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Year : 2020  |  Volume : 68  |  Issue : 2  |  Page : 509--511

Management Strategy of a Transorbital Penetrating Injury by a Wooden Stick

Yanming Ren, Chao You 
 Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China

Correspondence Address:
Chao You
Department of Neurosurgery, West China Hospital, Sichuan University, 37# Guo Xue Xiang Street, Chengdu, Sichuan 610041

How to cite this article:
Ren Y, You C. Management Strategy of a Transorbital Penetrating Injury by a Wooden Stick.Neurol India 2020;68:509-511

How to cite this URL:
Ren Y, You C. Management Strategy of a Transorbital Penetrating Injury by a Wooden Stick. Neurol India [serial online] 2020 [cited 2022 Jun 29 ];68:509-511
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Full Text


Transorbital penetrating injuries are relatively uncommon, accounting for only about one-fourth of penetrating head trauma cases in adults and one-half of those in children.[1] Here, we report yet another such rare case.

A 22-year-old man was brought to the emergency department 15 h after sustaining a penetrating injury to his left orbit with a 14-cm wooden stick, without any residual outside [Figure 1]a. No loss of consciousness was observed, the Glasgow Coma Score was 15/15 on admission, and his vital signs remained stable. A significant periorbital edema of the left eyelid made the assessment of vision difficult. The diameter of his left pupil was 3 mm, and light reflex was slow. Other neurologic deficits were not observed.{Figure 1}

A CT scan of the head showed the wooden stick traversing the orbit 10 cm intracranially region without hemorrhage [Figure 1]b and c]. A three-dimensional (3D) reconstructed CT scan demonstrated the wooden stick penetrating the anterior skull base [Figure 1]d.

The patient was taken to the operating room. He underwent a coronary craniotomy for extracting the wooden stick 16 h after the injury. A subfrontal dissection was performed with the visualization of the wooden stick as it transgressed the floor of the anterior fossa [Figure 1]e. The wooden stick was cautiously removed along the same trajectory to avoid any new injury [Figure 1]f. After clearing the bone fragments, the anterior fossa floor was repaired using human fibrin sealant and a pedicled pericranial flap. Finally, the area was washed repeatedly, and a drainage tube was placed in the wound cavity.

The patient was managed in the intensive care unit and weaned from mechanical ventilation. The drainage tube was extracted on a postoperative day 2. He underwent a CT scan one week after the operation, which revealed no bleeding within the injury bed [Figure 2]. He received anti-infection treatment (ceftriaxone 1 g/d i.v.) for two weeks and was then discharged home. He was neurologically intact at the 5-year follow-up.{Figure 2}

Transorbital penetrating head injuries (PHIs) have been caused by many objects, including wood, metal body, and plastic.[2] We present the case of a severe craniocerebral penetrating injury successfully management at our center. A thorough examination is necessary for any patient with a scalp wound, as penetrating foreign bodies may be obvious or occult.[3],[4] Radiological measurements, including CT, magnetic resonance imaging (MRI), plain radiographs, and DSA, are selectively applied based on the purpose. Head CT scan is the most valuable means for the initial evaluation of foreign objects and the extent of injury caused by them. However, it may not evaluate a plastic or wooden object; MRI is a better choice in such cases.[4],[5] Plain radiographs are useful for the intracranial localization of metallic foreign bodies when CT scans are limited by artifacts.[6] DSA or computed tomography angiography is required to evaluate the suspected vascular injury.[7]

The selection of surgical approaches is important and should be based on the location of the entry point and tip of the foreign body. Transorbital PHIs by foreign bodies, which are directed into different cerebral structures, are a threat to ocular and cerebral structures. Different approaches may be used to remove foreign objects along various trajectories, such as coronary, frontolateral, frontotemporal, subtemporal, and frontal orbitozygomatic approaches.[8] A coronary approach can be used when the tip of the foreign body is located in the supratentorial region close to the cerebral falx, as our case, or across the bilateral cerebral hemisphere.

Several complications may occur after PHIs, such as infection, Cerebrospinal Fluid (CSF) leakage, vascular vasospasm, traumatic aneurysms, pseudoaneurysms, and seizures.[4] Infection is the most common and life-threatening complication in such cases. Removal of necrotic debris around the injury site is a critical step, and the prolonged administration of broad-spectrum antibiotic treatment has been recommended.[9] The postoperative CSF leakage rate has reduced with the use of vascular pedicled flaps and advanced suturing techniques in recent years.[10] The vascular complications should be monitored by angiography repeatedly, and prophylactic anticonvulsants are recommended for the first seven days after injury.[11],[12]

In conclusion, a comprehensive preoperative examination, an emergent surgery, a suitable approach, removal of necrotic debris, and strict postoperative management are helpful to achieve a good outcome in the presence of a transorbital penetrating injury.

Supplemental data

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


1Arslan M, Eseoglu M, Gudu BO, Demir I. Transorbital orbitocranial penetrating injury caused by a metal bar. J Neurosci Rural Pract 2012;3:178-81.
2Sun G, Yagmurlu K, Belykh E, Lei T, Preul MC. Management strategy of a transorbital penetrating pontine injury by a wooden chopstick. World Neurosurg 2016;95:622.e7-622.
3Mzimbiri JM, Li J, Xia Y, Yuan J, Liu J, Liu Q. Surviving penetrating brainstem injury by bamboo sticks: Rare case reports and a brief review of literature. Neurosurgery 2016;78:E753-60.
4Zyck S, Toshkezi G, Krishnamurthy S, Carter DA, Siddiqui A, Hazama A, et al. Treatment of penetrating nonmissile traumatic brain injury. Case series and review of the literature. World Neurosurg 2016;91:297-307.
5Alafaci C, Caruso G, Caffo M, Adorno AA, Cafarella D, Salpietro FM, et al. Penetrating head injury by a stone: Case report and review of the literature. Clin Neurol Neurosurg 2010;112:813-6.
6Gutierrez-Gonzalez R, Boto GR, Rivero-Garvia M, Perez-Zamarron A, Gomez G. Penetrating brain injury by drill bit. Clin Neurol Neurosurg 2008;110:207-10.
7Testerman GM, Dacks LM. Multiple self-inflicted nail gun head injury. South Med J 2007;100:608-10.
8Gupta SK, Umredkar AA. Juxtapontine abscess around a retained wooden fragment following a penetrating eye injury: Surgical management via a transtentorial approach. J Neurosurg Pediatr 2012;9:103-7.
9Bayston R, de Louvois J, Brown EM, Johnston RA, Lees P, Pople IK. Use of antibiotics in penetrating craniocerebral injuries. “Infection in neurosurgery” working party of british society for antimicrobial chemotherapy. Lancet 2000;355:1813-7.
10Eloy JA, Kalyoussef E, Choudhry OJ, Baredes S, Gandhi CD, Govindaraj S, et al. Salvage endoscopic nasoseptal flap repair of persistent cerebrospinal fluid leak after open skull base surgery. Am J Otolaryngol 2012;33:735-40.
11Kazim SF, Shamim MS, Tahir MZ, Enam SA, Waheed S. Management of penetrating brain injury. J Emerg Trauma Shock 2011;4:395-402.
12Williams JR, Aghion DM, Doberstein CE, Cosgrove GR, Asaad WF. Penetrating brain injury after suicide attempt with speargun: Case study and review of literature. Front Neurol 2014;5:113.