Good outcome after delayed surgery for orbitocranial non-missile penetrating brain injury

Abstract

Nonmissile orbitocranial penetrating brain injuries are uncommonly dealt with in a civilian context. Surgical management is controversial, due to the lack of widely accepted guidelines. A 52-year-old man was hit in his left eye by a metallic foreign body (FB). Head computed tomography (CT) scan showed a left subcortical parietal FB with a considerable hemorrhagic trail originating from the left orbital roof. Surgical treatment was staged; an exenteratio oculi and a left parietal craniotomy to extract the FB under intraoperative CT guidance were performed at post trauma day third and sixth, respectively. A postoperative infectious complication was treated conservatively. The patient retained a right hemiparesis (3/5) and was transferred to rehabilitation in good clinical conditions at day 49(th). He had suspended antiepilectic therapy at that time. A case-by-case tailored approach is mandatory to achieve the best outcome in such a heterogeneous nosological entity. Case reporting is crucial to further understand its mechanism and dynamics.

Keywords: Brain abscess; foreign body; intracranial; orbitocranial; penetrating brain injury.

Figure 1

Admission head computed tomography scan, (a) sagittal and (b) axial cuts with three-dimensional reconstructions, showing a hyperdense thin elongated 4-cm long foreign body penetrated through the left orbit in the intracranial space leaving a considerable frontoparietal hemorrhagic trail. Note, a preexisting right frontotemporal craniotomy performed 10 years prior to present to clip a right middle cerebral artery unruptured aneurysm

Figure 2

A 4-cm long piece of iron thread was extracted trough a left parasagittal parietal craniotomy

Figure 3

Postoperative day 3 control head computed tomography scan. Extraction of the foreign body was achieved with 5.5 × 5.5 cm parasagittal parietal craniotomy. Note multiple subcentimetric hemorrhagic foci of the operative field. On the right, an axial cut showing stability of the preexisting hemorrhagic trail left by the foreign body

Figure 4

Postoperative day 12 brain magnetic resonance imaging performed upon neurologic deterioration. (a) Sagittal T2 cut showing foreign body frontoparietal trajectory; (b) gadolinium sagittal and axial cuts showing postcontrastographic enhancement strongly suggesting an on-going infectious complication

Figure 5

Brain magnetic resonance imaging at discharge. T1-weighted axial cuts

Figure 6

The patient at 6-month follow-up