Intracerebral bullet removal through an endoscopic transnasal craniectomy

Abstract

Background: In the past decade, the endoscopic transnasal technique has been broadly applied as a feasible and less invasive approach to the skull base. The adaptability of the endoscopic technique allows a case-specific approach in order to minimize both endonasal and cranio-cerebral manipulation; therefore it can be also used in patients complaining exceptional skull base lesions and in weak patients. The objective of this paper is to present the first case of intracerebral bullet removal using a pure endoscopic transnasal route through a custom made unilateral craniectomy.

Case description: A 59-year-old patient was admitted to the emergency department after a gunshot injury to the head, thorax, abdomen, and pelvis. Admission Glasgow Coma Scale was 7. Brain computed tomography (CT) scan highlighted a right occipital hole defect due to perforative impact, intracerebral dislocations of bone fragments, right intracerebral and subdural hematoma, and midline shift to the left side; the bullet was localized in the right frontal lobe and its tip was in contact with the ethmoid roof. The patient underwent emergency decompressive craniectomy and evacuation of the subdural hematoma and abdominal explorative laparotomy, ileum resection, and gastrorrhaphy. After 1 month, the patient underwent endoscopic transnasal removal of the bullet and skull base reconstruction due to cerebrospinal fluid infection. The postoperative course was uneventful and he has done well in follow-up with no evidence of cerebrospinal fluid leak and preservation of olfaction.

Conclusion: The adaptability of the endoscopic transnasal technique offers patients complaining exceptional skull base lesions a case-specific strategy minimizing morbidity and postoperative stay.

Keywords: Bullet removal; endoscopic; intracerebral; transnasal.

Figure 1

Preoperative CT scan: (a) three-dimensional reconstructions highlight the bullet (blue dot) and its trajectory. (b) multiplanar slices confi rmed the proximity of the bullet to the anterior skull base

Figure 2

Intraoperative images showing the bullet (black asterisk), the olfactory fi bers (°), the anterior ethmoidal artery (white arrows), the durotomy (dotted line) and the craniectomy (white asterisks). FS: Frontal Sinus, LP: Lamina Papyracea

Figure 3

Schematic drawings show the extension of the craniectomy along the coronal plane (a) and the multilayer reconstruction (b) with iliotibial tract (yellow) and the septal fl ap (pink)

Figure 4

(a) Postoperative CT scan. (b) Endoscopic examination 1 month after the operation with 0° telescope (left) and 70° telescope (right). White dotted line depicts the right pedicled septal flap. LP: Lamina papyracea, SS: Sphenoid sinus, NP: Nasopharynx, IT: Inferior turbinate, MT: Middle turbinate, ST: Superior turbinate, FS: Frontal sinus