Orbito-cranial injury caused by penetrating metallic foreign bodies: report of two cases

Management of Penetrating Brain Injury Caused by a Nail Gun: Three Case Reports and Literature Review

BACKGROUND

Penetrating brain injury (PBI) caused by a nail gun is an extremely rare neurosurgical emergency that poses a challenge for neurosurgeons because of its rarity and complexity.

CASE DESCRIPTION

Here we present 3 cases of PBI caused by a nail gun. In the first case, the nail entered through the right parietal bone and lodged in the right parietal lobe and basal ganglia. In the second case, the nail entered through the right occipital bone and lodged in the right occipital lobe. In the third case, the nail entered through the right parietal bone and lodged in the right frontal and parietal lobes. All patients underwent surgical removal of the nail. The first patient presented with reduced left-side strength, whereas the second and third patients were neurologically intact on presentation.

CONCLUSIONS

PBI caused by a nail gun can present with differing clinical manifestations, and most cases require immediate surgery. A rational management strategy should provide a good postoperative prognosis with minimal neurologic deficits in these patients.

Fatal orbito-cerebral penetration by industrial grease viscous: Rare case report

Assorted projectiles including shrapnel, sling shots, stones, metal and rock fragments and other missiles cause fatal penetrating skull injuries. In this case, a 34-year-old foreman suffered a fatal penetrating orbito-cerebral injury while lubricating a hydraulic rock-splitting machine with industrial grease viscous.

[Quantum of luck with a self-induced penetrating orbital injury]

Presentation of a patient with two foreign bodies each 21 cm long in left nasal orbit and penetrating as far as the sinciput. The patient had been knitting at the time of the accident and had probably autonomously thrust the two knitting needles into the left orbit, as assessed by questioning of other parties. The patient had a known history of paranoid schizophrenia and dementia. Central imaging revealed the position of the knitting needles with respect to the intracranial vessels to be threatening. The surgical removal of the knitting needles was carried out without any serious complications, such as intracranial hemorrhage.

Diamagnetic susceptibility artifact associated with graphite foreign body of the orbit

Imaging in traumatic injury to the orbits plays an important role to identify malformation of the globe, retrobulbar pathology, such as hematoma, the presence of fractures, and identification of foreign bodies. MRI can be especially useful in characterizing soft tissue abnormalities without the use of ionizing radiation. The authors report a case of penetrating injury to the orbit with a retained foreign body where the graphite core of a pencil ("pencil lead") resulted in metal-like diamagnetic susceptibility artifact. This was proven to have no metallic components by CT and surgical exploration. MRI performed in the setting of penetrating injury could aid in localization of a graphite foreign body, and if there is a known graphite foreign body, evaluation of immediately adjacent structures may be obscured.

Transorbital craniocerebral occult penetrating injury with cerebral abscess complication

Transorbital intracranial penetrating injury is an uncommon mechanism of head injury. These injuries can be occult during the initial clinical presentation. Certain patients develop an intracranial cerebral infection. Herein, we report a 5-year-old child with an occult transorbital intracranial penetrating injury caused by a pen. A retained pen tip was found at the superior orbital roof and was not noticed at initial presentation. This was complicated by a right frontal lobe cerebral abscess. This paper emphasizes the importance of orbitocranial imaging in any penetrating orbital injury. A review of the literature on intracranial infection locations in relation to the route and mechanism of injury is included to complement this report.

Transorbital Penetrating Intracranial Injury Caused by Sheppard's Hook

Intracranial injury resulting from transorbital penetrating objects is rare in a noncombat setting. As such there is a significant lack of data pertaining to the management of non-projectile traumatic brain injuries due to foreign bodies entering the brain. Intracranial complications can include intracerebral hematoma, cerebral contusion, intraventricular hemorrhage, pneumocephalus, brain stem injury, and carotid cavernous sinus fistula. This is the first report of a transorbital penetrating intracranial injury caused by a Sheppard’s hook, which was managed utilizing a multi-disciplinary, non-operative approach.

