Transorbital penetrating brain injury to frontal lobe by a wheel spoke.

Penetrating brain injury (PBI) is rare and the severest form of head injury with a high morbidity and mortality. A 3.5-year-old girl presented with PBI with a wheel spoke. Computerized tomography scan with three-dimensional skull reconstruction depicted its extent from the medial side of the roof of the right orbit to the right frontal lobe with a cavitation around the spoke. The spoke was removed by manipulation under general anesthesia from the entry site without a formal craniotomy. Postoperative outcome was uneventful.

Introduction

Penetrating brain injury (PBI) with low-velocity nonmissile objects is associated with high morbidity and mortality. It accounts for 0.04% of all head trauma. PBI has been reported with steel rod, screwdriver, knife, fork, wood stick, scissors, pencil, fence rod, javelin, coat hanger, billiard stick, toothbrush, and chopstick, etc., Majority of cases have to be dealt with the removal of the penetrating object by a formal craniotomy.[12345678910] We herein report a case of PBI with a wheel spoke, which was removed from the entry wound without a craniotomy.

Case Report

A 3.5-year-old girl presented to the surgical emergency with a metal rod intruded to the medial side of the right eye. The mother of this child had died. The incident occurred while she was playing with a bicycle wheel spoke and accidentally fell over it, resulting in penetrating injury [Figure 1]. The patient bled from the entry wound which could not be quantified. The bleeding, however, ceased spontaneously in the meantime when she arrived at us. She was vitally stable with a Glasgow Coma Scale score of 15/15 with no focal neurological deficit. Ophthalmologic examination ruled out an eyeball injury. Skull radiographs in antero-posterior and lateral views revealed angled end of a long wheel spoke penetrating about 10 cm deep into the cranium through the medial aspect of the roof of the right orbit [Figure 2]. The computerized tomography (CT) scan with three-dimensional reconstruction showed the spoke lying in the right frontal lobe (premotor area), the internal trajectory being perpendicular to roof of the orbit, away from brain vasculature and vital centers, and a cavitation around the spoke [Figure 3]. Blood investigations were within normal limits. The patient was taken to the operation theatre after optimization. The entrance wound was extended slightly and spoke pulled back bit by bit. It took half an hour to retrieve the spoke completely. The patient remained vitally stable throughout the procedure. The dural defect was packed with sponge-stone and bone-wax. Peri-orbita and the skin were closed [Figure 1]. Immediate postoperative recovery was uneventful. The patient was allowed orally on the following day of operation and discharged on the 4th postoperative day on antibiotics for 2 weeks. The patient has visited us twice; she is in a good state of health without any signs of local and central nervous system infections and cerebrospinal fluid (CSF) leakage.

Figure 1

Wheel spoke intruded transorbitally. Inset showed postremoval image

Figure 2

Radiographs showing spoke

Figure 3

Upper slices of computerized tomography (CT) scan showed rod in the right frontal region with a cavitation around the rod. Lower slices showed CT with three-dimensional reconstruction; left lower slice showed intracranial extent

Discussion

Penetrating brain injury to Phineas Gage, a railway worker, with an iron rod has been a very popular case in the United States. He, later on, died of posttraumatic epilepsy.[11] The prognosis depends on the site of involvement as to damage to major vessels and vital brain centers. Various complications of PBI are sudden death, life-threatening hemorrhage, intracranial hematoma, local trauma to the brain and its vasculature, brain abscesses, meningitis, CSF leakage, and neurological deficits. Epilepsy, behavioral, and psychological problems are also encountered in patients, especially with frontal lobe injury.[567891011]

The mode of injury is accidental in most of the pediatric cases; however, homicidal intent should be looked out for. Solarino et al.,[2] reported a case where the child got PBI by a coat hanger; the intent was to hit her mother, but the daughter got the brunt. In our case, the mother had died, and all five siblings had been distributed among various relatives. The index case was living with paternal aunt, and any other intent could not be ruled out.

The objectives of the intervention in case of PBI are to avoid further damage to the brain, remove the offending object, debridement of necrotic brain tissue, and evacuation of the hematoma. These objectives are, in the majority, accomplished by a formal craniotomy around the wound of entrance.[4789101112131415] In our case, we also planned a craniotomy, however, a cavitation phenomenon around the metal rod as divulged on CT scan and a safe trajectory of the wheel spoke led us to alter our strategy. The rod was an angled, but as it was in the frontal lobe away from the major brain vasculature. Therefore, we attempted to remove it through the entrance wound. Bit by bit retrieval with strict monitoring of the patient led to the successful removal.

Postoperative monitoring and follow-up are important as in the immediate postoperative period, brain edema, intracranial hematoma, CSF leakage, or meningitis may develop. A short postoperative course of anti-convulsant is quite useful in preventing immediate convulsions; however, epilepsy may develop months to years after the trauma.[891011] Postoperative course of prophylactic antibiotics is of equal importance for the prevention of infectious sequel. We gave antibiotics for 2 weeks to our patient. In the case of suspicion of any epileptic activity, electroencephalogram should be done. A perusal of the literature did not reveal any case of transorbital PBI with an angled wheel spoke.