Retrograde cranio-orbital penetrating injury: A case report

Abstract

Background: Transorbital (Orbito-cranial) injuries are uncommon, but they are among the most debilitating types of traumatic brain injury (TBI), mainly caused by high-velocity gunshot wounds. In addition, the management of transorbital TBI is well documented in the literature. In contrast, the cranio-orbital migration of a bullet following TBI is rarely reported. In this article, we report a reverse cranio-orbital penetration of a bullet after a TBI from the occiput with a discussion about its management.

Case description: A 34-year-old male presented with a loss of consciousness to the emergency department. His Glasgow Coma Scale was 10 (E3, V3, M4), with a left-sided weakness grade of 3 on the Medical Research Council of Canada scale. A head computed tomography (CT) scan was performed, which revealed a bullet embedded in the right orbit with an entrance point from the right occipital bone. Moreover, the CT scan showed an intraventricular hemorrhage in the lateral ventricle. The surgery was performed where the hematoma was evacuated, the scalp was debrided, and the bullet was removed successfully. However, the patient died on the 7^th postoperatively.

Conclusion: Cranio-orbital penetrating brain injury is a severe yet rare type of penetrating brain injury. The direction of cranio-orbital injury is usually from the orbital region to the cerebrum. In our case, the retrograde fashion of the bullet migration renders it unique and calls for further studies to highlight the differences in injury and management of such cases.

Keywords: Cranio-orbital; TBI; Traumatic brain injury.

Figure 1:

A head computed tomography scan (Axial section) bone window shows a bullet lodged in the right intra-orbital region with possible tract hematoma extending from the right occipital bone.

Figure 2:

(a) A cranial computed tomography (CT) scan (Axial section) reveals intraventricular hemorrhage in the right lateral ventricle extending to the left side. (b) A cranial CT scan (Sagittal view) shows the bullet’s settlement in the orbit.