Management of Penetrating Skull Base Injury: A Single Institutional Experience and Review of the Literature

Abstract

Background: Penetrating skull base injury (PSBI) is uncommon among head injuries, presenting unique diagnostic and therapeutic challenges. Although many cases of PSBIs have been reported, comprehensive understanding of its initial diagnosis, management, and outcome is still unavailable.

Materials and methods: A retrospective review was performed for patients treated in neurosurgical department of Changzheng Hospital for PSBIs. Presurgical three-dimensional (3D) Slicer-assisted reconstructions were conducted for each patient. Then we reviewed previous literature about all the published cases of PSBIs worldwide and discussed their common features.

Results: A total of 5 patients suffering PSBIs were identified. Penetrating points as well as the surrounding neurovascular structures were clearly visualized, assisting in the presurgical planning of optimal surgical approach and avoiding unexpected vascular injury. Four patients underwent craniotomy with foreign bodies removed successfully and 1 patient received conservative treatment. All of them presented good outcomes after proper management.

Conclusion: Careful physical examination and radiological evaluation are essential before operation, and angiography is recommended for those with suspected vascular injuries. 3D modeling with 3D Slicer is practicable and reliable, facilitating the diagnosis and presurgical planning. Treatment decision should be made upon the comprehensive evaluation of patient's clinicoradiological features and characteristics of foreign bodies.

Figure 1

Head CT scan demonstrated a bamboo stick (hollow arrow, ⇦) penetrating into the temporal lobe via superior orbital fissure. The bamboo stick presented as high density on the CT scan (a, b, c). Contrast enhanced MRI revealed an abscess (simple arrow, ←) around the bamboo stick in temporal lobe (d, e, f). 3D reconstruction of the skull, cerebral artery, and bamboo stick (hollow arrow, ⇦) was performed by 3D Slicer software to visualize the relationship among these structures (g). Intraoperative photography (h) displayed the bamboo stick in original place (o, orbital side; f, frontal side; t, temporal side). Photography showed the removed bamboo stick (i). 3D, three-dimensional; CT, computed tomography; MRI, magnetic resonance imaging.

Figure 2

Preoperative image of foreign body (burst outer rim of a grinding wheel) in the face and middle skull base. Anterior-posterior skull radiography (a) and lateral skull radiography (b) demonstrated the short piece (simple arrow, ←) in the face and long piece (hollow arrow, ⇦) penetrating into the middle skull base. Sagittal reconstruction of CT (c) showed the long piece penetrating into the middle cranial fossa through infratemporal fossa. A small piece of bone fragment (hollow arrowhead, ➤) was noticed above the long piece. The bone fragment arose from the hit of the long piece on the middle skull base. DSA (d & e) proved the integrity of MCA. Axial CT revealed close relationship between the bone fragment (hollow arrow head, ➤) and branch of MCA (f). 3D reconstruction (g, h, i) with 3D Slicer software displayed spatial correlation of two pieces of foreign body with the face and skull base. 3D, three-dimensional; CT, computed tomography; DSA, digital subtraction angiography; MCA, middle cerebral artery.

Figure 3

Photography showed the entry point (black triangle, ▼) of foreign body on face and incision for a frontotemporoorbitozygomatic approach (a). Short piece of foreign body (simple arrow, ←) in the face was exposed and removed by a maxillofacial surgeon (b). The infratemporal fossa was opened to expose the long piece of foreign body (c), and it (hollow arrow, ⇦) was removed in a retrograde fashion. During the removing process, yellowish pus (asterisk, ∗) was drained into the infratemporal fossa (d). Photography displayed short piece (simple arrow, ←) and long piece (hollow arrow, ⇦) of the foreign body (e). Postoperative skull radiography suggested complete removal of the foreign body (f). The small bone fragment (hollow arrow head, ➤) was left in place due to its close relationship with branch of MCA (g). Three-month follow-up MRI revealed no abscess formation (h). The patient recovered uneventfully (i). MCA, middle cerebral artery; MRI, magnetic resonance imaging.