[An unusual case of a serious blunt injury of the eye]

INTRODUCTION

Optic nerve avulsion is a serious injury of the eye. The objective of the paper was to present the peculiarity of the eye injury caused by a penetrating orbital wound with foreign body being retained in the orbit.

CASE REPORT

A 15-year-old boy who sustained injury by chain link is presented. While he was turning the chain round in his hand, the last link broke off, piercing the lower lid, penetrated the left orbital cavity and remained behind the eyeball at the foreign body caused a blunt injury of the eyeball and avulsion of the ocular nerve. The accurate localization of the foreign body was verified by X-ray and CT imaging. The foreign body was removed through the entry wound. The eye injury resulted in amaurosis.

CONCLUSION

This injury was one of those that could have been prevented.

Penetrating head injury from nailguns: a case series from New Zealand

Penetrating head injury from nailguns has become increasingly recognised due to their frequent use in the construction industry and home. We report a New Zealand case series of 12 penetrating nailgun head injuries, the largest of its type, detailing presentation, management, risk factors and outcomes. Recommendations based on these factors are provided, suggesting a minimal surgical approach and an individually case-assessed need for antibiotic prophylaxis and anti-epileptic drugs. Prognostic factors on initial imaging are discussed. The majority of injuries, despite being visually impressive, are associated with minimal neurological impairment.

Orbito-cranial injuries caused by penetrating non-missile foreign bodies. Experience with eighteen patients

BACKGROUND

Penetrating non-missile orbito-cranial injuries are uncommon civilian injuries which have some special features. Only limited case-reports are available in the international literature.

METHOD

We present a retrospective review of 18 such in presumed trivial orbital injury. Early identification and removal of retained foreign body fragments was achieved within 36 hours.

FINDINGS

Patients were operated on and followed up for at least of 3 years. The final clinical outcome was excellent: 16 had a Glasgow Outcome Scale (GOS) of 5 while in the remaining 2 it was 4.

CONCLUSION

The present report indicates that good results, in managing such injuries, can be achieved by a high index of suspicion and early diagnosis of intracranial injury in presumed trivial wounds and by the removal of every possible retained foreign body.

Self-inflicted nail-gun injury with 12 cranial penetrations and associated cerebral trauma

✓ In this case report, the authors describe a 33-year-old man who presented with headache due to the presence of 12 nail-gun nails impacted in his cranium and cerebral parenchyma. The authors also review the relevant literature regarding penetrating brain injury.

The patient's physical examination revealed a Glasgow Coma Scale score of 15 and impairment of abduction of the right eye and abduction of the jaw producing dysarthria; the remaining results of the neurological examination were normal. Both x-ray films and computerized tomography (CT) scans of the head revealed the presence of 12 nails, the majority of which were located intracranially. A scattering artifact limited the ability of CT scanning to demonstrate any intracranial hemorrhage. Angiography did not demonstrate any evidence of traumatic vascular injury. After general anesthesia had been induced in the patient, the nails were removed in the operating room. Following removal of the final nail, a small left temporal craniotomy was performed to control hemorrhage from a tear in the left middle meningeal artery. Despite the development of a postoperative insular hematoma, the patient was discharged home with minimal deficits.

This patient is the only known survivor of the largest number of foreign objects (12) to penetrate the skull intentionally. Overall, self-inflicted nail-gun injuries are less common than accidental discharges. A review of the literature, however, suggests that for penetrating brain injury, self-infliction is the more common mechanism. For those patients who survive such an injury, clinical decision making must focus on preventing further cortical or vascular damage. A rational management strategy should permit these patients to be discharged with no additional injury.

Penetrating intracranial stone

Traumatic intracranial foreign objects may cause cranial hemorrhage and contusion at an early stage and epileptic seizures and infections at a later stage, leading to morbidity and mortality in children. In the present study we report a case of a traumatic intracranial stone, which is a rarely encountered foreign object in intracranial traumatic injuries.

