All authors read and approved the final manuscript.

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Publication History

Article published online:
14 June 2022