Surgical Timing in Orbital Fracture Treatment: Experience with 108 Consecutive Cases

Orbital fractures can lead to esthetic deformities and functional impairments, and adequate surgical timing is considered important in obtaining good results from surgery. By means of chart review, a retrospective analysis was carried out in 108 consecutive cases of pure orbital fractures to investigate the differences in surgical timing and the correlations with patient age and clinical and radiographic findings. In this analysis, surgical timing of pure orbital fractures was strongly related to the combination of parameters such as anatomical location of the fracture, eventual exposure of the fracture, cerebrospinal fluid (CSF) leakage or penetrating wounds, age of patients, eventual functional impairments or muscle entrapment, and serious conditions of compression or ischemia. As the data confirmed, an urgent approach was considered indispensable in severe orbital apex fractures and in orbital fractures with CSF leakage, penetrating objects, or exposure. Early surgery was necessary within 3 days in children with diplopia (type IIIb) and mainly within 7 days in adults with double vision (type IIIa). Delayed surgery, within 12 days in all cases, was performed orbital wall fractures with no impairments (type II) or in orbital rim fractures (type I). Data from this retrospective analysis confirm the need for an aggressive approach to all orbital fractures. In our experience, surgery was performed within 12 days and most orbital fractures were treated during the first week after trauma, which is earlier than previously reported.

Endoscopic Assistance in the Removal of a Foreign Body in the Condylar Process

This case report describes the application of the endoscopic technique in the removal of a metallic foreign body in the condylar process in an 81-year-old man. The patient's history indicated 60 years of pain in the left preauricular region as well as complaints of localized headaches. Physical examination revealed multiple scars on the patient's left preauricular region. No limitation of mandibular movement and no joint clicking were detected. Maximal mouth opening was 45 mm. According to the patient, masticatory function was normal. Digital palpation of the temporomandibular joint did not produce pain. Radiographic diagnosis was performed, which showed a pointed metallic foreign body lodged in the left condylar process. The removal of the foreign body was performed under endoscopic visualization via an intraoral approach. A 30 degrees-angled 4-mm diameter endoscope (Karl Storz, Tuttlingen, Germany) with a xenon light source was used.

Self-inflicted transorbital and intracranial injury from eyeglasses

Orbital injuries are commonly seen in the emergency department, and if they are high-energy they can lead to concomitant intracranial injuries. Plain films, CT, MRI, and ultrasound are used in various combinations to evaluate the extent of these injuries. We describe a unique case of self-inflicted transorbital penetrating intracranial injury from the temporal wire rim of a pair of eyeglasses. Imaging well demonstrates the full course of the wire rim in situ, and pathoanatomic correlates are highlighted.

The value of protocol-driven CT scanning in stab wounds to the head

A prospective study involving 179 patients with cranial and orbital stab wounds was undertaken to evaluate the incidence and relationship of clinical findings, radiographs, and computed tomography (CT) findings and treatment decision. Indications for a CT scanning of the head are a of loss of consciousness, convulsions, any neurological deficit, palpable or visible fracture on the skull X-ray film after an attack with a sharp instrument, presence of an impaling weapon. A CT scan and plain radiography were performed in 179 patients. There were pathological CT findings in 128 patients (71.51%). In contrast only 35/179 (19.5%) X-ray films were positive; 11 (6.15%) patients had a palpable fracture. Approximately 80% of all cranial injuries would remain undetected if the diagnosis would be based on a visible fracture. Fifty percent of patients had an admission GCS of 15/15. The importance of a CT scan and the limited benefit of plain radiography alone in stab injuries to the head is discussed.

Usefulness of gradient-echo T2*-weighted MR imaging in evaluation of transorbital penetrating cerebral injury

Transorbital penetrating cerebral injury can cause severe morbidity if not identified and treated. After the removal of the object and without the clinical information, even the chance of suspicion of penetrating cerebral injury might be missed in the first investigation. We report a case of transorbital penetrating cerebral injury caused by a metal rod and diagnosed by MRI including gradient-echo T2*-weighted imaging.